The long-term survival and the risks and benefits of implantable cardioverter defibrillators in patients with hypertrophic cardiomyopathy
- Constantinos O'Mahony1,
- Pier D Lambiase1,
- Giovanni Quarta1,
- Montserrat Cardona1,
- Margherita Calcagnino1,
- Konstantinos Tsovolas1,
- Shereen Al-Shaikh1,
- Shafiqur M Rahman2,
- Samer Arnous1,
- Sue Jones3,
- William McKenna1,
- Perry Elliott1
- 1Inherited Cardiac Diseases Unit, The Heart Hospital, University College London, London, UK
- 2Department of Statistical Sciences, University College London, London, UK
- 3St George's Hospital, London, UK
- Correspondence to Dr Perry Elliott, The Heart Hospital, 16-18 Westmoreland Street, London, W1G 8PH, UK;
Contributors Dr O'Mahony designed the study, collected and interpreted the data, carried out the statistical analysis and wrote the manuscript. Dr Lambiase was involved in study design, data collection and interpretation and wrote the manuscript. Drs Quarta, Cardona, Calcagnino, Al-Shaikh, Tsovolas, Jones and Arnous collected and interpreted the data, as well as contributed to the writing of the manuscript. Mr Rahman carried out statistical analysis and contributed to the manuscript. Dr Elliott was involved in the design of the study, interpretation of data and writing of the manuscript. Prof McKenna was involved in the drafting of the manuscript and revising it critically for important intellectual content.
- Accepted 7 June 2011
- Published Online First 13 July 2011
Objective Implantable cardioverter defibrillators (ICDs) are routinely used to prevent sudden cardiac death (SCD) in selected hypertrophic cardiomyopathy (HCM) patients, but the determinants of device-related complications, therapies and long-term cardiovascular mortality in ICD recipients are not known.
Design Retrospective observational cohort study.
Setting Single-centre tertiary referral cardiomyopathy clinic.
Patients 334 consecutively evaluated HCM patients (median age 40 years, 62% male, 92% primary prevention) at risk of SCD treated with ICD. Thirty-six patients (11%) received concurrent cardiac resynchronisation therapy for heart failure symptoms.
Results During the 1286 patient-years of follow-up, cardiovascular mortality (including transplantation) occurred in 22 (7%) patients (1.7%/year) and was associated with New York Heart Association (NYHA) class III/IV (adjusted HR=9.38, 95% CI 3.31 to 26.55, p≤0.001), percentage fractional shortening (HR=0.92, 95% CI 0.87 to 0.96, p=0.001) and implantation for secondary prevention (HR=0.07, 95% CI 0.01 to 0.86, p=0.04). There were no SCD. Twenty-eight (8%) patients received appropriate shocks (2.3%/year), which were predicted by baseline fractional shortening (HR=0.96, 95% CI 0.92 to 0.99, p=0.04). Fifty-five (16%) patients received inappropriate shocks (4.6%/year). Sixty (18%) patients experienced implant-related complications (5.1%/year), including two deaths. Adverse ICD-related events (inappropriate shocks and/or implant complications) were seen in 101 (30%) patients (8.6%/year). Patients with cardiac resynchronisation therapy were more likely to develop implant complications than those with single-chamber ICDs (HR=4.39, 95% CI 1.44 to 13.35, p=0.009) and had a higher 5-year cardiovascular mortality than did the rest of the cohort (21% vs 6%, p<0.001).
Conclusions HCM patients with an ICD have a significant cardiovascular mortality and are exposed to frequent inappropriate shocks and implant complications. These data suggest that new strategies are required to improve patient selection for ICDs and to prevent disease progression in those that receive a device.
- Implantable cardioverter defibrillators
- hypertrophic cardiomyopathy
- sudden cardiac death
- ventricular arrhythmias
- implant complications
- implantable cardioverter defibrillator (ICD)
- ventricular fibrillation
- ventricular tachycardia
- cardiomyopathy hypertrophic
See Editorial, p 97
Funding This research was supported by grants from the Spanish Society of Cardiology (to Dr Cardona), European Society of Cardiology (to Dr Calcagnino and Dr Quarta) and Hellenic Society of Cardiology (to Dr Tsovolas). This work was undertaken at The Heart Hospital (University College London Hospitals NHS trust)/University College London, which received a proportion of funding from the Department of Health's National Institute for Health Research (NIHR) London Biomedical Research Centres funding scheme.
Competing interests Dr Lambiase received support from St Jude, and Dr Elliott received fees from Medtronic. All other authors have no potential conflicts of interest to declare.
Ethics approval Ethics approval not required under NHS research governance arrangements.
Provenance and peer review Not commissioned; externally peer reviewed.