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(Circulation. 2000;102:748.)
© 2000 American Heart Association, Inc.

Clinical Investigation and Reports

Randomized Comparison of Antiarrhythmic Drug Therapy With Implantable Defibrillators in Patients Resuscitated From Cardiac Arrest

The Cardiac Arrest Study Hamburg (CASH)

Karl-Heinz Kuck, MD; Riccardo Cappato, MD; Jürgen Siebels, MD; Rudolf Rüppel, MD; for the CASH Investigators

From St Georg Hospital, Hamburg, Germany.

Correspondence to Karl-Heinz Kuck, MD, AK St Georg, Lohmühlenstrasse 5, 20099 Hamburg, Germany. E-mail kuck{at}uke.uni-hamburg.de

Background—We conducted a prospective, multicenter, randomized comparison of implantable cardioverter-defibrillator (ICD) versus antiarrhythmic drug therapy in survivors of cardiac arrest secondary to documented ventricular arrhythmias.

Methods and Results—From 1987, eligible patients were randomized to an ICD, amiodarone, propafenone, or metoprolol (ICD versus antiarrhythmic agents randomization ratio 1:3). Assignment to propafenone was discontinued in March 1992, after an interim analysis conducted in 58 patients showed a 61% higher all-cause mortality rate than in 61 ICD patients during a follow-up of 11.3 months. The study continued to recruit 288 patients in the remaining 3 study groups; of these, 99 were assigned to ICDs, 92 to amiodarone, and 97 to metoprolol. The primary end point was all-cause mortality. The study was terminated in March 1998, when all patients had concluded a minimum 2-year follow-up. Over a mean follow-up of 57±34 months, the crude death rates were 36.4% (95% CI 26.9% to 46.6%) in the ICD and 44.4% (95% CI 37.2% to 51.8%) in the amiodarone/metoprolol arm. Overall survival was higher, though not significantly, in patients assigned to ICD than in those assigned to drug therapy (1-sided P=0.081, hazard ratio 0.766, [97.5% CI upper bound 1.112]). In ICD patients, the percent reductions in all-cause mortality were 41.9%, 39.3%, 28.4%, 27.7%, 22.8%, 11.4%, 9.1%, 10.6%, and 24.7% at years 1 to 9 of follow-up.

Conclusions—During long-term follow-up of cardiac arrest survivors, therapy with an ICD is associated with a 23% (nonsignificant) reduction of all-cause mortality rates when compared with treatment with amiodarone/metoprolol. The benefit of ICD therapy is more evident during the first 5 years after the index event.

Key Words: heart arrest • defibrillation • cardioversion • antiarrhythmia agents • resuscitation

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				A Y Patwala and D J Wright Device based treatment of heart failure Postgrad. Med. J., May 1, 2005; 81(955): 286 - 291. [Abstract] [Full Text] [PDF]

				P. S Spector Diagnosis and management of sudden cardiac death Heart, March 1, 2005; 91(3): 408 - 413. [Full Text] [PDF]

				P. W. Groeneveld, P. A. Heidenreich, and A. M. Garber Trends in implantable cardioverter-defibrillator racial disparity: The importance of geography J. Am. Coll. Cardiol., January 4, 2005; 45(1): 72 - 78. [Abstract] [Full Text] [PDF]

				C. J. Plummer, R. J. Irving, and J. M. McComb The incidence of implantable cardioverter defibrillator indications in patients admitted to all coronary care units in a single district Europace, January 1, 2005; 7(3): 266 - 272. [Abstract] [Full Text] [PDF]

				M. A. Hlatky, G. D. Sanders, and D. K. Owens Evidence-Based Medicine And Policy: The Case Of The Implantable Cardioverter Defibrillator Health Aff., January 1, 2005; 24(1): 42 - 51. [Abstract] [Full Text] [PDF]

				A. S. Desai, J. C. Fang, W. H. Maisel, and K. L. Baughman Implantable Defibrillators for the Prevention of Mortality in Patients With Nonischemic Cardiomyopathy: A Meta-analysis of Randomized Controlled Trials JAMA, December 15, 2004; 292(23): 2874 - 2879. [Abstract] [Full Text] [PDF]

				R. Parkash, A. Tang, G. Wells, J. Blackburn, I. Stiell, C. Simpson, P. Dorian, R. Yee, D. Cameron, S. Connolly, et al. Use of implantable cardioverter defibrillators after out-of-hospital cardiac arrest: a prospective follow-up study Can. Med. Assoc. J., October 26, 2004; 171(9): 1053 - 1056. [Abstract] [Full Text] [PDF]

				H. J.J. Wellens Cardiac arrhythmias: The quest for a cure: A historical perspective J. Am. Coll. Cardiol., September 15, 2004; 44(6): 1155 - 1163. [Abstract] [Full Text] [PDF]

				A. Voigt, R. Ezzeddine, W. Barrington, O. Obiaha-Ngwu, L. I. Ganz, B. London, and S. Saba Utilization of implantable cardioverter-defibrillators in survivors of cardiac arrest in the United States from 1996 to 2001 J. Am. Coll. Cardiol., August 18, 2004; 44(4): 855 - 858. [Abstract] [Full Text] [PDF]

				H. J. Wellens Randomized Clinical Trials: How Long Should They Last? Circulation, July 13, 2004; 110(2): 107 - 108. [Full Text] [PDF]