PREPARE Study Results - Sept 2008
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Transcript PREPARE Study Results - Sept 2008
Strategic Programming of Detection and
Therapy Parameters in Implantable
Cardioverter-Defibrillators Reduces Shocks
in Primary Prevention Patients:
Results from the PREPARE (Primary Prevention Parameters
Evaluation) Study1
Bruce L. Wilkoff, MD FACC*; Brian D. Williamson, MD FACC*; Richard S. Stern,
MD FACC*; Stephen L. Moore, DO FACC*; Fei Lu, MD FACC|*; Sung W. Lee,
MD FACC*; Ulrika M. Birgersdotter-Green, MD*; Mark S. Wathen, MD*, Isabelle
C. Van Gelder, MD*; Brooke M. Heubner, MS#; Mark L. Brown, PhD#; Keith K.
Holloman, BA#; for the PREPARE Study Investigators
1
J Am Coll Cardiol 2008; 52:541-50.
* Medtronic Consultant/Advisor & Investigator
# Medtronic Employee
Outline
Background
Methods
Results
Safety
Conclusions
Background
Background
1
In 2002, indications for ICDs were
expanded for “Primary Prevention
Patients” (MADIT II1 and SCD-HeFT2)
Primary prevention patients might be less
tolerant of shocks
Goal: Reduce shocks with specialized
programming
Moss AJ. N Engl J Med. 2002; 346:877-883.
2 Bardy GH. N Engl J Med. 2005; 352:225-237.
Programming Strategy for
Primary Prevention Patients
Build upon programming strategies tested
in previous trials
SCD-HeFT – Rx only for fast rhythms
PainFREE Rx II – ATP before shock
EMPIRIC – Prescribed programming for all
ICD recipients utilizing PF II programming and
SVT discriminators
Adapt for Primary Prevention Patients
PREPARE Hypothesis
Strategically chosen ICD VT/VF detection
and therapy parameters can reduce the
combined incidence of device-delivered
shocks, arrhythmic syncope and untreated
sustained symptomatic VT/VF in primary
prevention patients.
Methods
Methods
Prospective, historic cohort controlled study
Primary prevention ICD indications
700 pts
38 Centers, US & Europe
October 2003 – May 2005
1 year follow-up
Medtronic Marquis-based ICDs and leads
Single, dual and Bi-V patients
Bi-V & Non Bi-V Controls
MIRACLE ICD trial – 978 patients enrolled
EMPIRIC trial - 900 patients enrolled
All received Bi-V devices
415 primary prevention patients with physician-tailored
programming
All received dual chamber ICDs
276 primary prevention patients with physician-tailored
programming
Total Control Cohort
691 primary prevention, Bi-V and Non Bi-V
PREPARE Strategies to
Reduce Shocks1
Avoid detecting slower tachycardia
Avoid detecting non-sustained tachycardia
Avoid detecting SVT as VT/VF
ATP therapy for fast VT
High output 1st shock
1
Wilkoff BL, Stern R, Williamson B, et al. Design of the Primary Prevention Parameters
Evaluation (PREPARE) trial of implantable cardioverter defibrillators to reduce patient morbidity.
Trials 2006; 7:18.
VT/VF Detection
Detection
Heart Rate
Beats to
Detect
VF ON
> 250 bpm
30 of 40
FVT Via VF
182-250 bpm
1 seq ATP,
(30 of 40)
30-35J
VT Monitor
167-181 bpm
32
Therapies
30-35 J
None
PR Logic ON: AF/Afl, Sinus Tach (1:1 VT-ST = 66%) or
Wavelet ON: SVT Limit = 200 bpm
Primary Endpoint
Morbidity Index
Spontaneous episodes treated with shocks
Arrhythmic syncope
Untreated sustained symptomatic VT/VF
episodes
Secondary Endpoints
Morbidity-Tachycardia Index
Morbidity Index plus ATP episodes
Time to first shock
All-cause
Appropriate
Inappropriate
Statistical Methods
Primary Analyses
Morbidity Index
Comparison: Events per year of patient
follow-up
Analysis: Poisson model with GEE
methodology
Time to first shock and time to death
Comparison: Distribution of event times
Analysis: log-rank test of Kaplan-Meier curves
1
Intent-to-treat principle1
HRS LBCT presentation used per-protocol principle
Statistical Methods
Adjusted Analyses
Morbidity Index
Adjustment: Stratified by propensity score
Analysis: Primary analysis repeated for five
strata with balanced baseline covariates
Time to first shock and time to death
Adjustment: Baseline variables added to
model
Analysis: Cox proportional hazards
Intent-to-treat principle
Results
Baseline Characteristics
PREPARE
(n=700)
Control
(n=691)
P-value
67.4 12.2
65.5 11.7
0.003
79%
77%
0.3
27.6 10.4
24.7 9.8
<0.001
Ischemic CM
70%
57%
<0.001
Hypertension
57%
48%
<0.001
Age, Mean SD
Male
EF Mean SD
NYHA
0.06
Class 0/I/II
59%
54%
Class III-IV
41%
46%
Hx of AF/Afl/AT
33%
20%
<0.001
Baseline Medications
Medication
PREPARE Control
(n=700)
(n=691)
P-Value
Anti-Arrhythmic
12%
20%
<0.001
Beta-Blocker
84%
73%
<0.001
ACE Inh or ARBs
84%
83%
0.91
Implant and Device Type
PREPARE
(n=700)
Control
(n=691)
Non Bi-Ventricular
452 (65%)
276 (40%)
Single chamber
110 (16%)
0
Dual Chamber
342 (49%)
276 (40%)
247 (35%)
415 (60%)
1 (<1%)
N/A
Device Type
Bi-Ventricular
Unsuccessful implant
Therapy Rate Threshold
Rate Threshold,
Median (25%, 75%)
PREPARE
Control
P-value
182 bpm
(182, 182)
176 bpm
(162, 188)
< 0.001
ATP Programming
Number of intervals to detect
PREPARE
(n=700)
Control
(n=691)
7 (1%)
397 (58%)
18 of 24
4 (<1%)
291 (42%)
24 of 32
0 (0%)
1 (<1%)
30 of 40
687 (99%)
0
NID
12 of 16
Morbidity Index
(Primary Endpoint)
Incidence rate (events/pt-yr): 0.26 PREPARE vs. 0.69 Control
Incidence rate ratio: PREPARE / Control = 0.38 (62% relative reduction), p=0.003
Ratio adjusted for baseline characteristics = 0.44 (56% relative reduction), p=0.002
Shocked
1
Episodes
Incidence rate (events/pt-yr): 0.26 PREPARE vs. 0.69 Control
Incidence rate ratio: PREPARE / Control = 0.37 (63% relative reduction), p=0.003
Ratio adjusted for baseline characteristics = 0.42 (58% relative reduction), p=0.001
1
Peterson B and Rogers T. Medtronic data on file. August 2008.
Secondary Endpoint
Morbidity Tachycardia Index:
Morbidity Index events
Spontaneous episodes treated with shocks
Arrhythmic syncope
Untreated sustained symptomatic VT/VF episodes
Spontaneous episodes treated with ATP
Incidence rate lower for PREPARE
0.70 PREPARE vs. 1.96 Control
Ratio of 0.36 (64% relative reduction); p=0.02
Ratio of 0.34 (66% relative reduction); p<0.001
Adjusting for baseline characteristics
Patients Shocked at One year1
* Results remain significant after adjusting for differences in baseline characteristics.
** Not significant after adjusting for differences in baseline characteristics.
1 Wilkoff BL, Williamson BD, Stern RS, et al. Strategic programming of detection and therapy parameters in implantable cardioverter-defibrillators reduces
shocks in primary prevention patients: results from the PREPARE (Primary Prevention Parameters Evaluation) study. J Am Coll Cardiol. August 12,
2008;52(7):541-550.
Time to First Shock: All-Cause
Time to First Shock: Appropriate
Time to First Shock: Inappropriate
Safety
Syncope
Adverse Event
Syncope and near-syncope
Arrhythmia-related
True syncope
Arrhythmia-related
Related to PREPARE programming
Pts (%) Events
(n=700)
131 (18.7%) 290
27 (3.9%) 31
31 (4.4%) 40
11 (1.6%) 12
9 (1.3%) 10
10 events identified as possibly or probably related to PREPARE
programming in 9 patients.
None associated with injuries or death
7 patients completed study
2 patients withdrew for other reasons
Mortality
Death Related to PREPARE
Programming
One patient death was adjudicated as being
possibly related to PREPARE programming
Episode of slow VT detected in the monitor zone
that accelerated to VF and was terminated with
the sixth shock
Cause of death was determined to be possibly
related to the prolonged ventricular arrhythmia
Outcome likely the same with nominal
programming for primary prevention patients
Single high-rate therapy zone with or without low-rate
monitoring
Undersensing with Longer NIDs1
1
No difference in the rate of undersensing
between NID=12/16 and NID=30/40 for
induced or spontaneous VF/PVT
No difference in US early vs late in
episode
Avg number of US between onset and
shock was 2
Avg time from onset to shock increased
from 6 to 9.5 secs
Brown M, et al. Longer Ventricular Fibrillation Detection Duration Does Not Increase Rate of
Undersensing: Results from the PREPARE Study. Circulation, vol. 116, no 16, Supplement II,
October 16, 2007, p II-586.
Limitations
Non-randomized trial
Historical control cohort
Differences in baseline characteristics between
PREPARE group and controls
Significant reductions for endpoints remain when
adjusting for differences:
Morbidity Index, Morbidity Tachycardia Index, and shocked
episodes
Percent of patients receiving an all-cause shock
Percent of patients receiving an inappropriate shock
Conclusions
Conclusion
Strategically chosen VT/VF detection and
therapy options targeting primary
prevention patients can safely reduce the
morbidity related to ICD therapy
62% reduction in Morbidity Index
63% reduction in shocked episodes
64% reduction in Morbidity Tachycardia Index
8.5% vs. 16.9% pts shocked at 1 year
3.6% vs. 7.5% pts inappropriately shocked at 1 year
Implications
Large majority of ICD implants are for
primary prevention
Most ICD patients receive too many shocks
Using strategic PREPARE programming to
treat sustained and fast tachycardias with
ATP before shocks should safely reduce
ICD morbidity
Brief Statement for CRT and CRT-ICD Systems
Indications
CRT and CRT-ICD devices are indicated for the reduction of the symptoms of moderate to severe heart failure (NYHA
Functional Class III or IV) in those patients who remain symptomatic despite stable, optimal medical therapy, and have a left
ventricular ejection fraction ≤35% and a prolonged QRS duration.
The CRT device is also intended to provide rate adaptive pacing for patients who may benefit from increased pacing rates
concurrent with increases in activity. Rate adaptive pacing is intended only for those patients developing a bradycardia
indication who might benefit from increased pacing rates concurrent with increases in activity. Dual chamber and atrial
tracking modes are indicated for patients who may benefit from maintenance of AV synchrony.
CRT-ICD devices are also indicated for ventricular defibrillation for automated treatment of life threatening ventricular
arrhythmias.
Contraindications
Asynchronous pacing is contraindicated in the presence (or likelihood) of competitive or intrinsic rhythms.
Unipolar pacing is contraindicated in patients with an implanted defibrillator or cardioverter-defibrillator (ICD) because it may
cause unwanted delivery or inhibition of defibrillator or ICD therapy.
CRT-ICD devices are contraindicated for patients whose ventricular tachyarrhythmias may have transient or reversible
causes and for patients with incessant VT or VF.
CRT devices are contraindicated for dual chamber atrial pacing in patients with chronic refractory atrial tachyarrhythmias.
Warnings and Precautions
Changes in a patient’s disease and/or medications may alter the efficacy of the device’s programmed parameters.
Patients should avoid sources of magnetic and electromagnetic radiation to avoid possible underdetection, inappropriate
sensing and/or therapy delivery, tissue damage, induction of an arrhythmia, device electrical reset or device damage.
Do not place transthoracic defibrillation paddles directly over the device.
Certain programming and device operations may not provide cardiac resynchronization.
Potential Complications
Potential complications include, but are not limited to, rejection phenomena, erosion through the skin, muscle or nerve
stimulation, oversensing, failure to detect and/or terminate tachyarrhythmia episodes, acceleration of ventricular tachycardia,
and surgical complications such as hematoma, infection, inflammation, and thrombosis.
See the device manuals for detailed information regarding the implant procedure, indications, contraindications, warnings,
precautions, and potential complications/adverse events.
Caution: Federal law (USA) restricts these devices to sale by or on the order of a physician.