Published Online
on April 7, 2008

A more recent version of this article appeared on April 15, 2008

This Article Full Text (PDF) CME: Take the course for this article: Circulation: April 15, 2008, Volume 117, Number 15 All Versions of this Article: 117/15/1918    most recent CIRCULATIONAHA.107.742155v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Koller, M. T. Articles by Osswald, S. Search for Related Content PubMed PubMed Citation Articles by Koller, M. T. Articles by Osswald, S. Related Collections Health policy and outcome research Other heart failure Primary prevention Secondary prevention Ablation/ICD/surgery Arrhythmias, clinical electrophysiology, drugs Epidemiology Related Article

Submitted on September 26, 2007
Accepted on January 29, 2008

Death Without Prior Appropriate Implantable Cardioverter-Defibrillator Therapy. A Competing Risk Study

Michael T. Koller MD, MSc^*, Beat Schaer MD, Marcel Wolbers PhD, Christian Sticherling MD, Heiner C. Bucher MD, MPH, and Stefan Osswald MD

From the Basel Institute for Clinical Epidemiology (M.T.K., M.W., H.C.B.); and Department of Cardiology (B.S., C.S., S.O.), University Hospital Basel, Basel, Switzerland.

^* To whom correspondence should be addressed. E-mail: kollerm{at}uhbs.ch.

Background—Implantable cardioverter-defibrillators (ICDs) improve survival in selected patients with left ventricular systolic dysfunction in randomized trials. Competing death without prior appropriate ICD therapy might preclude benefit from ICD implantation in a less selected routine-care population.

Methods and Results—We selected all patients with ischemic or dilated cardiomyopathy with an ICD implanted for primary or secondary prevention from a single-center prospective registry between 1994 and 2006. The end point was time to first appropriate ICD therapy/confirmed ventricular fibrillation or death without prior appropriate ICD therapy. We analyzed cumulative incidence functions and used competing risk regression to study predictors of appropriate ICD therapy or prior death. In 442 patients, 73 deaths occurred during a median follow-up of 3.6 years (maximum, 12.7 years). The cumulative incidence of first appropriate ICD therapy until year 7 was 52%, whereas 11% died without prior ICD therapy. The cumulative incidence of appropriate ICD therapy for ventricular fibrillation was 13%, whereas 23% died without prior therapy for ventricular fibrillation. Appropriate ICD therapy was twice as likely in secondary prevention compared with primary prevention, whereas death rates before ICD therapy were similar in both groups. Diuretic use for heart failure compared with nonuse predicted a 4-fold-increased risk of death prior to ICD therapy, although the incidence of appropriate ICD therapy was similar in both groups.

Conclusion—In a contemporary ICD population, the risk of death without prior appropriate ICD therapy is substantial, especially in patients with advanced heart failure.

Key words: defibrillation • heart arrest • heart failure • prognosis • tachyarrhythmias

Related Article:

Clinical Summaries
Circulation 2008 117: 1909. [Extract] [Full Text]

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