Circulation, Vol 86, 1206-1216, Copyright © 1992 by American Heart Association
AE Epstein, KA Ellenbogen, KA Kirk, GN Kay, SM Dailey and VJ Plumb
BACKGROUND. Successful defibrillation by an implantable cardioverter-
defibrillator (ICD) depends on its ability to deliver shocks that exceed
the defibrillation threshold. This study was designed to identify clinical
characteristics that may predict the finding of an elevated defibrillation
threshold and to describe the outcome of patients with high defibrillation
thresholds. METHODS AND RESULTS. The records of 1,946 patients from 12
centers were screened to identify 90 patients (4.6%) with a defibrillation
threshold greater than or equal to 25 J. Excluding three patients who
received ICDs that delivered greater than 30 J, there were 81 men and six
women with a mean age of 59.5 +/- 10.1 years, a mean left ventricular
ejection fraction of 0.32 +/- 0.14, and a 76% prevalence of coronary artery
disease. Sixty-one patients (70%) were receiving antiarrhythmic drugs, and
45 (52%) were receiving amiodarone. Seventy-one patients (82%) received an
ICD. Death occurred in 27 patients--19 of the 71 (27%) with an ICD (eight
arrhythmic), and eight of the 16 (50%) without an ICD (four arrhythmic).
Actuarial survival for all patients at 5 years was 67%. Actuarial survival
rates at 2 years for patients with and without an ICD were 81% and 36%,
respectively (p = 0.0024). Actuarial survival at 5 years for the ICD
patients was 73%; no patient without an ICD has lived longer than 32
months. Actuarial survival free of arrhythmic death in the ICD patients at
5 years was 84%. Although the only variable to predict survival was ICD
implantation (p = 0.003), it is entirely possible that in this
retrospective analysis, clinical selection decisions to implant or to not
implant an ICD differentiated patients destined to have better or worse
outcomes, respectively. CONCLUSIONS. Antiarrhythmic drug use may be
causally related to the finding of an elevated defibrillation threshold.
When patients with high defibrillation thresholds receive an ICD,
arrhythmic death remains an important risk (42% of deaths in these patients
were arrhythmia related, with 16% actuarial incidence at 5 years). Vigorous
testing to optimize patch location can potentially benefit patients by
enhancing the margin of safety for effective defibrillation.
ARTICLES
Clinical characteristics and outcome of patients with high defibrillation thresholds. A multicenter study
Division of Cardiovascular Disease, University of Alabama, Birmingham 35294.
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