Cited by 2,489Cardiac electrophysiology and arrhythmiasCardiac pacing and defibrillation studiesCardiac Arrhythmias and Treatments

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A Randomized Study of the Prevention of Sudden Death in Patients with Coronary Artery Disease

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Buxton, Alfred E., Lee, Kerry L., Fisher, John D., Josephson, Mark E., Prystowsky, Eric N., Hafley, Gail·1999·New England Journal of Medicine

DOI 10.1056/nejm199912163412503

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Abstract

BACKGROUND: Empirical antiarrhythmic therapy has not reduced mortality among patients with coronary artery disease and asymptomatic ventricular arrhythmias. Previous studies have suggested that antiarrhythmic therapy guided by electrophysiologic testing might reduce the risk of sudden death. METHODS: We conducted a randomized, controlled trial to test the hypothesis that electrophysiologically guided antiarrhythmic therapy would reduce the risk of sudden death among patients with coronary artery disease, a left ventricular ejection fraction of 40 percent or less, and asymptomatic, unsustained ventricular tachycardia. Patients in whom sustained ventricular tachyarrhythmias were induced by programmed stimulation were randomly assigned to receive either antiarrhythmic therapy, including drugs and implantable defibrillators, as indicated by the results of electrophysiologic testing, or no antiarrhythmic therapy. Angiotensin-converting-enzyme inhibitors and beta-adrenergic-blocking agents were administered if the patients could tolerate them. RESULTS: A total of 704 patients with inducible, sustained ventricular tachyarrhythmias were randomly assigned to treatment groups. Five-year Kaplan-Meier estimates of the incidence of the primary end point of cardiac arrest or death from arrhythmia were 25 percent among those receiving electrophysiologically guided therapy and 32 percent among the patients assigned to no antiarrhythmic therapy (relative risk, 0.73; 95 percent confidence interval, 0.53 to 0.99), representing a reduction in risk of 27 percent). The five-year estimates of overall mortality were 42 percent and 48 percent, respectively (relative risk, 0.80; 95 percent confidence interval, 0.64 to 1.01). The risk of cardiac arrest or death from arrhythmia among the patients who received treatment with defibrillators was significantly lower than that among the patients discharged without receiving defibrillator treatment (relative risk, 0.24; 95 percent confidence interval, 0.13 to 0.45; P<0.001). Neither the rate of cardiac arrest or death from arrhythmia nor the overall mortality rate was lower among the patients assigned to electrophysiologically guided therapy and treated with antiarrhythmic drugs than among the patients assigned to no antiarrhythmic therapy. CONCLUSIONS: Electrophysiologically guided antiarrhythmic therapy with implantable defibrillators, but not with antiarrhythmic drugs, reduces the risk of sudden death in high-risk patients with coronary disease.

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“or II symptoms caused by nonischemic cardiomyopathy and associated heart failure symptoms.(4,6,21,76,98) For this reason, the 2012 practice guidelines designate the ICD as a Class I therapy in patients who meet these criteria.”
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Antiarrhythmic drug therapy in the Multicenter UnSustained Tachycardia Trial (MUSTT): drug testing and as-treated analysis
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A prospective study of anxiety in ICD patients with a pilot randomized controlled trial of cognitive behavioral therapy for patients with moderate to severe anxiety.
Qintar, M., George, J. J., Panko, M., Bea, S., Broer, K. A., St. John, J., Blissett, K.-A., Ching, E., Sears, S. F., Pedersen, S. S., et al. (2015) · Journal of Interventional Cardiac Electrophysiology · doi:10.1007/s10840-015-9990-7 · Cited by 30
“The implantable cardioverter defibrillator (ICD) provides lifesaving treatment for ventricular arrhythmias with indications having expanded for both primary and secondary prevention of sudden cardiac death [1–5].”
Background
Patient, Physician, and Procedural Factors Influencing the Use of Defibrillation Testing during Initial Implantable Cardioverter Defibrillator Insertion: Findings from the NCDR®
Russo, A. M., Wang, Y., Al‐Khatib, S. M., Curtis, J. P., & Lampert, R. J. (2013) · Pacing and Clinical Electrophysiology · doi:10.1111/pace.12248 · Cited by 30
A Study to Improve Communication Between Clinicians and Patients With Advanced Heart Failure: Methods and Challenges Behind the Working to Improve Discussions About Defibrillator Management Trial
Goldstein, N. E., Kalman, J., Kutner, J. S., Fromme, E. K., Hutchinson, M. D., Lipman, H. I., Matlock, D. D., Swetz, K. M., Lampert, R. J., Herasme, O. I., et al. (2014) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2014.03.005 · Cited by 30
Resting heart rate and risk of sudden cardiac death in the general population: Influence of left ventricular systolic dysfunction and heart rate-modulating drugs
Teodorescu, C., Reinier, K., Uy‐Evanado, A., Gunson, K., Jui, J., & Chugh, S. S. (2013) · Heart Rhythm · doi:10.1016/j.hrthm.2013.05.009 · Cited by 30
Electrophysiological Interventions for Inherited Arrhythmia Syndromes
Stephenson, E. A., & Berul, C. I. (2007) · Circulation · doi:10.1161/circulationaha.106.655779 · Cited by 30
Ventricular Tachycardia in Ischemic Heart Disease
Lo, R., Chia, K. K. M., & Hsia, H. H. (2017) · Cardiac Electrophysiology Clinics · doi:10.1016/j.ccep.2016.10.013 · Cited by 32
Reported mortality with rotating sheaths vs. laser sheaths for transvenous lead extraction
Diaz, C. L., Guo, X., Whitman, I. R., Marcus, G. M., Pellegrini, C. N., Beygui, R. E., Lee, S. Y., & Lee, B. K. (2019) · EP Europace · doi:10.1093/europace/euz238 · Cited by 30
The impact of gender on survival amongst patients with implantable cardioverter defibrillators for primary prevention against sudden cardiac death
Henyan, N. N., White, C. M., Gillespie, E. L., Smith, K. J., Coleman, C. I., & Kluger, J. (2006) · Journal of Internal Medicine · doi:10.1111/j.1365-2796.2006.01713.x · Cited by 30
Azimilide Reduces Emergency Department Visits and Hospitalizations in Patients With an Implantable Cardioverter-Defibrillator in a Placebo-Controlled Clinical Trial
Dorian, P., Al‐Khalidi, H. R., Hohnloser, S. H., Brum, J. M., Dunnmon, P. M., Pratt, C. M., Holroyde, M. J., & Kowey, P. R. (2008) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2008.05.055 · Cited by 29
Diretrizes Brasileiras de Dispositivos Cardíacos Eletrônicos Implantáveis (DCEI)
(2007) · Arquivos Brasileiros de Cardiologia · doi:10.1590/s0066-782x2007001800017 · Cited by 29
Carvedilol's antiarrhythmic properties: Therapeutic implications in patients with left ventricular dysfunction
Naccarelli, G. V., & Lukas, M. A. (2005) · Clinical Cardiology · doi:10.1002/clc.4960280403 · Cited by 30
Inverse Relationship of Blood Pressure Levels to Sudden Cardiac Mortality and Benefit of the Implantable Cardioverter-Defibrillator in Patients With Ischemic Left Ventricular Dysfunction
Goldenberg, I., Moss, A. J., McNitt, S. A., Zaręba, W., Hall, W. J., & Andrews, M. L. (2007) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2006.11.042 · Cited by 30
Positionspapier zur kardialen Resynchronisationstherapie
Stellbrink, C., Auricchio, A., Lemke, B., von Scheidt, W., & Vogt, J. (2003) · Zeitschrift für Kardiologie · doi:10.1007/s00392-003-0906-7 · Cited by 30
“Allerdings konnte in mehreren Studien eine Reduktion der Gesamtletalität durch den ICD bei Postinfarktpatienten mit eingeschränkter linksventrikulärer Funktion gezeigt werden, von denen mehr als die Hälfte eine Herzinsuffizienz hatten (8, 45, 46).”
Background
Dietary prevention of sudden cardiac death
de Lorgeril, M. (2002) · European Heart Journal · doi:10.1053/euhj.2001.2656 · Cited by 30
Infarct Characteristics by CMR Identifies Substrate for Monomorphic VT in Post‐MI Patients with Relatively Preserved Systolic Function and ns‐VT
Yalın, K., Gölcük, E., Buyukbayrak, H., Yılmaz, R., Arslan, M., Dursun, M., Bilge, A. K., & Adalet, K. (2013) · Pacing and Clinical Electrophysiology · doi:10.1111/pace.12289 · Cited by 29
Defibrillator patients should not be denied a peaceful death
Westerdahl, A. K., Sutton, R., & Frykman, V. (2015) · International Journal of Cardiology · doi:10.1016/j.ijcard.2015.01.012 · Cited by 28
“The implantable cardioverter defibrillator (ICD) is highly effective in saving lives [1–5].”
Background
Holter monitoring for syncope: diagnostic yield in different patient groups and impact on device implantation
Kühne, M., Schaer, B. A., Moulay, N., Sticherling, C., & Osswald, S. (2007) · QJM · doi:10.1093/qjmed/hcm104 · Cited by 29
Sudden cardiac death and implantable cardioverter defibrillators: two modern epidemics?
Katritsis, D. G., & Josephson, M. E. (2012) · EP Europace · doi:10.1093/europace/eus001 · Cited by 28
Self-citation
One conversion of ventricular fibrillation is adequate for implantable cardioverter-defibrillator implant: An analysis from the Low Energy Safety Study (LESS)
Higgins, S. L., Mann, D., Calkins, H. G., Estes, N. A. M., Strickberger, S. A., Breiter, D. J., Lang, D. J., & Hahn, S. J. (2005) · Heart Rhythm · doi:10.1016/j.hrthm.2004.10.043 · Cited by 29
Characteristics and early clinical outcomes of patients undergoing totally subcutaneous vs. transvenous single chamber implantable cardioverter defibrillator placement
Mithani, A. A., Kath, H., Hunter, K. M., Andriulli, J. A., Ortman, M. L., Field, J., & Russo, A. M. (2017) · EP Europace · doi:10.1093/europace/eux026 · Cited by 29
The Limitations of Symptom-based Heart Failure Management
Papadimitriou, L., Moore, C. K., Butler, J., & Long, R. C. (2019) · Cardiac failure review · doi:10.15420/cfr.2019.3.2 · Cited by 30
Equivalent arrhythmic risk in patients recently diagnosed with dilated cardiomyopathy compared with patients diagnosed for 9 months or more
Makati, K. J., Fish, A. E., England, H. H., Tighiouart, H., Estes, N. A. M., & Link, M. S. (2006) · Heart Rhythm · doi:10.1016/j.hrthm.2006.01.012 · Cited by 29
Outcomes After Ventricular Fibrillation Out-of-Hospital Cardiac Arrest: Expanding the Chain of Survival
Bunch, T. J., Hammill, S. C., & White, R. D. (2005) · Mayo Clinic Proceedings · doi:10.1016/s0025-6196(11)61532-2 · Cited by 29
Implantable cardioverter-defibrillators in France: practices and regional variability
Lazarus, A., Biondi, N., Thébaut, J.-F., Durand‐Zaleski, I., & Chauvin, M. (2011) · EP Europace · doi:10.1093/europace/eur238 · Cited by 29
Targeted ablation of cardiac sympathetic neurons reduces the susceptibility to ischemia-induced sustained ventricular tachycardia in conscious rats
Lujan, H. L., Palani, G., Zhang, L., & DiCarlo, S. E. (2010) · American Journal of Physiology-Heart and Circulatory Physiology · doi:10.1152/ajpheart.00955.2009 · Cited by 29
Induction of ventricular tachycardia with the fourth extrastimulus and its relationship to risk of arrhythmic events in patients with post-myocardial infarct left ventricular dysfunction
Zaman, S. J., Kumar, S., Narayan, A., Sivagangabalan, G., Thiagalingam, A., Ross, D. L., Thomas, S. P., & Kovoor, P. (2012) · EP Europace · doi:10.1093/europace/eus199 · Cited by 29
Determinants of geographic variations in implantation of cardiac defibrillators in the European Society of Cardiology member countries--data from the European Heart Rhythm Association White Book
Lubiński, A., Bissinger, A., Boersma, L. V. A., Leenhardt, A., Merkely, B. P., Oto, A., Proclemer, A., Brugada, J., Vardas, P. E., & Wolpert, C. (2011) · EP Europace · doi:10.1093/europace/eur066 · Cited by 29
Independent predictors of mortality in patients with advanced heart failure treated by cardiac resynchronization therapy
Kreuz, J., Horlbeck, F., Linhart, M., Mellert, F., Fimmers, R., Schrickel, J. W., Nickenig, G., & Schwab, J. O. (2012) · EP Europace · doi:10.1093/europace/eus152 · Cited by 29
Analysis of Implantable Defibrillator Longevity Under Clinical Circumstances: Implications for Device Selection
Knops, P., Theuns, D. A. M. J., Res, J., & Jordaens, L. J. L. M. (2009) · Pacing and Clinical Electrophysiology · doi:10.1111/j.1540-8159.2009.02482.x · Cited by 29
Determinants of Recurrent Ventricular Arrhythmia or Death in 300 Consecutive Patients with Ischemic Heart Disease Who Experienced Aborted Sudden Death: Data from the Leiden Out‐of‐Hospital Cardiac Arrest Study
Kiès, P., Boersma, E. H., Bax, J. J., van der Burg, A. E. B., Bootsma, M., van Erven, L., van der Wall, E. E., & Schalij, M. J. (2005) · Journal of Cardiovascular Electrophysiology · doi:10.1111/j.1540-8167.2005.50006.x · Cited by 29
Guías de Práctica Clínica del ACC/AHA/ESC 2006 sobre el manejo de pacientes con arritmias ventriculares y la prevención de la muerte cardiaca súbita.Versión resumida
Informe del Grupo de Trabajo del American College of Cardiology/American Heart Association, Súbita), D. C. D. G. D. P. C. D. L. S. E. D. C. (. P. E. D. D. G. D. P. C. P. E. M. D. P. C. A. V. Y. L. P. D. L. M. C., & desarrollado en colaboración con la European Heart Rhythm Association y la Heart Rhythm Society (2006) · Revista Española de Cardiología · doi:10.1157/13096582 · Cited by 30
In-vivo testing of digital cellular telephones in patients with implantable cardioverter-defibrillators
Chiladakis, J. A. (2001) · European Heart Journal · doi:10.1053/euhj.2000.2516 · Cited by 29
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Background
The need for studies to evaluate the reproducibility of the T-wave alternans (TWA), and the rationale for a correction index of the TWA.
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Implantable Cardioverter Defibrillator Electrogram Adjudication for Device Registries: Methodology and Observations from ALTITUDE
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Relationship between cardiac autonomic function and sustained ventricular tachyarrhythmias in patients with an implantable cardioverter defibrillators
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Early Repolarization Pattern Associated with Sudden Cardiac Death: Long‐Term Follow‐Up in Patients with Chronic Heart Failure
FURUKAWA, Y., YAMADA, T., Morita, T., Iwasaki, Y., Kawasaki, M., Kikuchi, A., Naito, T., Fujimoto, T., Ozu, K., Kondo, T., et al. (2013) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.12093 · Cited by 28

Authors: Buxton, A. E., Lee, K. L., Fisher, J. D., Josephson, M. E., Prystowsky, E. N., & Hafley, G.
Affiliations: Brown University (US)
Duke University (US)
Albert Einstein College of Medicine (US)
Beth Israel Deaconess Medical Center (US)
ORCID: Buxton, Alfred E.
Lee, Kerry L.
Fisher, John D.
Prystowsky, Eric N.
Venue: New England Journal of Medicine
Publisher: Massachusetts Medical Society
Published: 1999-12-16
Volume: 341
Issue: 25
Pages: 1882-1890
ISSN: 0028-4793 (ISSN-L)
1533-4406
DOI: 10.1056/nejm199912163412503
OpenAlex: W2313547185
Cited by: 2,489
References: 34
Citations by year: 2026: 20 · 2025: 36 · 2024: 23 · 2023: 34 · 2022: 44 · 2021: 41 · 2020: 51 · 2019: 54 · 2018: 54 · 2017: 92 · 2016: 75 · 2015: 87 · 2014: 95 · 2013: 114 · 2012: 122
FWCI: 70.29
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: New England Journal of Medicine (publishedVersion)
PubMed (publishedVersion)
Funders: National Institutes of Health (5u01hl045726-06)
National Heart, Lung, and Blood Institute (UO1HL45700, UO1-HL45726, U01HL045700)
Topics: Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
Keywords: coronary artery disease, asymptomatic ventricular arrhythmia, implantable cardioverter-defibrillator, antiarrhythmic drugs, electrophysiologic testing, programmed electrical stimulation, cardiac arrest, all-cause mortality, left ventricular ejection fraction, ACE inhibitors, beta-blockers
MeSH terms: Aged, Anti-Arrhythmia Agents, Cardiac Pacing, Artificial, Coronary Disease, Electrophysiology, Female, Humans, Male, Middle Aged, Survival Analysis, Death, Sudden, Cardiac, Defibrillators, Implantable, Tachycardia, Ventricular

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A Randomized Study of the Prevention of Sudden Death in Patients with Coronary Artery Disease

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