Clinical trials of prophylactic implantable defibrillator therapy in patients with nonischemic cardiomyopathy: what have we learned and what can we expect from future trials?

Several randomized clinical trials have been designed to evaluate the usefulness of prophylactic implantable cardioverter defibrillator (ICD) therapy in patients with nonischemic cardiomyopathy. In 2 trials, CAT and AMIOVIRT, no survival benefit was reported for patients with dilated cardiomyopathy and prophylactic ICD therapy. The major limitation of both trials is the small sample size of 104 patients in CAT and 103 patients in AMIOVIRT. Another limitation of both trials is the lack of a run-in phase on optimized medical therapy. Since LV function may improve considerably on optimized medical therapy, LV function should be reevaluated 3 to 4 months after initiation of ACE inhibitors, ss-blockers and aldosterone antagonists before prophylactic ICD therapy is considered. Two additional trials, DEFINITE and SCD-HEFT, are still ongoing. Particularly SCD-HEFT will follow a sufficient number of patients with nonischemic cardiomyopathy to give a more definitive answer with regard to the clinical usefulness of prophylactic ICDs in patients with nonischemic cardiomyopathy. Recently, the Marburg Cardiomyopathy study (MACAS) was finished. The results of MACAS strongly suggest that reduced LV ejection fraction is the most important arrhythmia risk predictor in idiopathic dilated cardiomyopathy, whereas signal-averaged ECG, baroreflex sensitivity, heart rate variability and T wave alternans do not appear to be helpful for arrhythmia risk stratification. In addition, MACAS showed that total mortality in patients with idiopathic dilated cardiomyopathy and an ejection fraction <30% is only about 5% per year on optimized medical therapy after exclusion of patients with end stage heart failure and after exclusion of patients with sustained ventricular arrhythmias. Thus, any future study designed to demonstrate a mortality benefit by prophylactic ICD therapy with an 80% power in this patient population needs to enroll more than 1000 patients.