Optimal timing of implantable cardioverter-defibrillator implantation after myocardial infarction: a decision analysis.
BACKGROUND
The optimal timing of implantable cardioverter defibrillator (ICD) placement for the primary prevention of sudden cardiac death after myocardial infarction (MI) remains unknown.


RESULTS
We developed a Markov model to investigate the optimal timing of ICD implantation after MI (no ICD, ICD at 60 days, 6 months, and 1 year) in patients who meet current guidelines. Estimates of arrhythmic death (baseline risk 6%, range 1-20% per year), nonarrhythmic death, and ICD efficacy were based upon MADIT-II and other contemporary post-MI clinical trials. We used both deterministic and stochastic modeling processes in our analysis. After 10 years follow-up, the baseline probability of survival was higher in those treated with ICD implantation versus not (42% vs 30%, P < 0.001). Survival was highest with ICD implantation at 60 days versus 6 months versus 1 year: 42.4%, 42.3%, and 42.0% (P = 0.0028). ICD implantation at 60 days provided a mean incremental survival of 0.28 months and 0.84 months per patient (compared with implantation at 6 months and 1 year). In sensitivity analyses, patients' competing risk for nonarrhythmic death was the primary determinant of benefit from ICD implantation. Overall, ICD implantation at 60 days resulted in the greatest life expectancy over a wide range of plausible nonarrhythmic and arrhythmic death rates.


CONCLUSIONS
The benefits of early ICD implantation are modest when compared with delayed implantation at 6 months/1 year. Our results suggest that making sure a patient receives an ICD, when appropriate, may be more important than the timing of the implantation procedure.
Duke Clinical Research Institute and the Duke University School of Medicine, Durham, North Carolina 27705, USA. jonathan.piccini@duke.edu
Jonathan P
JP
Piccini
Sana M
SM
Al-Khatib
Evan R
ER
Myers
Kevin J
KJ
Anstrom
Alfred E
AE
Buxton
Eric D
ED
Peterson
Gillian D
GD
Sanders
D001145:Arrhythmias, Cardiac / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D003198:Computer Simulation; D016757:Death, Sudden, Cardiac / Q000209:etiology / Q000517:prevention & control*; D003661:Decision Support Techniques; D017147:Defibrillators, Implantable; D004554:Electric Countershock / Q000295:instrumentation*; D006801:Humans; D008390:Markov Chains; D009010:Monte Carlo Method; D009203:Myocardial Infarction / Q000150:complications / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D015203:Reproducibility of Results; D018570:Risk Assessment; D012307:Risk Factors; D013269:Stochastic Processes; D013997:Time Factors