Risk Stratification of Post-MI Patients. What Are the Limitations of MADIT? What Does the Future Hold in Store?

  • M. Brignole
  • C. Menozzi


That the implantable cardioverter-defibrillator (ICD) prevents sudden death, and does so more effectively than any other therapy, is clear and inarguable. Aside from countless eyewitness accounts of cardiac arrest being aborted by ICDs, published reports have, from the very beginning, clearly documented the remarkable effectiveness of this device in terminating lethal ventricular arrhythmias [1–4]. In patients who received the ICD the incidence of sudden death was reduced to < 2% at 1 year and ≤ 6% at 5 years. Thus, by the late 1980s, accumulated data from around the world provided ample proof that the ICD was highly effective at doing exactly what it was designed to do and that no other therapy provided the same level of protection against sudden death. The fact that the ICD prevents sudden death leads immediately to a truth that is so self-evident and indisputable as to constitute an axiom [4]. The axiom states that the ability of the ICD to measurably prolong survival depends on the population of patients to which it is applied. Indeed, in a given population followed for a given period of time, the ICD will measurably prolong overall survival whenever the risk of sudden death from ventricular tachyarrhythmias is sufficiently greater than the risk of dying from all other causes combined.


Sudden Death Ventricular Tachycardia Nonsustained Ventricular Tachycardia Implantable Defibrillator Multicenter Automatic Defibrillator Implantation Trial 
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  1. 1.
    Winkle R, Mead H, Ruder MA, Gaudiani VA, Smith NA, Buch WS, Schmidt P, Shipman T (1989) Long-term outcome with the automatic implantable cardioverter-defibrillator. Am J Coll Cardiol 13: 1353–1361CrossRefGoogle Scholar
  2. 2.
    Fogoros RN, Elson JJ, Bonnet Ca, Fiedler SB, Chenarides JG (1992) Long-term outcome of survivors of cardiac arrest whose therapy is guided by electrophysiologic testing. J Am Coll Cardiol 19: 780–788PubMedCrossRefGoogle Scholar
  3. 3.
    Thomas AC, Moser SA, Smutka ML, Wilson PA (1988) Implantable defibrillation: eight years clinical experience. PACE 11: 2053–2058PubMedCrossRefGoogle Scholar
  4. 4.
    Fogoros RN (1996) Impact of the implantable defibrillator on mortality: the axiom of overall implantable cardioverter-defibrillator survival. Am J Cardiol 78 (suppl 5A): 57–61PubMedCrossRefGoogle Scholar
  5. 5.
    Weyer E, Hauer R, van Capelle F, Tijssen J, Crijns H, Algra A, Wiesfeld A, Bakker P, Robles de Medina E (1995) Randomized study of implantable defibrillator as first choice therapy versus conventional strategy in post-infarct sudden death survivals. Circulation 91: 2195–2203CrossRefGoogle Scholar
  6. 6.
    Weyer E, Hauer R, Schrijvers G, Van Capelle F, Tijssen J, Crijns H, Algra A, Ramanna H, Bakker P, Robles de Medina E (1996) Cost-effectiveness of implantable defibrillator as first-choice versus electrophysiological guided, tiered strategy in postinfarct sudden death survivors. A randomized study. Circulation 93: 489–496CrossRefGoogle Scholar
  7. 7.
    Moss A, Hall J, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M (1996) Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. N Engl J Med 335: 1933–1940PubMedCrossRefGoogle Scholar
  8. 8.
    Wellens JJ (1997) Announced at MADIT Workshop, Jan 10–11, BrusselsGoogle Scholar
  9. 9.
    The Norwegian Multicenter Study Group (1981) Timolol-induced reduction in mortality and reinfarction in patients surviving acute myocardial infarction. N Engl J Med 304: 801–807CrossRefGoogle Scholar
  10. 10.
    Beta-blocker Heart Attack Trial Research Group (1982) A randomized trial of propranolol in patients with acute myocardial infarction. JAMA 247: 1707–1714CrossRefGoogle Scholar
  11. 11.
    Hjalmarson A, Elmfeldt D, Herlitz J, Holmberg S, Malek I, Nyberg G, Ryden L, Swedberg K, Vedin A, Waagstein F, Waldenstrom A, Waldestrom J, Wedel H, Wilhelmsen L, Wilhelmsson C (1981) Effect on mortality of metoprolol in acute myocardial infarction: a double-blind randomized trial. Lancet 2: 823–827PubMedCrossRefGoogle Scholar
  12. 12.
    Kadda K, Goldstein S, Byington R, Curb JD (1986) Effects of propranolol after acute myocardial infarction in patients with congestive heart failure. Circulation 73: 503–510CrossRefGoogle Scholar
  13. 13.
    Yousuf S, Wittes J, Friedman L (1980) Overview of results of randomized clinical trials in heart diseases. I. Treatments following myocardial infarction. JAMA 260: 2088–2093Google Scholar
  14. 14.
    Packer M, Bristow MR, Cohn JN, Colucci WS, Fowler MB, Gilbert EM, Shusterman NH (1996) The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med 334: 1349–1355PubMedCrossRefGoogle Scholar
  15. 15.
    Waagstein F, Bristow MR, Swedberg K, Camerini F, Fowler ME, Silver MA, Gilberg EM, Johnson MR, Gross FG, Hjalmarson A for the Metoprolol in Dilated Cardiomyopathy (MDC) Trial Study Group (1993) Beneficial effects of metoprolol in idiopathic dilated cardiomyopathy. Lancet 342: 1441–1446CrossRefGoogle Scholar
  16. 16.
    CIBIS Investigators and Committees (1994) A randomized trial of beta-blockade in heart failure: the Cardiac Insufficiency Bisoprolol Study (CIBIS). Circulation 90: 1765–1773CrossRefGoogle Scholar
  17. 17.
    The Cardiomyopathy Trial Investigators (1992) Cardiomiopathy trial. PACE 15: 697–700CrossRefGoogle Scholar
  18. 18.
    Defibrillat study group (1991) Actuarial risk of sudden death while awaiting cardiac transplantation in patients with artherosclerotic heart disease. Am J Cardiol 68: 545–546CrossRefGoogle Scholar
  19. 19.
    Moss A (1997) Multicenter Automatic Defibrillator Implantation trial (MADIT II) Announced at MADIT Workshop, Jan 10–11, BrusselsGoogle Scholar
  20. 20.
    Friedman PL, Stevenson WG (1996) Unsustained ventricular tachycardia–to treat or not to treat. N Engl J Med 335: 1984–1985PubMedCrossRefGoogle Scholar
  21. 21.
    Mushlin A (1996) Preliminary study results: implantable heart defibrillator appears cost-effective. Press Release. University of Rochester Medical Center, Nov 11Google Scholar
  22. 22.
    Saksena S, Madan N, Lewis C (1996) Implantable cardioverter-defibrillators are preferable to drugs as primary therapy in sustained ventricular tachyarrhythmias. Prog Cardiovasc Dis 38: 445–454PubMedCrossRefGoogle Scholar
  23. 23.
    Kupersmith J, Hogan A, Guerrero P (1995) Evaluating and improving the cost-effectiveness of the implantable defibrillator. Am Heart J 130: 507–515PubMedCrossRefGoogle Scholar
  24. 24.
    Hlatky MA, Rogers WJ, Johnstone I, Boothroid D, Brooks MM, Pitt B, Reeder G, Ryan T, Smith H, Whithlow P, Wiens R, Mark DB (1997) Medical care costs and quality of life after randomization to coronary angioplasty or coronary by-pass surgery. N Engl J Med 336: 92–99PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 1998

Authors and Affiliations

  • M. Brignole
    • 1
  • C. Menozzi
    • 2
  1. 1.Sezione di AritmologiaOspedali RiunitiLavagnaItaly
  2. 2.Ospedale S. Maria NuovaReggio EmiliaItaly

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