Do sudden cardiac death rates warrant earlier treatment following myocardial infarction? experience from the VALIANT Trial

Purpose: Patients with left ventricular ejection fraction (LVEF) ≤30% following myocardial infarction (MI) are at greater risk for sudden cardiac death (SCD). Current guidelines recommend implantable cardioverter defibrillator (ICD) placement in patients with EF ≤30% beyond 30 days post-MI. We determined the incidence and timing of SCD in a high-risk MI population. Methods: The VALsartan In Acute myocardial iNfarcTion (VALIANT) trial enrolled 14,703 patients with left ventricular systolic dysfunction (LVSD), heart failure (HF), or both following MI (median 4.9 days post-MI, mean age 64.8 years, 31% women, mean EF 35.3%). SCD was defined as unexpected out-of-hospital death by a central committee. Results: EF was recorded in 11,338 patients. A total of 925 patients experienced SCD during the study. Of these, 634 occurred in the first year and 131 occurred within 30 days. Among patients with EF ≤30% (n = 2468), 335 had SCD in year 1 with 74 occurring ≤30 days. Of 5830 patients with EF 30–40%, 213 had SCD in year 1 with 38 occurring ≤30 days. Of 3040 patients with EF >40%, only 84 had SCD in the first year (Figure). Conclusions: More than half of the patients who had SCD post-MI had an EF <30%. In patients meeting current LVEF criteria for ICD, 22% had sudden death within 30 days of MI, suggesting a role for earlier implantation of ICD after MI.[figure1]