|
The Multicenter Automatic Defibrillator Implantation Trial (MADIT)
evaluated the role of the Implantable Cardioverter Defibrillator (ICD) as prophylaxis in a high-risk coronary
population, with nonsustained ventricular tachycardia (NSVT), but without previous history of sustained
ventricular fibrillation or tachycardia (VT/VF). MADIT reported a 54% reduction (p=0.009) in all-cause mortality
for ICD therapy, compared with conventional therapy (75% amiodarone). However, some people have criticized
its design, patient selection, and use of beta-blockers.
The Multicenter UnSustained Tachycardia Trial (MUSTT) studied a nearly identical patient cohort, and reported
– four years after MADIT – a nearly identical 51% lower mortality (p = 0.001) for patients receiving ICD therapy,
compared to placebo or electrophysiologically-guided antiarrhythmic therapy. MUSTT was a much larger study
(704 randomized patients compared to 196 for MADIT) and essentially validates the MADIT outcome, and also
responds to the beta-blocker and other major concerns about MADIT. The two studies together, plus the other
recently completed ICD trials and pharmacological studies, make ICD the therapy of first choice for patients at
high risk of VT/VF.
CONCLUSIONS. The MADIT and MUSTT studies indicate that coronary patients – whether early or late following
infarction – are at high risk and need to be Holter monitored to document NSVT. Those with NSVT need to
undergo programmed ventricular stimulation, and if inducible, should be considered for ICD implantation.
|
