Circulation, Vol 87, 1880-1888, Copyright © 1993 by American Heart Association
W Grimm, BT Flores and FE Marchlinski
BACKGROUND. The purpose of this study was to determine the influence of
clinical characteristics on shock occurrence and survival in 241 patients
with implantable cardioverter-defibrillator (ICD) therapy. METHODS AND
RESULTS. Two hundred forty-one consecutive patients underwent ICD
implantation between November 1982 and November 1991 and were subsequently
followed for 26 +/- 22 months (intention-to-treat analysis). Actuarial
incidence of "appropriate" shocks was 13%, 42%, and 63%, and the incidence
of any spontaneous shocks was 15%, 51%, and 76% at 1, 3, and 5 years of
follow-up, respectively. Poor left ventricular function (ejection fraction
< or = 30%) was associated with an earlier occurrence of both
appropriate and any spontaneous ICD shocks (p = 0.001). Appropriate and any
spontaneous shocks occurred significantly later in patients who presented
with cardiac arrest and in patients in whom only ventricular fibrillation
but no uniform ventricular tachycardia was induced during preoperative
programmed stimulation. In addition, amiodarone treatment at implant was
associated with later occurrence of any spontaneous shocks. Cumulative
survival from all-cause mortality including perioperative mortality was
84%, 62%, and 57%, and survival from arrhythmic death was 97%, 89%, and 83%
at 1, 3, and 5 years, respectively. Ejection fraction < or = 30% was the
best predictor of both total arrhythmic death (p = 0.019) and total
mortality (p = 0.003). Antiarrhythmic therapy with class 1 agents at
implant was also associated with a higher total mortality during follow-up
(p = 0.023) but not with total arrhythmic death. Age, sex, underlying heart
disease, clinical presentation, and preoperative response to programmed
stimulation did not predict long-term survival. In addition, survival
curves were similar for patients with and without spontaneous shocks.
CONCLUSIONS. The majority of patients receive shocks during long-term
follow-up. The occurrence of appropriate or any spontaneous shocks during
follow-up is not associated with increased arrhythmic or total mortality
consistent with effective prevention of sudden cardiac death with ICD
therapy in this high-risk patient population. Although low ejection
fraction is the strongest predictor of both shock occurrence and mortality
during follow-up, no easy algorithm can be derived from the analyzed
clinical characteristics to predict which patients will benefit most from
ICD implantation.
ARTICLES
Shock occurrence and survival in 241 patients with implantable cardioverter-defibrillator therapy
Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia.
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