Secondary prevention of sudden cardiac death in heart failure and cardiomyopathy
- Joseph E Marine, MD, FACC, FHRS
Joseph E Marine, MD, FACC, FHRS
- Associate Professor of Medicine
- Associate Director of Electrophysiology
- Johns Hopkins University School of Medicine
- Andrea M Russo, MD, FACC, FHRS
Andrea M Russo, MD, FACC, FHRS
- Professor of Medicine
- Cooper Medical School of Rowan University
- Section Editors
- Bradley P Knight, MD, FACC
Bradley P Knight, MD, FACC
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Feinberg School of Medicine, Northwestern University
- Samuel Lévy, MD
Samuel Lévy, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Cardiology
- University of Marseille, France
Life-threatening ventricular arrhythmias, including sustained ventricular tachycardia (VT) and ventricular fibrillation (VF), are common in patients with heart failure (HF) and cardiomyopathy and may lead to sudden cardiac death (SCD). Secondary prevention of SCD refers to medical or interventional therapy undertaken to prevent SCD in patients who have experienced symptomatic life-threatening sustained VT/VF or have been successfully resuscitated from sudden cardiac arrest (SCA). The secondary prevention of SCD in patients with heart failure and cardiomyopathy will be reviewed here, with emphasis on the role of implantable cardioverter-defibrillators (ICDs). The different types of ventricular arrhythmias, the effects of HF therapy on ventricular arrhythmias, and the role of electrophysiologic testing are discussed separately. (See "Ventricular arrhythmias in heart failure and cardiomyopathy".)
The approaches to the treatment of ventricular arrhythmias related to specific heart muscle diseases, such as hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and isolated left ventricular noncompaction, are discussed elsewhere. (See "Hypertrophic cardiomyopathy: Assessment and management of ventricular arrhythmias and sudden cardiac death risk" and "Arrhythmogenic right ventricular cardiomyopathy: Treatment and prognosis" and "Isolated left ventricular noncompaction".)
CAUSES OF DEATH IN HEART FAILURE
While the exact percentages and mode of death in patients with heart failure vary with heart failure class and type of cardiomyopathy, progressive pump failure, unexpected sudden cardiac death (SCD), and SCD during episodes of clinical worsening of HF each account for approximately one-third of deaths in HF patients . VT and VF are the most common arrhythmic causes of SCD, although bradyarrhythmias and pulseless electrical activity (PEA) are responsible in 5 to 33 percent of cases [2,3]. (See "Prognosis of heart failure", section on 'Causes of death in HF'.)
More severe HF is associated with a higher overall mortality rate and a higher absolute rate of SCD, but a decreasing proportion of SCD to total deaths. This trend was illustrated in the MERIT-HF (Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure) trial in which patients with increasing HF class (NYHA class II, III and IV) had increasing rates of SCD at one year (6.3, 10.5, and 18.6 percent, respectively), but a decreasing percentage of deaths that were classified as SCD (64, 59, and 33 percent, respectively) .
Patients who have received an implantable cardioverter defibrillator (ICD) for secondary prevention have significantly higher rates of recurrent ventricular arrhythmias triggering appropriate ICD intervention than recipients of primary prevention ICDs, approximately threefold higher in one national registry from Israel . Although ICD therapy improves survival of patients who suffered prior SCA, mortality remains high. The mechanisms of death in such patients were illustrated in analyses from several secondary prevention ICD studies [6-8]:
- Narang R, Cleland JG, Erhardt L, et al. Mode of death in chronic heart failure. A request and proposition for more accurate classification. Eur Heart J 1996; 17:1390.
- Cleland JG, Erhardt L, Murray G, et al. Effect of ramipril on morbidity and mode of death among survivors of acute myocardial infarction with clinical evidence of heart failure. A report from the AIRE Study Investigators. Eur Heart J 1997; 18:41.
- Greenberg H, Case RB, Moss AJ, et al. Analysis of mortality events in the Multicenter Automatic Defibrillator Implantation Trial (MADIT-II). J Am Coll Cardiol 2004; 43:1459.
- Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet 1999; 353:2001.
- Sabbag A, Suleiman M, Laish-Farkash A, et al. Contemporary rates of appropriate shock therapy in patients who receive implantable device therapy in a real-world setting: From the Israeli ICD Registry. Heart Rhythm 2015; 12:2426.
- Causes of death in the Antiarrhythmics Versus Implantable Defibrillators (AVID) Trial. J Am Coll Cardiol 1999; 34:1552.
- Grubman EM, Pavri BB, Shipman T, et al. Cardiac death and stored electrograms in patients with third-generation implantable cardioverter-defibrillators. J Am Coll Cardiol 1998; 32:1056.
- Mitchell LB, Pineda EA, Titus JL, et al. Sudden death in patients with implantable cardioverter defibrillators: the importance of post-shock electromechanical dissociation. J Am Coll Cardiol 2002; 39:1323.
- Pires LA, Lehmann MH, Steinman RT, et al. Sudden death in implantable cardioverter-defibrillator recipients: clinical context, arrhythmic events and device responses. J Am Coll Cardiol 1999; 33:24.
- Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 2008; 117:e350.
- A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. N Engl J Med 1997; 337:1576.
- Domanski MJ, Sakseena S, Epstein AE, et al. Relative effectiveness of the implantable cardioverter-defibrillator and antiarrhythmic drugs in patients with varying degrees of left ventricular dysfunction who have survived malignant ventricular arrhythmias. AVID Investigators. Antiarrhythmics Versus Implantable Defibrillators. J Am Coll Cardiol 1999; 34:1090.
- Kuck KH, Cappato R, Siebels J, Rüppel R. Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest : the Cardiac Arrest Study Hamburg (CASH). Circulation 2000; 102:748.
- Connolly SJ, Gent M, Roberts RS, et al. Canadian implantable defibrillator study (CIDS) : a randomized trial of the implantable cardioverter defibrillator against amiodarone. Circulation 2000; 101:1297.
- Lee DS, Green LD, Liu PP, et al. Effectiveness of implantable defibrillators for preventing arrhythmic events and death: a meta-analysis. J Am Coll Cardiol 2003; 41:1573.
- Connolly SJ, Hallstrom AP, Cappato R, et al. Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Antiarrhythmics vs Implantable Defibrillator study. Cardiac Arrest Study Hamburg . Canadian Implantable Defibrillator Study. Eur Heart J 2000; 21:2071.
- Betts TR, Sadarmin PP, Tomlinson DR, et al. Absolute risk reduction in total mortality with implantable cardioverter defibrillators: analysis of primary and secondary prevention trial data to aid risk/benefit analysis. Europace 2013; 15:813.
- Chan PS, Hayward RA. Mortality reduction by implantable cardioverter-defibrillators in high-risk patients with heart failure, ischemic heart disease, and new-onset ventricular arrhythmia: an effectiveness study. J Am Coll Cardiol 2005; 45:1474.
- Schaer B, Kühne M, Reichlin T, et al. Incidence of and predictors for appropriate implantable cardioverter-defibrillator therapy in patients with a secondary preventive implantable cardioverter-defibrillator indication. Europace 2016; 18:227.
- Healey JS, Hallstrom AP, Kuck KH, et al. Role of the implantable defibrillator among elderly patients with a history of life-threatening ventricular arrhythmias. Eur Heart J 2007; 28:1746.
- Panotopoulos PT, Axtell K, Anderson AJ, et al. Efficacy of the implantable cardioverter-defibrillator in the elderly. J Am Coll Cardiol 1997; 29:556.
- Narasimhan C, Dhala A, Axtell K, et al. Comparison of outcome of implantable cardioverter defibrillator implantation in patients with severe versus moderately severe left ventricular dysfunction secondary to atherosclerotic coronary artery disease. Am J Cardiol 1997; 80:1305.
- Huang DT, Sesselberg HW, McNitt S, et al. Improved survival associated with prophylactic implantable defibrillators in elderly patients with prior myocardial infarction and depressed ventricular function: a MADIT-II substudy. J Cardiovasc Electrophysiol 2007; 18:833.
- Duray G, Richter S, Manegold J, et al. Efficacy and safety of ICD therapy in a population of elderly patients treated with optimal background medication. J Interv Card Electrophysiol 2005; 14:169.
- Betz JK, Katz DF, Peterson PN, et al. Outcomes Among Older Patients Receiving Implantable Cardioverter-Defibrillators for Secondary Prevention: From the NCDR ICD Registry. J Am Coll Cardiol 2017; 69:265.
- Epstein AE, DiMarco JP, Ellenbogen KA, et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2013; 61:e6.
- Wyse DG, Friedman PL, Brodsky MA, et al. Life-threatening ventricular arrhythmias due to transient or correctable causes: high risk for death in follow-up. J Am Coll Cardiol 2001; 38:1718.
- Viskin S, Halkin A, Olgin JE. Treatable causes of sudden death: not really "treatable" or not really the cause? J Am Coll Cardiol 2001; 38:1725.
- European Heart Rhythm Association, Heart Rhythm Society, Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247.
- Steinberg JS, Martins J, Sadanandan S, et al. Antiarrhythmic drug use in the implantable defibrillator arm of the Antiarrhythmics Versus Implantable Defibrillators (AVID) Study. Am Heart J 2001; 142:520.
- Ha AH, Ham I, Nair GM, et al. Implantable cardioverter-defibrillator shock prevention does not reduce mortality: a systemic review. Heart Rhythm 2012; 9:2068.
- Gasparini M, Proclemer A, Klersy C, et al. Effect of long-detection interval vs standard-detection interval for implantable cardioverter-defibrillators on antitachycardia pacing and shock delivery: the ADVANCE III randomized clinical trial. JAMA 2013; 309:1903.
- Wilkoff BL, Fauchier L, Stiles MK, et al. 2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement on optimal implantable cardioverter-defibrillator programming and testing. Heart Rhythm 2016; 13:e50.
- Exner DV, Reiffel JA, Epstein AE, et al. Beta-blocker use and survival in patients with ventricular fibrillation or symptomatic ventricular tachycardia: the Antiarrhythmics Versus Implantable Defibrillators (AVID) trial. J Am Coll Cardiol 1999; 34:325.
- Mitchell LB, Powell JL, Gillis AM, et al. Are lipid-lowering drugs also antiarrhythmic drugs? An analysis of the Antiarrhythmics versus Implantable Defibrillators (AVID) trial. J Am Coll Cardiol 2003; 42:81.
- De Sutter J, Tavernier R, De Buyzere M, et al. Lipid lowering drugs and recurrences of life-threatening ventricular arrhythmias in high-risk patients. J Am Coll Cardiol 2000; 36:766.
- Vyas AK, Guo H, Moss AJ, et al. Reduction in ventricular tachyarrhythmias with statins in the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II. J Am Coll Cardiol 2006; 47:769.
- Jenkins DJ, Josse AR, Beyene J, et al. Fish-oil supplementation in patients with implantable cardioverter defibrillators: a meta-analysis. CMAJ 2008; 178:157.
- Wissner E, Stevenson WG, Kuck KH. Catheter ablation of ventricular tachycardia in ischaemic and non-ischaemic cardiomyopathy: where are we today? A clinical review. Eur Heart J 2012; 33:1440.
- Soejima K, Stevenson WG, Sapp JL, et al. Endocardial and epicardial radiofrequency ablation of ventricular tachycardia associated with dilated cardiomyopathy: the importance of low-voltage scars. J Am Coll Cardiol 2004; 43:1834.
- Yamada T, Kay GN. Optimal ablation strategies for different types of ventricular tachycardias. Nat Rev Cardiol 2012; 9:512.
- Knecht S, Sacher F, Wright M, et al. Long-term follow-up of idiopathic ventricular fibrillation ablation: a multicenter study. J Am Coll Cardiol 2009; 54:522.
- Mallidi J, Nadkarni GN, Berger RD, et al. Meta-analysis of catheter ablation as an adjunct to medical therapy for treatment of ventricular tachycardia in patients with structural heart disease. Heart Rhythm 2011; 8:503.
- Anter E, Hutchinson MD, Deo R, et al. Surgical ablation of refractory ventricular tachycardia in patients with nonischemic cardiomyopathy. Circ Arrhythm Electrophysiol 2011; 4:494.
- Jeevanandam V, Bielefeld MR, Auteri JS, et al. The implantable defibrillator: an electronic bridge to cardiac transplantation. Circulation 1992; 86:II276.
- Grimm M, Wieselthaler G, Avanessian R, et al. The impact of implantable cardioverter-defibrillators on mortality among patients on the waiting list for heart transplantation. J Thorac Cardiovasc Surg 1995; 110:532.
- Bolling SF, Deeb GM, Morady F, et al. Automatic internal cardioverter defibrillator: a bridge to heart transplantation. J Heart Lung Transplant 1991; 10:562.
- Lorga-Filho A, Geelen P, Vanderheyden M, et al. Early benefit of implantable cardioverter defibrillator therapy in patients waiting for cardiac transplantation. Pacing Clin Electrophysiol 1998; 21:1747.
- Saba S, Atiga WL, Barrington W, et al. Selected patients listed for cardiac transplantation may benefit from defibrillator implantation regardless of an established indication. J Heart Lung Transplant 2003; 22:411.
- Grimm M, Grimm G, Zuckermann A, et al. ICD therapy in survivors of sudden cardiac death awaiting heart transplantation. Ann Thorac Surg 1995; 59:916.
- CAUSES OF DEATH IN HEART FAILURE
- SECONDARY PREVENTION OF SCD
- Reversible causes of SCA or sustained VT
- Use of an ICD
- - AVID trial
- - CASH trial
- - CIDS trial
- - Meta-analysis
- - Generalizability of ICD clinical trial results
- - Effect in elderly patients
- - Effect in heart failure
- - Patients with syncope
- - Patients with transient or reversible disorders
- - SCD despite ICD implantation
- Other treatment options
- - Antiarrhythmic drugs
- - Other medical therapies
- Beta blockers
- Lipid-lowering therapy
- - Radiofrequency ablation
- - Arrhythmia surgery
- Ischemic cardiomyopathy
- Nonischemic cardiomyopathy
- - Cardiac transplantation
- OUR APPROACH
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS