Device Therapy for Sudden Cardiac Death Prophylaxis After Acute Coronary Syndrome: When and Why?
Implantable cardioverter-defibrillators (ICDs) are a powerful tool in preventing sudden cardiac death due to ventricular arrhythmias in ischemic cardiomyopathy. ICD indications and timing in acute coronary syndromes are unclear.
Purpose of Review
We reviewed several trials that delineated the indications for a cardiac defibrillator in patients with coronary artery disease.
The role of cardiac defibrillators in secondary prevention has been well established by AVID, CIDS, and CASH trials. AVID showed reduction in both all-cause mortality and arrhythmic death while the two smaller trials showed only improvement in arrhythmic death. Similarly, trials like MADIT, CABG Patch, MUSTT, MADIT-II, DINAMIT, and the IRIS trial have fine-tuned the indications for ICD in primary prevention of sudden cardiac death. Benefits of an ICD were most pronounced in those with reduced ejection fraction and 40 days or more since myocardial infarction or in those who were not immediately post revascularization. The recent VEST trial aimed to study wearable cardioverter-defibrillators (WCDs) in patients who did not have an indication for an implantable defibrillator. The arrhythmic deaths (1.6% vs. 2.4%) were not reduced by the WCD.
Based on consistent reduction in arrhythmic death in all primary and secondary prevention trials, defibrillators are effective in carefully selected patients.
KeywordsSudden cardiac death Implantable cardioverter-defibrillator Wearable cardioverter-defibrillator Ventricular arrhythmias Acute coronary syndrome
Compliance with Ethical Standards
Conflict of Interest
Faheemullah Beg, Miguel Valderrabano, and Paul Schurmann declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as:•• Of major importance
- 7.Kuck KH, Schaumann A, Eckardt L, Willems S, Ventura R, Delacretaz E, et al. Catheter ablation of stable ventricular tachycardia before defibrillator implantation in patients with coronary heart disease (VTACH): a multicentre randomised controlled trial. Lancet. 2010;375(9708):31–40.CrossRefGoogle Scholar
- 11.•• Causes of death in the Antiarrhythmics Versus Implantable Defibrillators (AVID) Trial. J Am Coll Cardiol. 1999;34(5):1552–9. Landmark article showing evidence to use implantable defibrillators for sudden cardiac death. Google Scholar
- 12.•• Connolly SJ, Gent M, Roberts RS, Dorian P, Roy D, Sheldon RS, et al. Canadian implantable defibrillator study (CIDS) : a randomized trial of the implantable cardioverter defibrillator against amiodarone. Circulation. 2000;101(11):1297–302. Landmark article showing evidence to use implantable defibrillators for sudden cardiac death. CrossRefGoogle Scholar
- 14.Connolly SJ, Hallstrom AP, Cappato R, Schron EB, Kuck KH, Zipes DP, et al. Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Antiarrhythmics vs Implantable Defibrillator study. Cardiac Arrest Study Hamburg . Canadian Implantable Defibrillator Study. Eur Heart J. 2000;21(24):2071–8.CrossRefGoogle Scholar
- 15.Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. N Engl J Med. 1996;335(26):1933–40.CrossRefGoogle Scholar
- 19.Schrage B, Uijl A, Benson L, Westermann D, Stahlberg M, Stolfo D, et al. Association between use of primary prevention implantable cardioverter-defibrillators and mortality in patients with heart failure: a prospective propensity-score matched analysis from the Swedish Heart Failure Registry. Circulation. 2019.Google Scholar
- 20.Bauer A, Klemm M, Rizas KD, Hamm W, von Stulpnagel L, Dommasch M, et al. Prediction of mortality benefit based on periodic repolarisation dynamics in patients undergoing prophylactic implantation of a defibrillator: a prospective, controlled, multicentre cohort study. Lancet. 2019.Google Scholar
- 24.Bigger JT Jr, Whang W, Rottman JN, Kleiger RE, Gottlieb CD, Namerow PB, et al. Mechanisms of death in the CABG Patch trial: a randomized trial of implantable cardiac defibrillator prophylaxis in patients at high risk of death after coronary artery bypass graft surgery. Circulation. 1999;99(11):1416–21.CrossRefGoogle Scholar
- 25.Haanschoten, D. (2019). Long-term outcome of the Defibrillator After Primary Angioplasty (DAPA) trial. European Society of Cardiology Congress, Paris, France.Google Scholar
- 26.•• Olgin JE, Pletcher MJ, Vittinghoff E, Wranicz J, Malik R, Morin DP, et al. Wearable cardioverter-defibrillator after myocardial infarction. N Engl J Med. 2018;379(13):1205–15. This article shows new evidence on wearable cardiac-defibrillator for prevention of sudden cardiac death, which may impact the current guideline and its use. CrossRefGoogle Scholar
- 27.Kutyifa V, Moss AJ, Klein H, Biton Y, McNitt S, MacKecknie B, et al. Use of the wearable cardioverter defibrillator in high-risk cardiac patients: data from the Prospective Registry of Patients Using the Wearable Cardioverter Defibrillator (WEARIT-II Registry). Circulation. 2015;132(17):1613–9.CrossRefGoogle Scholar