Meta-analysis: Age and effectiveness of prophylactic implantable cardioverter-defibrillators

Background: Implantable cardioverter-defibrillators (ICDs) for the primary prevention of sudden cardiac death have been proven effective in several clinical trials. Purpose: To summarize evidence about the effectiveness of ICDs versus standard medical therapy for the primary prevention of sudden cardiac death in different age groups of patients with severe left ventricular dysfunction. Data Sources: MEDLINE, Embase, CENTRAL, BioMed Central, Cardiosource, ClinicalTrials.gov, and ISI Web of Science (January 1970 to April 2010) were searched with no language restrictions. Study Selection: Two independent reviewers screened titles and abstracts to identify randomized, controlled trials of prophylactic ICD versus medical therapy in patients with severe left ventricular dysfunction that provided data about mortality outcomes for different age groups. Data Extraction: Two independent reviewers assessed risk for bias of trials and extracted patient and study characteristics and hazard ratios (HRs) relevant to all-cause mortality. Data Synthesis: Five trials (MADIT-II, DEFINITE, DINAMIT, SCDHeFT, and IRIS) that enrolled 5783 patients (44% were elderly) were included. The primary analysis, which excluded the 2 trials enrolling patients early after acute myocardial infarction (DINAMIT and IRIS), found that prophylactic ICD therapy reduced mortality in younger patients (HR, 0.65 [95% Cl, 0.50 to 0.83]; P < 0.001). A smaller and statistically nonsignificant survival benefit was found in elderly patients (HR, 0.81 [Cl, 0.62 to 1.05]; P = 0.11). The inclusion of data from DINAMIT and IRIS did not change these results. Limitations: Four potentially eligible trials were not included in the meta-analysis because mortality data by age group were not available. Adjustment for differences in comorbid conditions and medical therapies among patients enrolled in the trials was not possible. Conclusion: Available data do not conclusively show that prophylactic ICD therapy improves survival in elderly patients with severe left ventricular dysfunction. Primary Funding Source: None. © 2010 American College of Physicians