Implementation of MADIT and MUSTT in clinical practice: results of an international survey.
BACKGROUND
The long-awaited dramatically positive outcome of the Multicenter Automatic Defibrillator Implantation Trial (MADIT II), just published by Moss et al.,(14) has generated cardiologists' interest on the implementation into clinical practice of that trial. Important lessons may be learned by examining the clinical implementation of two preceding randomized, prospective, prophylactic ICD trials: the original MADIT trial, published late 1996, and the Multicenter Unsustained Tachycardia Trial (MUSTT), published late 1999. Both demonstrated that implantable cardioverter defibrillators reduce all-cause mortality by over 50% in high risk patients without previous sustained arrhythmias.


METHODS
In early 2000, we surveyed 133 active electrophysiology centers (47 American, 81 European, 5 Canadian) to determine the extent to which these practices have been implemented in clinical practice during 1999, and the responses were compared to a similar survey for the year 1998.


RESULTS
ICDs implanted for MADIT or MUSTT criteria accounted for 18% of new ICD implants in 1999, 65% greater than in 1998, increasing from 6% to 11% in Europe, and from 15% to 24% in America. During 1999, 53% of patients receiving ICDs for these indications were inpatients identified during hospitalization, 27% were outpatients referred specifically for MADIT/MUSTT indications, and 20% were identified by routine screening. Per the survey, in 1999 68% of responders were "somewhat (10-20%)" and 14% were "considerably (>20%)" more likely to implant ICDs for all indications.


CONCLUSIONS
Extrapolating the results of this survey to all initial ICD implants for 1999, we estimate that 8500 implants for MADIT/MUSTT criteria took place in 1999, with the overall number of such implants substantially increased over the previous year, irrespective of geographic location, and influenced significantly by the publication of MUSTT. However, screening and implant practices between centers continue to vary over a broad spectrum. It will be interesting to observe whether similar patterns will follow with MADIT II.
Nisam
Seah
S
Guidant Europe NV/SA, Park Lane, Culliganlaan 2B, 1831 Diegem, Belgium. snisam@guidant.com
Henry
Sophie
S
Wilber
David J
DJ
D002986:Clinical Trials as Topic; D017147:Defibrillators, Implantable / Q000706:statistics & numerical data*; D005060:Europe; D006801:Humans; D015337:Multicenter Studies as Topic; D009203:Myocardial Infarction / Q000628:therapy*; D009656:North America; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D018487:Ventricular Dysfunction, Left / Q000628:therapy