Benefit of implantable cardioverter defibrillator use in Japanese patients based on modified MADIT‐ICD benefit score
Toshinori ChibaYusuke KondoYuki ShikoMasahiro NakanoTakatsugu KajiyamaMiyo NakanoRyô ItôMasafumi SugawaraYutaka YoshinoSatoko RyuzakiYukiko TakanashiYuya KomaiYoshio Kobayashi
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Abstract Aims The MADIT‐ICD benefit score is used to stratify the risk of life‐threatening arrhythmia and non‐arrhythmic mortality. We sought to develop an implantable cardioverter defibrillator (ICD) benefit‐prediction score for Japanese patients with ICDs. Methods Patients who underwent ICD implantation as primary prophylaxis were retrospectively enrolled. Based on their MADIT‐ICD benefit scores, we developed a modified MADIT‐ICD benefit score adapted to the Japanese population. The primary endpoints were appropriate ICD therapy and all‐cause death without appropriate ICD therapy (non‐arrhythmic death). We used the Fine and Gray multivariate model and Cox proportional hazard regression to identify factors for adjusting the MADIT‐ICD benefit–risk score specifically for the Japanese population. The scoring points for the original MADIT‐ICD benefit score were adjusted to optimal points based on the multivariate analysis results in the population. Results The study enrolled 167 patients [age, 61.9 ± 12.3 years; male individuals, 138 (82.6%); cardiac resynchronization therapy, 73 (43.7%); ischaemic cardiomyopathy, 53 (31.7%)]. Fourteen patients received anti‐tachycardia pacing (ATP) therapy, and 23 received shock therapy as the initial appropriate ICD therapy. Non‐arrhythmic deaths occurred in 37 patients. The original MADIT‐ICD benefit score could not stratify non‐arrhythmic mortality in the Japanese population. The patients were reclassified into three groups according to the modified MADIT‐ICD benefit score. The modified MADIT‐ICD benefit score could effectively stratify the incidence of appropriate ICD therapy and non‐arrhythmic mortality. In the highest‐benefit group, the 10 year cumulative rates of appropriate ICD therapy and non‐arrhythmic mortality were 56.8% and 12.9%, respectively ( P < 0.01). In the intermediate‐benefit group, these rates were 20.2% and 40.2% ( P = 0.01). In the lowest‐benefit group, the incidence of non‐arrhythmic deaths was 68.1%, and no patient received appropriate ICD therapy. Conclusions The modified MADIT‐ICD benefit score may be useful for stratifying ICD candidates in the Japanese population.Background: Underutilization of ICD's for primary prevention of SCD has been previously reported. Whether ethnic differences in utilization play a role in this is unclear. Method: Retrospective chart review of consecutive heart failure (HF) pts in a suburban outpatient cardiology practice from Jan 2006-Dec 2010. Results: Of the 2813 HF pts, 533 (19/%) had an ejection fraction of <35%, of whom 170 (32%) received an ICD device. Of the 533 pts, 23% were Caucasian (C), 67% African American (AA), 6% Southeast Asian (SEA), 3% East Indian (EI), 2% Hispanic (H). The mean age was 63+18 yrs, with AA (60 yrs) being youngest and C (72 yrs) the oldest (p<0.001). Mean EF (23%) ranged from 21% in EI to 25% in C (p<0.04). EI pts had more CAD (71%, p=<0.01) while AA pts had more hypertension (91%, p<0.001). No sig differences in smoking (16%) diabetes (39%), PVD (24%) hyperlipidemia (62%) or family history (37%) was seen. In those pts without an ICD (n=363) no documentation of a discussion was noted in 55% of charts. Documented pt refusal of an ICD trended higher in EI pts (29% p>0.057) Although males made up 62% of the group and were younger (62 vs 65 yrs,p<0.05) no gender differences in ICD implantation rates were seen. Pts were well treated for HF with no ethnic differences noted for use of diuretics (81%), ACEI/ARB (79%), beta-blockers (89%), digoxin (28%) warfarin 22% and aspirin (59%) Only statins were used more commonly in EI vs AA (71% vs 50%, p<0.05) Conclusions: Our findings suggest that ICD's for primary prevention of SCD are underutilized in multiple ethnic groups. Lack of a documented discussion re ICD's is too common. There are significant ethnic differences in pt characteristics for HF etiology but not for HF pharmacotherapy utilization. Patient refusal rates for ICD's also vary among ethnic groups and require further evaluation to see if these differences can explain the observed underutilization of device therapy.
Primary Prevention
Sudden Death
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Sudden Death
Primary Prevention
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Haemodynamic response
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Background— Recent studies have demonstrated that a positive response to cardiac resynchronization therapy (CRT) is related to the presence of preimplantation left ventricular (LV) dyssynchrony. The time course and the extent of LV resynchronization after CRT implantation and their relationship to response are currently unknown. Methods and Results— One hundred consecutive patients scheduled for implantation of a CRT device were prospectively included if they met the following criteria: New York Heart Association class III to IV, LV ejection fraction ≤35%, QRS duration >120 ms, and LV dyssynchrony (≥65 ms) on color-coded tissue Doppler imaging. Immediately after CRT implantation, LV dyssynchrony was reduced from 114±36 to 40±33 ms ( P <0.001), which persisted at the 6-month follow-up (35±31 ms; P <0.001 versus baseline; P =0.14 versus immediately after implantation). At the 6-month follow-up, 85% of patients were classified as responders to CRT (defined as >10% reduction in LV end-systolic volume). Immediately after implantation, the responders to CRT demonstrated a significant reduction in LV dyssynchrony from 115±37 to 32±23 ms ( P <0.001). The nonresponders, however, did not show a significant reduction in LV dyssynchrony (106±29 versus 79±44 ms; P =0.08). If the extent of acute LV resynchronization was <20%, response to CRT at the 6-month follow-up was never observed. Conversely, 93% of patients with LV resynchronization ≥20% responded to CRT. Conclusions— LV resynchronization after CRT is an acute phenomenon and predicts response to CRT at 6-month follow-up in patients with echocardiographic evidence of LV dyssynchrony at baseline.
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Objective To report the clinical oberservation of 50 patients with implantable cardioverter defibrillator(ICD).Methods Observe the patients with ICD from May,1998 to Nov.2005.Results There were more than a thousand episodes of ventricular tachycardia ventricular fibrillation(VT/VF) detected and terminated by ICD devices.Conclusions ICD with tiered therapy function has high efficacy on the termination of ventricular tachyarrhythmias.It is important to follow up the patients and dynamically optimize the system of ICD.
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Although cardiac resynchronization therapy is currently used for treatment of refractory heart failure in patients with low ejection fraction and cardiac dyssynchrony, there is a substantial number of non-responders. This indicates that, in addition to cardiac dyssynchrony, there are other factors affecting response to cardiac resynchronization therapy. Pre-implant identification of these factors appears of crucial importance in order to finalize the resynchronization treatment to those patients who have the highest probability of a positive response. In this review the main non-dyssynchrony determinants of response to cardiac resynchronization therapy are presented and discussed.
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The implantable cardioverter-defibrillator (ICD) is the mainstay therapy for primary prevention of sudden cardiac death in patients with heart failure with a reduced ejection fraction. Current indications for prophylactic ICD are based on the results of randomized controlled trials dating back to 15-20 years ago, which have usually enrolled highly selected patients with few comorbidities and only a small number of patients aged >75 years. Existing literature suggest an age-dependent attenuation of the efficacy of the ICD. Because of the ageing of the population, there is need for data addressing device efficacy among older patients that also considers the impact of geriatric syndromes on health status. The assessment of frailty may be of value in identifying elderly patients who may or may not benefit from ICD placement for primary prevention of sudden cardiac death.
Primary Prevention
Secondary Prevention
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