Archives

  • 2018-07
  • 2018-10
  • 2018-11
  • 2019-04
  • 2019-05
  • 2019-06
  • 2019-07
  • 2019-08
  • 2019-09
  • 2019-10
  • 2019-11
  • 2019-12
  • 2020-01
  • 2020-02
  • 2020-03
  • 2020-04
  • 2020-05
  • 2020-06
  • 2020-07
  • 2020-08
  • 2020-09
  • 2020-10
  • 2020-11
  • 2020-12
  • 2021-01
  • 2021-02
  • 2021-03
  • 2021-04
  • 2021-05
  • 2021-06
  • 2021-07
  • 2021-08
  • 2021-09
  • 2021-10
  • 2021-11
  • 2021-12
  • 2022-01
  • 2022-02
  • 2022-03
  • 2022-04
  • 2022-05
  • 2022-06
  • 2022-07
  • 2022-08
  • 2022-09
  • 2022-10
  • 2022-11
  • 2022-12
  • 2023-01
  • 2023-02
  • 2023-03
  • 2023-04
  • 2023-05
  • 2023-06
  • 2023-08
  • 2023-09
  • 2023-10
  • 2023-11
  • 2023-12
  • 2024-01
  • 2024-02
  • 2024-03
  • 2024-04
  • 2024-05

    • In the univariate subgroup analysis the factors that predict

    2019-05-21

    In the univariate subgroup analysis, the factors that predicted reduced survival were increased age, significant mitral regurgitation (≥ grade 2), and creatinine level (Table 4). After multivariate analysis, (+)PES followed by ICD smad pathway was a strong predictor of reduced mortality, along with creatinine level and MR grade (Table 5).
    Discussion The main findings of our study are that patients with inducible VT during PES and underwent ICD implantation exhibited a trend towards improved survival compared to patients with non-inducible PES. Therefore, PES cannot reliably predict mortality in the general population of patients with ischemic cardiomyopathy. Interestingly, subgroup analysis according to age showed poor survival among non-inducible patients<68 years old (the median age in the study) who did not undergo ICD implantation compared to patients who underwent ICD implantation, especially in those with severely reduced LVEF (≤25%) (Table 2 and Fig. 1B). On the other hand, survival of elderly patients (>68 years old) was similar in both groups. Several large studies evaluated the effectiveness of PES for the risk stratification of patients with CAD who have moderately to severely reduced LVEF. The MUSTT study compared EP-guided therapy vs. conventional therapy in inducible patients with CAD and reduced LVEF, and found that ICD implantation, but not AAD, reduced the risk of sudden death in inducible patients [6]. In addition to the main MUSTT trial, the non-inducible patients were included in a registry. The mortality rate of the non-inducible patients was significantly lower than that of the inducible patients receiving non-EP-guided therapy [10], but this rate was still high (21% in two years). Treatment with β-blockers was prescribed to less than half of the patients. The authors of the MUSTT trial concluded that non-inducibility during PES is a good predictor for improved survival [11]. The MADIT I study examined the effectiveness of ICD on mortality rate in CAD patients with LVEF≤35%, with inducible but not suppressible VT during PES [8]. However, the outcome of non-inducible patients in this study is not known. β-Blockers were administered to less than 10% of the patients. In the MADIT II trial, patients with CAD and severely reduced LVEF (≤30%) were randomized to ICD implantation or conventional therapy without requiring PES [9]. Nonetheless, PES was encouraged by the study committee, and 82% of the patients in the ICD arm underwent PES [12]. In the subgroup analysis, appropriate ICD therapy was more common in the inducible patients, but was still high in the non-inducible group (25.5% at two years). However, appropriate ICD therapy for ventricular arrhythmia occurs more frequently than death among those patients and therefore cannot be used as a surrogate for mortality. Furthermore, β-blockers and angiotensin-converting-enzyme inhibitors were administered to approximately 70% of the patients. Thus, we lack updated data regarding the outcome of non-inducible patients who were treated based on current guidelines and recommendations, including the use of β-blockers. Recently, Zaman et al. showed that PES is a strong predictor of mortality early after acute MI [13]. Current guidelines recommend ICD for patients with EF≤35% and New York Heart Association (NYHA) class II or III status, without the need to induce VT during PES. This recommendation is based on the large trials mentioned above. However, MADIT II included patients with EF≤30%. Although the SCD-Heft study [7] recruited patients with EF≤35%, the subgroup with EF>30% was small (285 patients) and subgroup analysis failed to demonstrate a survival benefit with ICD in this group. In the MUSTT study, patients underwent PES for risk stratification. However, the MUSTT study excluded non-inducible patients while the MUSTT registry compared only between non-inducible patients to inducible patients whom did not underwent ICD implantation. Thus, our study provides information that supports the current guidelines and recommendations for ICD implantation for the primary prevention of ventricular arrhythmias without using PES for risk stratification. Because device implantation carries a substantial cost and potential for complications, further risk stratification is needed [14]. Thus far, many predictors of SCD risk have been identified, including age [15], renal function, degree of LV dysfunction, and electrocardiographic parameters such as QRS duration and notching [14]. However, none of these parameters could clearly influence the guidelines and recommendations owing to the lack of specificity. Subgroup analysis of our results shows that in elderly patients, the survival rate was similar in both groups, despite the lack of ICD implantation in the (−)PES group (Table 2 and Fig. 1C). Mortality causes in this group may be different, and thus, the ICD benefit may reduce [16]. In contrast, younger patients (≤68 years old) who did not undergo ICD implantation had a significantly lower survival rate despite showing (−)PES, with a hazard ratio of 0.3. However, this finding should be confirmed in larger patient populations, as the current study was underpowered for this type of analysis.