Duke Clinical Research Institute and the Duke University School of Medicine, Durham, North Carolina 27705, USA.
J Cardiovasc Electrophysiol. 2010 Jul;21(7):791-8. doi: 10.1111/j.1540-8167.2009.01696.x. Epub 2010 Feb 1.
The optimal timing of implantable cardioverter defibrillator (ICD) placement for the primary prevention of sudden cardiac death after myocardial infarction (MI) remains unknown.
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.
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.
心肌梗死后（MI）应用植入式心脏复律除颤器（ICD）进行心源性猝死的一级预防的最佳时机仍不清楚。
我们开发了一个马尔可夫模型，以调查符合当前指南的 MI 患者（无 ICD、ICD 植入后 60 天、6 个月和 1 年）后 ICD 植入的最佳时机。心律失常性死亡（基线风险 6%，每年 1-20%）、非心律失常性死亡和 ICD 疗效的估计值基于 MADIT-II 和其他当代 MI 后临床试验。我们在分析中同时使用了确定性和随机建模过程。10 年随访后，与未接受 ICD 植入治疗的患者相比，接受 ICD 植入治疗的患者生存概率更高（42% vs 30%，P<0.001）。ICD 植入 60 天的生存率最高，其次是 6 个月和 1 年：42.4%、42.3%和 42.0%（P=0.0028）。与 6 个月和 1 年相比，ICD 植入 60 天可为每位患者提供 0.28 个月和 0.84 个月的平均增量生存。在敏感性分析中，患者非心律失常性死亡的竞争风险是从 ICD 植入中获益的主要决定因素。总体而言，在广泛的非心律失常性和心律失常性死亡率范围内，ICD 植入 60 天可带来最长的预期寿命。
与 6 个月/1 年的延迟植入相比，早期 ICD 植入的获益有限。我们的结果表明，在适当的情况下确保患者获得 ICD 可能比植入手术的时机更为重要。
