Eduardo Benchimol Saad
Sixth year medical student - The Federal University of Rio de Janeiro
Sudden death prophylaxis is one of the most challeging issues in modern Cardiology, which necessitates an accurate recognition of patients at high risk, as therapy is not without risks and carry some morbidity.
Clearly, post AMI patients with Non Sustained Ventricular Tachycardia ( NSVT ) and left ventricular dysfunction constitute a very selected group with a high risk of sudden death.
The MADIT Trial, published in The New England Journal Of Medicine in December 1996, created many controversies. In this trial, 196 post AMI patients with NYHA class I to III, an ejection fraction of less than 35 % and at least one documented assynptomatic episode of NSVT were taken to an electrophysiologic study and had Sustained VT induced, not responsive to Procainamide administration in the lab.
They were then randomized to either receive an Implantable Cardioverter Defibrilator ( ICD - 95 patients ) or what they called ‘ standard medical treatment ’ ( 101 patients ). This was not standardized, with about 60 % of patients receiving Amiodarone ( in different doses ), 11 % receiving class Ia drugs ( which are known to increase sudden death in post MI patients ) and about 8 % receiving b blockers ( the most beneficial drugs in post MI patients ). So, this medical treatment was one of the most questionable aspects of the trial, which could affect its results. Primary end point was total mortality.
After 27 months of follow up, mortality was 15.7 % in the ICD group and 38.6 % in the medical group, with a relative risk of 0.46 ( p=0.009 ). After this trial, the FDA approved the ICD for this highly selected group of high risk patients, even though the costs of such an strategy are tremendous. The MUSTT Trial, awaited for 1998, has a similar design and could provide answers for a still nondefined issue.
2 ) Unstable Angina / Non Q wave AMI
5 ) Atrial Fibrilation and Atrial Flutter
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