Optimal timing of implantable cardioverter-defibrillator implantation after myocardial infarction: A decision analysis

Jonathan P. Piccini, Sana M. Al-Khatib, Evan R. Myers, Kevin J. Anstrom, Alfred E. Buxton, Eric D. Peterson, Gillian D. Sanders

Research output: Contribution to journalArticlepeer-review

Abstract

ICD Implant Timing. Background: The optimal timing of implantable cardioverter defibrillator (ICD) placement for the primary prevention of sudden cardiac death after myocardial infarction (MI) remains unknown. Methods and Results: We developed a Markov model to investigate the optimal timing of ICD implantation after MI (no ICD, ICD at 60 days, 6 months, and 1 year) in patients who meet current guidelines. Estimates of arrhythmic death (baseline risk 6%, range 1-20% per year), nonarrhythmic death, and ICD efficacy were based upon MADIT-II and other contemporary post-MI clinical trials. We used both deterministic and stochastic modeling processes in our analysis. After 10 years follow-up, the baseline probability of survival was higher in those treated with ICD implantation versus not (42% vs 30%, P < 0.001). Survival was highest with ICD implantation at 60 days versus 6 months versus 1 year: 42.4%, 42.3%, and 42.0% (P = 0.0028). ICD implantation at 60 days provided a mean incremental survival of 0.28 months and 0.84 months per patient (compared with implantation at 6 months and 1 year). In sensitivity analyses, patients' competing risk for nonarrhythmic death was the primary determinant of benefit from ICD implantation. Overall, ICD implantation at 60 days resulted in the greatest life expectancy over a wide range of plausible nonarrhythmic and arrhythmic death rates. Conclusions: The benefits of early ICD implantation are modest when compared with delayed implantation at 6 months/1 year. Our results suggest that making sure a patient receives an ICD, when appropriate, may be more important than the timing of the implantation procedure.

Original languageEnglish (US)
Pages (from-to)791-798
Number of pages8
JournalJournal of Cardiovascular Electrophysiology
Volume21
Issue number7
DOIs
StatePublished - Jul 2010
Externally publishedYes

Keywords

  • congestive heart failure
  • decision analysis
  • implantable cardioverter defibrillator
  • myocardial infarction
  • sudden cardiac death

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

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