The document presents a comprehensive overview of studies related to heart failure treatment, focusing on the efficacy of various antiarrhythmic drugs and implantable cardioverter-defibrillators (ICDs). It discusses mortality rates and survival probabilities among heart failure patients treated with amiodarone, ICDs, and other therapies, highlighting significant findings across multiple trials. The evidence suggests that ICDs may be more effective than amiodarone in reducing all-cause mortality in various patient populations.

2. Disclosures
• None

4. Prevent. Treat. Monitor.

5. Prevent.

7. Alfred E. Buxton Circulation. 2005;111:2537-2549 Copyright © American Heart Association, Inc. All rights reserved.

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9. MERIT-HF. Lancet 1999;353:2001–7.
Severity of heart failure and the mode of death in the MERITHF study

10. Image from https://www.flickr.com/photos/emagineart/
Let’susepills!

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14. STAT CHF Trial. STEVEN N. SINGH et al. N Engl J Med. 1995;333:77-82.

15. Julian DG, et al. Lancet. 1997;349:667-674.
EMIAT: All-Cause Mortality: LVEF and by Group
Months Since Randomization Months Since Randomization
ProbabilityofSurvival
ProbabilityofSurvival
Amiodarone
Placebo
Ejection fraction < 30%
Ejection fraction 31%-40%

16. CAMIAT: All-Cause Mortality and Nonarrhythmic Death
Cairns JA, et al. Lancet. 1997;349:675-682.
Months Since Randomization
CumulativeRisk(%)
Months Since Randomization
CumulativeRisk(%)
P=0.072
P=0.130
Amiodarone
Placebo

17. D-Sotalol post Myocardial Infarction
(SWORD Trial)
Total Mortality (%)
p=0.006
10
6
4
2
8
0
d-sotalol placebo
SWORD, Waldo et al., Lancet 1996
3.1
48/1572
5.0
78/1549

18. Antiarrhythmic Drugs to Prevent SCA
Julian et al, Journal of American Medical Association 1993
Echt et al, New England Journal of Medicine 1991
Class IA
10.00.1 1.0
1.19
1.06
2.38
0.81
1.04
0.96
0.91
5.0
Class IB
Class IC (CAST)
B-blockers
Calcium Channel Blockers
DIAMOND MI
Amiodarone: EMIAT
Mortality Hazard Ratio

19. 156
145
22
48
79
12
CIBIS II (1999) MERIT-HF (1999) USCHFT (1996)
Total Deaths Sudden Deaths
1 CIBIS-II Investigators, Lancet 1999
2 MERIT-HF Study Group, Lancet 1999
3 Packer M, N Engl J Med 1996
Residual Risk of SCD in Treatment Arms of
CHF Beta Blocker Trials
54%31% 54%
% Sudden
Death

20. Image from https://www.flickr.com/photos/emagineart/
Pillsalone…Probablynotagoodidea…

21. Trial (Follow up
Analysis) Year Published
Study Group
Defined Entry Criteria
All-Cause
Mortality
Benefit
Control ICD RRR ARR
AVID (2 years) 1997 VF, VT with syncope,
VT with EF <40%
25% 18% -27% -7%
CIDS (2 years) 2000 VF, out-of-hospital cardiac
arrest due to VF or VT,
VT with syncope, VT with
symptoms and EF
<35%, unmonitored
syncope with
subsequent spontaneous
or induced VT
21% 15% -30% -6%
CASH (9 years) 2000 VT, VF 44% 36% -23% -8%
Adapted from Myerburg RJ, Reddy V, Castellanos A. Indications for Implantable Cardioverter-Defibrillators Based on Evidence and Judgment. J Am Coll Cardiol.
2009;54(9):747-763. doi:10.1016/j.jacc.2009.03.078.

22. AVID. N Engl J Med 1997; 337: 1576-83

23. Update of CIDS Trial:
11-Year Follow-Up From One Center
• Original study randomized amiodarone vs ICD in VT/VF survivors
(N=659)
• Long-term follow-up from 1 center–amiodarone (N=60)
• All-cause mortality higher in amiodarone (N=28) vs ICD (N=16)
• Annual mortality rate–amiodarone, 8.4%–ICD, 4.8%
• Amiodarone patients
• 82% had side effect
• 50% had significant side effect
Bokhari FA, et al. Circulation. 2002;106(19 suppl II):II-497.

24. CIDS Update: 11-Year Follow-Up
ICD
Amiodarone
100
80
60
40
20
0
20 40 60 80 100 120 140
P=0.021
Months
ActuarialSurvival(%)
Bokhari FA, et al. Circulation. 2002;106(19 suppl II):II-497.

25. Trial (Follow up
Analysis) Year Published
Study Group
Defined Entry Criteria
All-Cause
Mortality
Benefit
Control ICD RRR ARR
MADIT
(2-yr analysis)
1996
Prior MI, EF <35%, NS VT,
inducible VT, failed IV Procainamide
32% 13% -59% -19%
CABG-Patch
(2-yr analysis)
1997
Coronary artery bypass surgery,
EF <36%, SAECG(+)
18% 18% N/A N/A
MUSTT
(5-yr analysis)
1999
CAD (prior MI ~95%), EF
<40%, NS VT, inducible VT
55% 24% -58% -31%
Adapted from Myerburg RJ, Reddy V, Castellanos A. Indications for Implantable Cardioverter-Defibrillators Based on Evidence and
Judgment. J Am Coll Cardiol. 2009;54(9):747-763. doi:10.1016/j.jacc.2009.03.078.

26. Trial (Follow up
Analysis) Year Published
Study Group
Defined Entry Criteria
All-Cause
Mortality
Benefit
Control ICD RRR ARR
MADIT-II
(2-yr analysis)
2002
Prior MI (>1 month), EF <30% 22% 16% -28% -6%
DEFINITE
(2.5-yr analysis)
2004
Nonischemic CM, history of
HF, EF <35%, >10 PVCs/h,
or NS VT
14% 8% -44% -6%
DINAMIT
(2.5-yr analysis)
2004
Recent MI (6–40 days),
EF <35%, abnormal HRV, or
mean 24 heart rate >80
beats/min
17% 19% N/A N/A
SCD-HeFT
(5-yr analysis)
2005
NYHA functional class II–III
CHF, EF ?35%
36% 29% -23% -7%
Adapted from Myerburg RJ, Reddy V, Castellanos A. Indications for Implantable Cardioverter-Defibrillators Based on
Evidence and Judgment. J Am Coll Cardiol. 2009;54(9):747-763. doi:10.1016/j.jacc.2009.03.078.

27. Kaplan-Meier Estimates of Death from Any Cause
Bardy, G. et al. N Engl J Med 2005;352:225-237

28. Kaplan-Meier Estimates of Death from Any Cause for the Prespecified Subgroups of Ischemic
CHF (Panel A) and Nonischemic CHF (Panel B)
Bardy, G. et al. N Engl J Med 2005;352:225-237

29. Kaplan-Meier Estimates of Death from Any Cause for the Prespecified Subgroups of Ischemic
CHF (Panel A) and Nonischemic CHF (Panel B)
Bardy, G. et al. N Engl J Med 2005;352:225-237

30. Clinical Cardiac Pacing, Defibrillation and Resynchronization
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32. Treat.
"Cardiac resynchronisation therapy" by Gregory Marcus, MD,
MAS, FACC

34. Image from Wikimedia User Cosmed:
http://commons.wikimedia.org/wiki/File:Ergospirometry_laboratory.jpg
6MWD
Peak VO2
Exercise Capacity
QOL
NYHA FC
LVEF
Improvement in
ventricular volumes

35. MUSTIC:http://bit.ly/mustic
PATH CHF: http://bit.ly/pathchf
PATH CHF II: http://bit.ly/pathchf2
MIRACLE:http://bit.ly/miracleCRT
Image from Flickr user:https://www.flickr.com/photos/imbasith/

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39. BLOCK HF Trial. N Engl J Med 2013;368:1585-93.

40. "Cardiac resynchronisation therapy" by Gregory Marcus, MD,
MAS, FACC
Heartfailure,NYHA
FC II,IIIorambulatory
IV
w/Wide QRS (better
if > 150 ms andLBBB
morphology)
----
LV dysfunction+
HeartBlock

41. Monitor.

42. Risk of Stroke or Systemic EmbolismRisk of Clinical Atrial Tachyarrhythmia
ASSERT Trial. N Engl J Med 2012;366:120-9

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45. PARTNERS HF Study
Whellan DJ, et al. Late-Breaking Clinical Trials. HFSA 2008.
Unadjusted Kaplan-Meier estimates

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based intrathoracic impedance trends identifies relatively increased
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47. Abraham, W. T., et al. Pulmonary artery pressure management in heart failure patients
with reduced ejection fraction significantly reduces heart failure hospitalizations and
mortality above and beyond background guideline-directed medical therapy. Abstract
902-04 presented at ACC 2015, San Diego, CA.

48. Prevent. Treat. Monitor.

49. 1.4
10.9
1.5
50
124
0.4
54.3
13
16.2
9.8
4
ICD IMPLANTATION PER MILLION INHABITANTS FOR THE YEAR 2013
IN ASIA PACIFIC
Data from Asia Pacific Heart Rhythm Society White Book 2014

50. 1.6
1.5
33.5
21
0.2
23.9
3.2
6.8
3.7
CRT IMPLANTATION PER MILLION INHABITANTS FOR THE YEAR 2013 IN ASIA
PACIFIC
Data from Asia Pacific Heart Rhythm Society White Book 2014

51. Data from Asia Pacific Heart Rhythm Society White Book 2014

52. Prevent. Treat. Monitor.

53. @HeartRhythmMD
mjagbayani@gmail.com
http://bit.ly/phatalk2015

54. Acknowledgements
• Photo for title slide from Flickr User Michela:
https://www.flickr.com/photos/sfagogo/