In post-MI patients with low LVEF, wearable cardioverter-defibrillator reduces total mortality
Efficacy of a Wearable Cardioverter-Defibrillator after Myocardial Infarction: Results of the Vest Prevention of Early Sudden Death Trial (VEST)
Presented at ACC.18 by Jeffrey Olgin (San Francisco, CA, USA)Mar. 13, 2018 - news
Introduction and methods
Rate of sudden cardiac death (SCD) after myocardial infarction (MI) is high in patients with low left ventricle ejection fraction (LVEF). Implantable cardioverter defibrillators (ICD) are not indicated immediately post-MI until after 40-90 days, depending on revascularization for several reasons. First, large studies have failed to show that implanting an ICD during this period results in long-term reductions in mortality. Second, in many cases someone’s LVEF will improve in the ensuing months post-MI. Lastly, there is competing risk of death from other causes not preventable with an ICD.
The multi-center, randomized, open-label Vest Prevention of Early Sudden Death (VEST) trial was conducted to examine whether a wearable cardioverter-defibrillator (WCD) reduces SCD in the immediate post-MI period (<90 days) in patients with reduced LVEF to bridge evaluation for ICD.
Patients with MI and an LVEF≤35% were enrolled and randomized in a 2:1 ratio to receive medical therapy with vs without WCD at hospital discharge. The primary outcome was SCD at 3 months and secondary outcomes were total mortality, cause-specific death and non-fatal outcomes.
- After a mean follow-up of 84.3 ±15.6 days, no difference was seen for SCD between the WCD group (n=1524) and the control group (n=778) (1.6% vs. 2.4%, P=0.18)
- No significant differences were found cause-specific death (except for stroke) and non-fatal outcomes between the 2 groups.
- Total mortality was significantly reduced in the WCD group (3.1%) compared to the control group (4.9%) (P=0.04).
- Adverse events that were observed in the WCD group were: rash in any location, rash on torso, itch in any location, itch on torso.
In post-MI patients with a LVEF≤35%, a WCD did not significantly reduced SCD, but was associated with a lower total mortality after 3 months. These findings indicate that WCD in high-risk patients with a low LVEF post-MI could give protection until evaluation for ICD at 40-90 days.
In a press release dr. Olgin said: ““It is possible that sudden deaths were misclassified as it’s difficult to define sudden death with accuracy when a death is unwitnessed and there is little documentation. But the cause of death is irrelevant if we can prevent it. This study found that the device was associated with fewer deaths among people recovering from a heart attack with low ejection fraction. It’s also the first therapy associated with a mortality benefit above and beyond standard medical therapy immediately after heart attack.”
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