Patients who are at high-risk of death may benefit from early implantable cardioverter-defibrillator (ICD) implantation after they have had primary percutaneous coronary intervention (PCI). Although the trial was halted prematurely due to a slow accrual rate, the early data warrant further research into this particular field.
The DAPA trial aimed to examine whether ICD implantation between 30 and 60 days after primary angioplasty for STEMI was able to offer a survival benefit in patients who are at high risk of death, which was defined as at least one of the following: primary ventricular fibrillation, left ventricular ejection fraction below 30%, Killip class 2 or higher, or thrombolysis in myocardial infarction flow less than 3 after primary PCI. Patients were randomised to prophylactic ICD implantation or optimal medical therapy. Primary endpoint of the study was all-cause mortality after at least 3 years of follow-up for each patient. The secondary endpoint was cardiac death. Although the trial was halted prematurely, a total of 266 patients were randomised. Median follow-up was 9 years. It was shown that ICD implantation significantly lowered the risk of all-cause and cardiac mortality, with all-cause mortality observed in 24.4% of patients in the ICD group versus 35.5% of patients in the control group (HR 0.58, 95% CI 0.37 to 0.91). Cardiac death occurred in 11.4% of patients in the ICD group and 18.5% in the control group (HR 0.52, 95% CI 0.28 to 0.99). There were no significant differences with regard to sudden cardiac death between groups. The researchers pointed out that it was clear to see that the all-cause mortality curves started to diverge before the first year and the beneficial effects of prophylactic ICD use were preserved throughout the follow-up of 9 years. It was concluded that these results – in conjunction with those from earlier trials – may contribute to the early selection of high-risk patients who will profit from an ICD after primary PCI for STEMI .
1. Haanschoten DM. DAPA – Long-term outcome of the Defibrillator After Primary Angioplasty Trial – Implantable Defibrillator Early After Primary Percutaneous Intervention for ST-Elevation Myocardial infarction. FP Number 6050. . ESC Congress 2019, 31 Aug-4 Sept, Paris, France.
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