Mortality reduction in relation to implantable cardioverter defibrillator programming in the Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy (MADIT-RIT)

Anne-Christine Ruwald; Claudio Schuger; Arthur J Moss; Valentina Kutyifa; Brian Olshansky; Henry Greenberg; David S Cannom; N A Mark Estes; Martin H Ruwald; David T Huang; Helmut Klein; Scott McNitt; Christopher A Beck; Robert Goldstein; Mary W Brown; Josef Kautzner; Morio Shoda; David Wilber; Wojciech Zareba; James P Daubert

doi:10.1161/CIRCEP.114.001623

Mortality reduction in relation to implantable cardioverter defibrillator programming in the Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy (MADIT-RIT)

Circ Arrhythm Electrophysiol. 2014 Oct;7(5):785-92. doi: 10.1161/CIRCEP.114.001623. Epub 2014 Aug 18.

Authors

Anne-Christine Ruwald¹, Claudio Schuger¹, Arthur J Moss¹, Valentina Kutyifa¹, Brian Olshansky¹, Henry Greenberg¹, David S Cannom¹, N A Mark Estes¹, Martin H Ruwald¹, David T Huang¹, Helmut Klein¹, Scott McNitt¹, Christopher A Beck¹, Robert Goldstein¹, Mary W Brown¹, Josef Kautzner¹, Morio Shoda¹, David Wilber¹, Wojciech Zareba¹, James P Daubert²

Affiliations

¹ From the Heart Research Follow-up Program, University of Rochester Medical Center, NY (A.-C.R., A.J.M., V.K., M.H.R., D.T.H., H.K., S.M., C.A.B., M.W.B., W.Z.); Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark (A.-C.R., M.H.R.); Division of Cardiology, Henry Ford Hospital, Detroit, MI (C.S.); Department of Medicine, University of Iowa Health Care, Iowa City (B.O.); St Luke's and Roosevelt Hospitals, Departments of Medicine and Epidemiology, Columbia University, New York, NY (H.G.); Division of Cardiology, Hospital of the Good Samaritan, Los Angeles, CA (D.S.C.); Cardiology Division, Cedars-Sinai Heart Institute, Los Angeles, CA (D.S.C.); New England Cardiac Arrhythmia Center, Tufts-New England Medical Center, Boston, MA (N.A.M.E.); Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD (R.G.); Cardiology Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan (M.S.); Cardiovascular Institute, Loyola University Medical Center, Chicago, IL (D.W.); and Cardiology Division, Department of Medicine, Duke University Medical Center, Durham, NC (J.P.D.).
² From the Heart Research Follow-up Program, University of Rochester Medical Center, NY (A.-C.R., A.J.M., V.K., M.H.R., D.T.H., H.K., S.M., C.A.B., M.W.B., W.Z.); Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark (A.-C.R., M.H.R.); Division of Cardiology, Henry Ford Hospital, Detroit, MI (C.S.); Department of Medicine, University of Iowa Health Care, Iowa City (B.O.); St Luke's and Roosevelt Hospitals, Departments of Medicine and Epidemiology, Columbia University, New York, NY (H.G.); Division of Cardiology, Hospital of the Good Samaritan, Los Angeles, CA (D.S.C.); Cardiology Division, Cedars-Sinai Heart Institute, Los Angeles, CA (D.S.C.); New England Cardiac Arrhythmia Center, Tufts-New England Medical Center, Boston, MA (N.A.M.E.); Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD (R.G.); Cardiology Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan (M.S.); Cardiovascular Institute, Loyola University Medical Center, Chicago, IL (D.W.); and Cardiology Division, Department of Medicine, Duke University Medical Center, Durham, NC (J.P.D.). daube001@duke.edu.

PMID: 25136077
DOI: 10.1161/CIRCEP.114.001623

Abstract

Background: The benefit of novel implantable cardioverter defibrillator (ICD) programming in reducing inappropriate ICD therapy and mortality was demonstrated in Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy (MADIT-RIT). However, the cause of mortality reduction remains incompletely evaluated. We aimed to identify factors associated with mortality, with focus on ICD therapy and programming in the MADIT-RIT population.

Methods and results: In MADIT-RIT, 1500 patients with a primary prophylactic indication for ICD or cardiac resynchronization therapy with defibrillator were randomized to 1 of 3 different ICD programming arms: conventional programming (ventricular tachycardia zone ≥170 beats per minute), high-rate programming (ventricular tachycardia zone ≥200 beats per minute), and delayed programming (60-second delay before therapy ≥170 beats per minute). Multivariate Cox models were used to assess the influence of time-dependent appropriate and inappropriate ICD therapy (shock and antitachycardia pacing) and randomized programming arm on all-cause mortality. During an average follow-up of 1.4±0.6 years, 71 of 1500 (5%) patients died: cardiac in 40 patients (56.3%), noncardiac in 23 patients (32.4%), and unknown in 8 patients (11.3%). Appropriate shocks (hazard ratio, 6.32; 95% confidence interval, 3.13-12.75; P<0.001) and inappropriate therapy (hazard ratio, 2.61; 95% confidence interval, 1.28-5.31; P=0.01) were significantly associated with an increased mortality risk. There was no evidence of increased mortality risk in patients who experienced appropriate antitachycardia pacing only (hazard ratio, 1.02; 95% confidence interval, 0.36-2.88; P=0.98). Randomization to conventional programming was identified as an independent predictor of death when compared with patients randomized to high-rate programming (hazard ratio, 2.0; 95% confidence interval, 1.06-3.71; P=0.03).

Conclusions: In MADIT-RIT, appropriate shocks, inappropriate ICD therapy, and randomization to conventional ICD programming were independently associated with an increased mortality risk. Appropriate antitachycardia pacing was not related to an adverse outcome.

Clinical trial registration url: clinicaltrials.gov Unique identifier: NCT00947310.

Keywords: arrhythmias, cardiac; mortality.

Publication types

Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Aged, 80 and over
Canada / epidemiology
Chi-Square Distribution
Defibrillators, Implantable*
Electric Countershock / adverse effects
Electric Countershock / instrumentation*
Electric Countershock / mortality*
Europe / epidemiology
Heart Rate
Humans
Israel / epidemiology
Japan / epidemiology
Kaplan-Meier Estimate
Male
Middle Aged
Multivariate Analysis
Proportional Hazards Models
Prosthesis Design*
Prosthesis Failure*
Risk Factors
Tachycardia, Ventricular / diagnosis
Tachycardia, Ventricular / mortality*
Tachycardia, Ventricular / physiopathology
Tachycardia, Ventricular / therapy*
Time Factors
Treatment Outcome
United States / epidemiology

Associated data

ClinicalTrials.gov/NCT00947310