First, recurrent tachycardia less likely in women versus men with primary prevention ICD


disclosures: Saxena does not report any relevant financial disclosures. See the study for the relevant financial disclosures from all other authors. Sticherling reports that he has received personal benefits from Abbott, Biotronik, Boston Scientific and Medtronic.


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Women with HF who received an implantable cardioverter-defibrillator for primary prevention were less likely to experience first and recurrent life-threatening ventricular tachycardias compared with men, researchers reported.

“Previous studies of patients with an ICD have shown conflicting results regarding the association of sex with the incidence of appropriate device therapy, overall mortality and thus the benefit of prophylactic placement of ICDs in women with HF,” Shireen Saxena, BAMD candidate at the Clinical Cardiovascular Research Center at the University of Rochester Medical Center, New York, and colleagues wrote in JAMA network opened† “We wanted to evaluate the association between gender and the risk of first occurrence of sustained ventricular tachyarrhythmia, total ventricular tachyarrhythmia, and shock load during the follow-up period in an analysis of recurrent events and non-arrhythmic mortality in all patients with primary prevention ICD implantation. enrolled in the landmark Multicenter Automatic Defibrillator Implantation Trials (MADIT).”


ICD

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The MADIT trials

The MADIT studies evaluated the outcomes of patients with ischemic cardiomyopathy, left ventricular ejection fraction less than 35%, and ventricular tachycardia implanted with an ICD or defibrillator for cardiac resynchronization therapy compared to no implant.

as Healio previously reportedCRT in patients with HF and ventricular tachycardia was associated with lower rates of ventricular arrhythmia, sudden cardiac death and all-cause death over time compared to those without an ICD.

In the current analysis of the MADIT studies, researchers evaluated sex differences in the risk of mortality and ventricular tachycardia in 4,506 patients (mean age 64 years; 76% males). The primary endpoint was sustained ventricular tachycardia, defined as ICD-registered, treated, or monitored ventricular tachycardia of at least 170 beats per minute or ventricular fibrillation. Secondary endpoints were ventricular tachycardia of at least 200 beats per minute, appropriate ICD shocks, and appropriate anti-tachycardia pacing.

Within this cohort, both age and LVEF were comparable between males and females; however, women experienced less non-ischemic cardiomyopathy (42% vs. 74%).

Researchers noted that women had a lower 3-year risk of sustained ventricular tachycardia (16% vs. 26%), rapid ventricular tachycardia (9% vs. 17%) and appropriate ICD shocks (7% vs. 15%) in comparison with men (p for all < .001).

Women had an approximately 40% lower risk for all endpoints (p for all < 0.001), including the primary endpoint (HR for first event = 0.6; 95% CI, 0.5-0.73; p < .001; HR for recurring event = 0.49; 95% CI, 0.43-0.55; p <.001), according to the study.

Saxena and colleagues reported that these findings were consistent in subgroup analysis and were more pronounced in women with non-ischemic cardiomyopathy than in men (HR for non-ischemic = 0.5; 95% CI 0.38-0.66; p < .001; HR for ischemic = 0.73; 95% CI, 0.56-0.95; p = .02; p for female gender interaction and cardiomyopathy = .03).

“To our knowledge, this is the first study to investigate gender differences not only in the first occurrence of ventricular tachyarrhythmia or the first appropriate ICD therapy, but also in the overall burden of each of these endpoints in patients with primary prevention- ICD implantation,” the researchers wrote. “More specifically, our findings showed that women have about half the risk of recurrent ventricular tachyarrhythmias, or recurrent appropriate ICD shocks, compared to men, which again was more pronounced in non-ischemic cardiomyopathy than in ischemic cardiomyopathy.”

Importance of gender-specific risk stratification

In a related editorial, Christian Sticherling, MDDeputy Chief Physician and Chief of Electrophysiology of the Department of Cardiology, University Hospital of Basel, University of Basel, Switzerland, discussed how these findings highlight the importance of gender-specific risk stratification.

“How can the presented results be helpful in day-to-day decision making? It is unlikely that the specificity and negative predictive value of a single risk parameter … will be sufficient to replace left ventricular ejection fraction as a risk marker in primary prevention. Composite risk scores such as the MADIT-ICD benefit score or the DERIVATE score are more likely to be of benefit,” Sticherling wrote. “The work of Saxena et al underlines once again that there are important differences in cardiovascular outcomes between men and women and that the underrepresentation of women in randomized controlled trials is an issue to be reckoned with.”

Reference:

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