Subanalyses of secondary prevention implantable cardioverter-defibrillator trials: antiarrhythmics versus implantable defibrillators (AVID), Canadian Implantable Defibrillator Study (CIDS), and Cardiac Arrest Study Hamburg (CASH)

Abstract

Purpose of review: Controlled trials for secondary prevention of sudden death--Antiarrhythmics Versus Implantable Defibrillators (AVID), Canadian Implantable Defibrillator Study (CIDS), and Cardiac Arrest Study Hamburg (CASH)--have been published and subanalyses of them provide useful clinical information on the outcome during the follow-up of this population.

Recent findings: Results from a meta-analysis showed a significant risk reduction (RR) of 25 to 27% of total mortality (P < 0.001) and 50 to 52% of arrhythmic death (P < 0.001). Compared with amiodarone, patients treated with an implantable cardioverter-defibrillator (ICD) in AVID had a maximal benefit in survival when the ejection fraction (EF) was between 20 and 34%. In CIDS, the group of higher risk (older than 70 years, EF less than 3.5%, and New York Heart Association class III-IV) presented a 50% RR of mortality. It has been demonstrated that the imbalance in beta-blocker use cannot explain the better survival in the ICD patients. After 3 years the recurrence of arrhythmia was 64% in the ICD group of the AVID trial. Patients enrolled after an episode of ventricular tachycardia were more likely to have appropriate therapy during follow-up. Older age, lower blood pressure, history of atrial fibrillation, diabetes, congestive heart failure, and prior pacemaker were parameters used for high-risk stratification. Conversely, inducibility of ventricular tachyarrhythmias on electrophysiology did not predict death.

Summary: Patients with ICD after ventricular tachyarrhythmias have a 28% RR in total mortality. Individuals with EF between 20 to 34% received the highest benefit with ICD therapy.