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.
Piccini
Jonathan P
JP
Duke Clinical Research Institute and the Duke University School of Medicine, Durham, North Carolina 27705, USA. jonathan.piccini@duke.edu
Al-Khatib
Sana M
SM
Myers
Evan R
ER
Anstrom
Kevin J
KJ
Buxton
Alfred E
AE
Peterson
Eric D
ED
Sanders
Gillian D
GD
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