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Implantable cardioverter/defibrillators for primary prevention in dilated cardiomyopathy post-DANISH: an updated meta-analysis and systematic review of randomized controlled trials

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Abstract

Background

Sudden cardiac death (SCD) is frequent in patients with heart failure due to dilated cardiomyopathy (DCM). Implantable cardioverter/defibrillator (ICD) device therapy is currently used for primary prevention. However, publication of the DANISH trial has recently given reason for doubt, showing no significant improvement in all-cause mortality in comparison to contemporary medical therapy.

Methods

We performed a meta-analysis of all randomized controlled trials comparing ICD therapy to medical therapy (MT) for primary prevention in DCM. The primary outcome was all-cause mortality; secondary analyses were performed on sudden cardiac death, cardiovascular death and non-cardiac death.

Results

Five trials including a total of 2992 patients were included in the pooled analysis. Compared to contemporary medical treatment there was a significant mortality reduction with ICD device therapy [odds ratio (OR) 0.77, 95% confidence interval (CI) 0.64–0.93; p = 0.006]. SCD was decreased significantly (OR 0.43, CI 0.27–0.69; p = 0.0004), while cardiovascular death and non-cardiac death showed no differences. Sensitivity analyses showed no influence of amiodarone therapy on overall results. Analysis of MT details revealed the DANISH population to adhere the most to current guideline recommendations. In addition, it was the only study including a substantial amount of CRT devices (58%).

Conclusions

Our meta-analysis of all available randomized evidence shows a survival benefit of ICD therapy for primary prevention in DCM. DANISH results suggest an attenuation of this ICD advantage when compared to contemporary medical and cardiac resynchronization therapy. Until larger trials have confirmed this finding, ICD therapy should remain the recommendation for primary prevention of SCD in DCM.

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Abbreviations

ACEI:

Angiotensin-converting enzyme inhibitor

ARB:

Angiotensin receptor blocker

ARNI:

Angiotensin receptor neprilysin inhibitor

ATP:

Antitachycardia pacing

BB:

Betablocker

CA:

Cardiac arrest

CAD:

Coronary artery disease

CVD:

Cardiovascular death

CHF:

Congestive heart failure

CI:

Confidence interval

CRT:

Cardiac resynchronization therapy

DI:

Device infection

DCM:

Dilated cardiomyopathy

FU:

Follow-up

HFrEF:

Heart failure with reduced ejection fraction

ICD:

Implantable cardioverter/defibrillator

ICM:

Ischemic cardiomyopathy

LBBB:

Left bundle-branch block

MT:

Medical therapy

MRA:

Mineralocorticoid receptor antagonist

OR:

Odds ratio

RBBB:

Right bundle branch block

SCD:

Sudden cardiac death

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Authors and Affiliations

  1. Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany

    Georg Wolff, Yingfeng Lin, Athanasios Karathanos, Maximilian Brockmeyer, Susanne Wolters, Alexander Fürnkranz, Hisaki Makimoto, Malte Kelm & Volker Schulze

  2. Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany

    Bernd Nowak & Alexander Fürnkranz

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  1. Georg Wolff
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  2. Yingfeng Lin
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Correspondence to Georg Wolff.

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Wolff, G., Lin, Y., Karathanos, A. et al. Implantable cardioverter/defibrillators for primary prevention in dilated cardiomyopathy post-DANISH: an updated meta-analysis and systematic review of randomized controlled trials. Clin Res Cardiol 106, 501–513 (2017). https://doi.org/10.1007/s00392-017-1079-0

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