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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThe Immediate Risk Stratification Improves Survival [IRIS] trial compared the safety and efficacy of the early insertion of an implantable cardiac defibrillator or medical treatment alone in 898 patients who were at high risk for sudden cardiac death after myocardial infarction.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology Clinical Trials\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EThe Immediate Risk Stratification Improves Survival (IRIS) trial compared the safety and efficacy of the early insertion of an implantable cardiac defibrillator (ICD) or medical treatment alone in 898 patients who were at high risk for sudden cardiac death (SCD) after myocardial infarction (MI). The primary analysis of the IRIS trial showed significantly fewer deaths due to SCD in the ICD group compared with medical therapy alone (27 vs 60 deaths; p=0.049). However, this was offset by an increase in non-SCD (68 vs 39 deaths; p=0.001), resulting in a neutral effect on total mortality after 72 months (HR, 1.04; p=0.76) [Steinbeck G et al. \u003Cem\u003ENew Engl J Med\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EGerhard Steinbeck, MD, University of Munich, Munich, Germany, presented results from an exploratory post hoc analysis of the IRIS trial, designed to elucidate predictors and mechanisms that contribute to the observed increase in non-SCD in the ICD group.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EIn the current analysis, investigators applied different statistical tools\u2014the kernel method for smoothed hazard curve estimation\u2014to examine daily mortality risk over time. They found that ICD use decreased the risk for SCD but only within the first 2 years following implantation. Conversely, ICD use was associated with a steady increase in the risk of non-SCD after implantation, particularly after 3 years of follow-up.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EIn a multivariate analysis, mortality risk patterns were consistent across 30 subgroups, with early ICD associated with decreased risk of SCD and increased risk of non-SCD in each subgroup, except for a small group of 91 patients with STEMI who did not undergo reperfusion (interaction p\u0026lt;0.001). Further prospective data are needed to better understand this observation in a small subgroup whose characteristics may differ from the overall cohort.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EIndependent of ICD use, five factors predicted total mortality: older age (HR, 1.49; p\u0026lt;0.001), left main or three-vessel disease (HR, 1.48; p=0.004), QRS \u2265120 ms (HR, 1.60; p=0.001), New York Heart Association class 3 or 4 heart failure (HR, 2.00; p\u0026lt;0.001), and ejection fraction \u0026lt;35% (HR, 2.18; p\u0026lt;0.001). Conversely, use of an angiotensin receptor-converting inhibitor or angiotensin receptor blocker (HR, 0.56; p=0.003) and administration of clopidogrel (HR, 0.64; p=0.001) are associated with lower mortality risk.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003ERight ventricular pacing was associated with increased total mortality (HR, 2.1; p\u0026lt;0.001) due to an elevated risk of non-SCD (HR, 3.8; p\u0026lt;0.001). Periods of appropriate or inappropriate shocks were associated with a particularly high risk of total mortality (HR, 4.7; p\u0026lt;0.001) due to increased non-SCD (HR, 9.9; p\u0026lt;0.001).\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003ECurrent guidelines for primary prevention exclude ICD implantation in patients within the first 40 days after MI. However, this restriction excludes a vulnerable population, given that the SCD is significantly higher immediately post-MI, especially in patients with low left ventricular ejection fraction.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EDiscussant Christophe Leclercq, MD, Rennes University Hospital, Rennes, France, said that the new IRIS analysis did not answer the question of why ICD fails to reduce total mortality early after MI. As such, there is no evidence to support changes to the current guidelines for ICD implantation, he concluded.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2011 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/11\/10\/23.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmz01\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}