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Background: The prophylactic use of the implantable cardioverter-defibrillator (ICD) has been shown to decrease mortality in patients with depressed left ventricular ejection function (LVEF ≤ 35%). Whether this beneficial effect persists in the presence of chronic obstructive pulmonary disease (COPD) is not established., Methods: We examined the medical records of patients with LVEF ≤ 35% and COPD and analyzed the data for total mortality by ICD status. Each ICD patient was matched by age and LVEF with two to three controls. The Charlson comorbidity index and propensity score were used to correct for differences in comorbidities and biases between the study groups., Results: A total of 100 patients (30 with ICD and 70 controls) were included in this analysis. The overall cohort had a mean age of 65 ± 15 years with a predominance of white (79%) men (72%). Compared to controls, ICD patients had a wider QRS complex (150 ± 32 ms vs 110 ± 24 ms, P < 0.001) and were less likely to be on steroid therapy (10% vs 31%, P = 0.018) for COPD. At a mean follow-up of 3.1 ± 2.7 years, ICD patient had a lower total mortality (2-year survival of 88% in the ICD group vs 59% in the controls, P = 0.016). The lower death rate in the ICD group persisted after correcting for differences in the QRS interval and for discrepancies race and in the incidence of steroid use in a multivariate Cox regression model (odds ratio = 0.300, adjusted P = 0.016)., Conclusion: Patients with COPD extract survival benefit from the ICD and should therefore not be denied this life-saving therapy., (©2010, The Authors. Journal compilation ©2010 Wiley Periodicals, Inc.)

Background: Cardiac arrest (CA) concurrent with acute myocardial infarction (AMI) claims the life of many patients with coronary artery disease (CAD). In this study, we investigated the predictors of CA during AMI., Method: Patients admitted with CA concurrent with AMI (n = 31) were matched by age, gender, race, and left ventricular ejection fraction (LVEF) to patients with AMI but no CA (n = 70). All patients underwent coronary angiography. Binary logistic regression was used to identify independent predictors of CA during AMI., Results: A total of 101 patients (age = 61 +/- 13 years, men 76%, Caucasians 98%, LVEF 33 +/- 12%) admitted to the University of Pittsburgh Medical Center with AMI were included in this analysis. Patients with CA concurrent with the AMI were more likely to have proximal rather than distal coronary artery culprit lesions (odds ratio (OR) = 7.2, P = 0.019). Other predictors of CA in the context of AMI included negative family history of CAD (OR = 8.0, P = 0.026) and absence of sinus rhythm upon hospital admission (OR = 5.1, P = 0.030)., Conclusion: Proximity of culprit coronary lesion and presence of rhythm other than sinus rhythm at hospital admission are two strong predictors of CA in the context of AMI. The implication is that the mechanism of CA is primarily that of a large area of myocardial ischemia leading to lethal ventricular arrhythmia. Other predispositions such as genetic make-up cannot be ruled out.

Background: Most defibrillator (ICD) trials have excluded patients on hemodialysis (HD). It is therefore not known whether the ICD, when indicated, confers the same mortality benefit to HD and non-HD patients., Method: HD patients implanted with an ICD from July 2001 to June 2004 were matched by age, gender, left ventricular ejection fraction (LVEF), and class of heart failure to non-HD ICD recipients., Results: Forty-six (16 on HD) patients (age = 65 +/- 15 yrs, LVEF = 30 +/- 14%, 44% in class III-IV HF) were followed for a mean of 30 +/- 16 months (range, 4-61 months) after ICD implantation. During this period, 12/16 HD versus 9/30 non-HD patients died (P = 0.006). The two-year mortality rates were 54% and 29% in the HD and non-HD groups, respectively (P = 0.01). After correcting for age, gender, race, LVEF, class of HF, and ICD indication (primary vs. secondary prevention) in a Cox regression model, HD remained a significant predictor of the time to death (HR = 2.9, adjusted P = 0.023)., Conclusion: Despite having an ICD, HD patients have approximately a three-fold increase in total mortality and may therefore not extract the same survival benefits from the ICD as their non-HD counterparts. If duplicated in larger randomized trials, these results may demonstrate the futility of implanting defibrillators in HD patients.