Transcript MADIT II - Boston Scientific

MADIT II
Multicenter Automatic Defibrillator Implantation Trial II
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MADIT II
Multicenter Automatic Defibrillator
Implantation Trial II
Status: Completed in 2001
First trial to show the life-saving benefits
of ICDs without requiring patients to have
a documented history of abnormal
heart rhythms
Design1
Patients were randomized into two
treatment arms in a 3:2 ratio.
Patients in the first arm were treated
with conventional drug treatment and
also implanted with an ICD.
The second group was treated
exclusively with conventional drug
treatment, as prescribed by the patient's
attending physician (control arm).
Patients were seen in the follow-up
clinic at 1 month after randomization,
and then at 3-month intervals until the
termination date of the study or death.
Patient Population
• Eligible study participants included both male and female patients
over 21 years of age that had experienced an MI at least 30 days
prior to study enrollment and demonstrated an ejection fraction (EF) <
30%.
• Some of the exclusion criteria were
–
–
–
–
prior cardiac arrest
syncope unrelated to an acute MI
NYHA Class IV
CABG or non-CABG revascularization less than 3 months prior to
enrollment
– use of antiarrhythmic agents, except for atrial arrhythmias
– Comorbidity associated with decreased survival for trial duration.
• 76 Centers worldwide
– 71 US
– 5 European
• 1232 patients enrolled
Clinical Relevance
• To evaluate the effect of prophylactic ICD therapy on survival in
patients with prior MI and LV dysfunction.
• The primary endpoint was death from any cause
• First trial to show the life-saving benefits of ICDs without requiring
patients to have a documented history of abnormal heart rhythms
Results2
Mortality over an average follow-up of 20 months
Conventional Group (n=490)
ICD Group
(n=742)
Hazard Ratio
(95% CI)
P-value
19.8 (97)
14.2 (105)
.69 (0.51-0.93)
0.016
• 31% reduction in the risk of death at any
interval among patients in the defibrillator
group as compared with patients in the
conventional-therapy group
• The cumulative survival curves represent
a decrease in death rates in the defibrillator
group (95% confidence limits; P-value) of
12% at 1 year (27 to 40%), 28% at 2 years
(4 to 46%), and 29% at 3 years (5 to 46%).
Additional Results – MADIT II 8-Year Data3
Mortality over an average of 7.6 years* post-enrollment
Cumulative Probability of Mortality (n=1232)
ICD
No ICD (Conventional Therapy)
49%
62%
• 34% relative reduction in the risk of
death at any interval among patients
with a defibrillator as compared with
patients without an ICD
• Number needed to treat (NNT)
• 8 at 8 years
• 17 at 2 years
• Analysis showed sustained benefit
with primary ICD therapy in the MADIT
II study population
*median
Hazard Ratio (95% CI)
p-value
0.66 (0.56-0.78)
<0.001
References
1Moss
A, Cannom D, Daubert J et al. Multicenter Automatic
Defibrillator Implantation Trial II (MADIT II): Design and Clinical
Protocol. Ann Noninvasive Electrocardiol 1999;4:83-91.
2Moss
A, Zareba W, Hall W, et al, for the Multicenter Automatic
Defibrillator Implantation Trial II Investigators. Prophylactic
implantation of a defibrillator in patients with myocardial
infarction and reduced ejection fraction. N Engl J Med.
2002;346:877-883.
3Goldenberg I, Moss A, Hall W, et al. Long-Term Benefit of Primary
Prevention with an Implantable Cardioverter Defibrillator: An
Extended 8-Year Follow-Up Study of the Multicenter Automatic
Defibrillator Implantation Trial II. Circulation. 2010; xxxx
Brief Summary
ICD Systems from Boston Scientific CRM
ICD Indications and Usage
ICDs are intended to provide ventricular antitachycardia pacing and ventricular defibrillation for automated treatment of life-threatening ventricular
arrhythmias. ICDs with atrial therapies are also intended to provide atrial antitachycardia pacing and atrial defibrillation treatment in patients who
have or are at risk of developing atrial tachyarrhythmias.
Contraindications
Use of ICD systems are contraindicated in: Patients whose ventricular tachyarrhythmias may have reversible cause, such as 1) digitalis
intoxication, 2) electrolyte imbalance, 3) hypoxia, or 4) sepsis, or whose ventricular tachyarrhythmias have a transient cause, such as 1) acute
myocardial infarction, 2) electrocution, or 3) drowning. Patients who have a unipolar pacemaker.
Warnings
Read the product labeling thoroughly before implanting the pulse generator to avoid damage to the ICD system. Such damage can result in
patient injury or death. Program the pulse generator ventricular Tachy Mode to Off during implant, explant or post-mortem procedures to avoid
inadvertent high voltage shocks. Always have sterile external and internal defibrillator protection available during implant. If not terminated in a
timely fashion, an induced tachyarrhythmia can result in the patient’s death. Ensure that an external defibrillator and medical personnel skilled in
cardiopulmonary resuscitation (CPR) are present during post-implant device testing should the patient require external rescue. Patients should
seek medical guidance before entering environments that could adversely affect the operation of the active implantable medical device, including
areas protected by a warning notice that prevents entry by patients who have a pulse generator. Do not expose a patient to MRI device scanning.
Strong magnetic fields may damage the device and cause injury to the patient. Do not subject a patient with an implanted pulse generator to
diathermy since diathermy may cause fibrillation, burning of the myocardium, and irreversible damage to the pulse generator because of induced
currents. Do not use atrial tracking modes (or an AVT device) in patients with chronic refractory atrial tachyarrhythmias. Tracking of atrial
arrhythmias could result in VT or VF. (Applies to dual-chamber devices only.) Do not use this pulse generator with another pulse generator. This
combination could cause pulse generator interaction resulting in patient injury or lack of therapy delivery. Do not kink leads. Kinking leads may
cause additional stress on the leads, possibly resulting in lead fracture. For specific models, when using a subpectoral implantation, place the pulse
generator with the serial number facing away from the ribs. Implanting the pulse generator subpectorally with the serial number facing the ribs
may cause repetitive mechanical stress to a specific area of the titanium case, potentially leading to a component failure and device malfunction.
Precautions
For information on precautions, refer to the following sections of the product labeling: clinical considerations; sterilization, storage and handling;
implantation and device programming; follow-up testing; explant and disposal; environmental and medical therapy hazards; home and
occupational environments. Advise patients to avoid sources of electromagnetic interference (EMI) because EMI may cause the pulse generator to
deliver inappropriate therapy or inhibit appropriate therapy.
Potential Adverse Events
Potential adverse events from implantation of the ICD system include, but are not limited to, the following: allergic/physical/physiologic reaction,
death, erosion/migration, fibrillation or other arrhythmias, lead or accessory breakage (fracture/insulation/lead tip), hematoma/seroma,
inappropriate or inability to provide therapy (shocks/pacing/sensing), infection, procedure related, psychologic intolerance to an ICD system patients susceptible to frequent shocks despite antiarrhythmic medical management/imagined shocking, and component failure. In rare cases
severe complications or device failures can occur.
Refer to the product labeling for specific indications, contraindications, warnings/ precautions and adverse events. Rx only.
(Rev. M)