Early EPS/ICD strategy in survivors of acute myocardial infarction with severe left ventricular dysfunction on optimal beta-blocker treatment.  The BEta-blocker STrategy plus ICD trial.
OBJECTIVE
This multicentre prospective randomised trial was undertaken to evaluate the usefulness of an electrophysiological study (EPS)-guided/implantable cardioverter defibrillator (ICD) strategy in patients at high risk of sudden death (SD) early after myocardial infarction (MI). Previous studies have shown the benefits of such a strategy only in high-risk patients late after MI.


RESULTS
We enrolled 143 survivors of acute MI (<1 month) with left ventricular ejection fraction < or = 35% and either frequent (> or =10/h) premature ventricular complexes (PVCs), or depressed heart rate variability (SDNN < 70 ms) or abnormal signal-averaged ECG, who were able to tolerate optimised beta-blocker therapy (68 +/- 40 mg/day of metoprolol). Of these, 138 were randomised, in a 2:3 ratio, to two therapeutic strategies: conventional (CONV) strategy (n = 59) or EPS-guided/ICD strategy (n = 79). The latter resulted in ICD implantation in 24 inducible patients and in CONV therapy in the remaining 55. During a mean follow-up of 540 +/- 378 days, 26 patients (19%) died: nine (6.5%) SD, nine (6.5%) non-SD, and four (3%) non-cardiac death; in four patients (3%) the cause of death was unknown. The actuarial overall mortality for the CONV and EPS-guided/ICD arms was 18% vs 14% after 1 year and 29.5% vs 20% after 2 years, respectively (P = 0.3 and 0.2).


CONCLUSIONS
Despite optimal therapy, mortality remains significant in high-risk patients following MI. Although there is a trend in favour of EPS-guided/ICD, our data are insufficient to demonstrate a survival benefit of this strategy early after MI.
Raviele
Antonio
A
Cardiology Division, Ospedale Umberto I, Via Circonvallazione, 50-30170 Mestre-Venezia, Italy.
Bongiorni
Maria Grazia
MG
Brignole
Michele
M
Cappato
Riccardo
R
Capucci
Alessandro
A
Gaita
Fiorenzo
F
Gulizia
Michele
M
Mangiameli
Salvatore
S
Montenero
Annibale Sandro
AS
Pedretti
Roberto F E
RF
Uriarte
Jorge A Salerno
JA
Sermasi
Sergio
S
Nisam
Seah
S
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000368:Aged; D016757:Death, Sudden, Cardiac / Q000517:prevention & control; D017147:Defibrillators, Implantable; D004562:Electrocardiography; D004594:Electrophysiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D011446:Prospective Studies; D018487:Ventricular Dysfunction, Left / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*
D000319:Adrenergic beta-Antagonists