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ICDs for Primary Prevention in High-Risk Patients with Nonischemic DCM?

Implantable cardioverter-defibrillators showed a trend toward improved survival in patients with nonischemic dilated cardiomyopathy.

Despite the survival benefits of ACE inhibitors and beta-blockers, sudden death remains a substantial problem for patients with left-ventricular dysfunction (ischemic or nonischemic) and heart failure. Implantable cardioverter-defibrillators (ICDs) reduce sudden-death risk in cardiac arrest survivors, patients with sustained ventricular tachycardia, and post-MI patients with LV dysfunction (Journal Watch Cardiology May 3 2002).

Now, in the DEFINITE trial, researchers evaluated ICDs for primary prevention in patients with NYHA class I-III nonischemic dilated cardiomyopathy (DCM) and histories of symptomatic heart failure. They randomized 458 patients (71% men; mean LV ejection fraction, 21.4%, maximum LVEF, <36%) to receive standard medical therapy plus an ICD or medical therapy alone (control); each group had 229 patients.

During a mean follow-up of 29 months, there were fewer all-cause deaths among ICD recipients than among controls (28 vs. 40 deaths; hazard ratio, 0.65; P=0.08) and significantly fewer arrhythmia-related sudden deaths (3 vs. 14; P=0.006). Numbers of heart failure deaths were similar (9 and 11, respectively). NYHA class III patients saw the greatest advantage of ICD therapy: In this subgroup, ICD recipients had an all-cause mortality hazard ratio of 0.37 (P=0.02) compared with controls.

Comment: Numerous clinical trials have shown that ICDs prevent sudden cardiac death very effectively. Despite the small sample size, this mortality study documented a favorable trend with ICD therapy for nonischemic DCM. Prophylactic ICD implantation should be considered for patients with mild-to-moderate LV systolic heart failure (LVEF, <36%). For such patients with HF of ischemic etiology, the published evidence is strong; for those with nonischemic etiology, the published evidence is trending strong, bolstered by persuasive data from the forthcoming SCD-HeFT trial (American College of Cardiology Scientific Sessions, New Orleans, March 2004).

— William T. Abraham, MD

Published in Journal Watch Cardiology June 18, 2004

Citation(s):

Kadish A et al. for the Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) Investigators. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J Med 2004 May 20; 350:2151-8.

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