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Background/Objective <p>Heart failuret (HF)is a growing global health burden. In Saskatchewan, ~ 5% of residents live with HF with a reduced ejection fraction (HFrEF) and guideline-directed medical therapy (GDMT) remains underutilized. Landmark trials supporting primary prevention implantable cardioverter defibrillators (ICDs) predate modern GDMT, raising questions about the residual benefit of ICDs in optimized patients.</p> Methods <p>We retrospectively analyzed 590 patients who underwent primary prevention ICD implantation between January 2005 and December 2023. Baseline demographics, Charlson Comorbidity Index (CCI), and GDMT prescriptions were recorded at implantation. The primary endpoint was all-cause mortality. Kaplan–Meier survival, Cox regression (adjusted for age, sex, ejection fraction, CCI, GDMT count, antiarrhythmic use), and restricted cubic spline modeling were used.</p> Results <p>Among ICD only patients (413;70%), GDMT use at implantation was: beta blockers 96%,&#xa0;renin angiotensin inhibitors 92%,&#xa0;mineralocorticoid receptor antagonists 54%, and sodium glucose co-transporter inhibitors (SGLT2i) 7%. Mortality rates decreased with increasing GDMT count: 100% for 0 drugs, 52–53% for 1–2, 49% for 3, and 6% for 4. Cox models showed significant survival benefits for each additional GDMT agent prescribed compared to 0: HR 0.10–0.23 (<i>p</i>-values 0.007–0.03). Spline regression confirmed a non-linear association. SGLT2i used conferred independent survival benefit (<i>p</i> = 0.0002). CCI, age, implantation year, and antiarrhythmic use also significantly influenced mortality.</p> Conclusion <p>In this study, higher GDMT exposure at time of ICD implantation was associated with improved survival. Although causality cannot be inferred from this retrospective design, our findings support hypothesis that optimized GDMT may reduce residual mortality in patients with HFrEF, raising questions about contemporary ICD benefit.</p>

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Association of Mortality and use of Guideline-Directed Medical Therapy Post-Primary Prevention Defibrillator Implantation

  • 期刊论文

  • 发表日期：

    2025年8月13日

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  • Rishi Thakkar,
  • Munawar Peer,
  • Anand Patel,
  • Taranveer Toor,
  • Mohamed Saber Omar,
  • Maaraj Mahmood,
  • Muzzafar Haque,
  • Jyotpal Singh,
  • Omar Sultan

摘要

Background/Objective

Heart failuret (HF)is a growing global health burden. In Saskatchewan, ~ 5% of residents live with HF with a reduced ejection fraction (HFrEF) and guideline-directed medical therapy (GDMT) remains underutilized. Landmark trials supporting primary prevention implantable cardioverter defibrillators (ICDs) predate modern GDMT, raising questions about the residual benefit of ICDs in optimized patients.

Methods

We retrospectively analyzed 590 patients who underwent primary prevention ICD implantation between January 2005 and December 2023. Baseline demographics, Charlson Comorbidity Index (CCI), and GDMT prescriptions were recorded at implantation. The primary endpoint was all-cause mortality. Kaplan–Meier survival, Cox regression (adjusted for age, sex, ejection fraction, CCI, GDMT count, antiarrhythmic use), and restricted cubic spline modeling were used.

Results

Among ICD only patients (413;70%), GDMT use at implantation was: beta blockers 96%, renin angiotensin inhibitors 92%, mineralocorticoid receptor antagonists 54%, and sodium glucose co-transporter inhibitors (SGLT2i) 7%. Mortality rates decreased with increasing GDMT count: 100% for 0 drugs, 52–53% for 1–2, 49% for 3, and 6% for 4. Cox models showed significant survival benefits for each additional GDMT agent prescribed compared to 0: HR 0.10–0.23 (p-values 0.007–0.03). Spline regression confirmed a non-linear association. SGLT2i used conferred independent survival benefit (p = 0.0002). CCI, age, implantation year, and antiarrhythmic use also significantly influenced mortality.

Conclusion

In this study, higher GDMT exposure at time of ICD implantation was associated with improved survival. Although causality cannot be inferred from this retrospective design, our findings support hypothesis that optimized GDMT may reduce residual mortality in patients with HFrEF, raising questions about contemporary ICD benefit.