Wearable cardioverter-defibrillator in patients at risk of sudden cardiac death: consensus document from Kalarus et al. contradicts current guideline recommendations—Authors’ reply Free

We appreciate the response to the EHRA consensus document on arrhythmias in the setting of acute coronary syndrome.¹ The letter concerns the recommendation that a wearable cardioverter-defibrillator (WCD) is not indicated in post-myocardial infarction (MI) patients with reduced left ventricular ejection fraction. Our consensus document was written after publication of the VEST trial,² which is the only randomized controlled trial (RCT) on WCD, and the VEST trial was published after the current sudden cardiac death (SCD) guidelines.³ The VEST trial was a well-powered RCT investigating the benefit of WCD in post-MI patients with the primary endpoint arrhythmic death. The patients in the trial had ejection fraction below 35% and were randomized in a 2:1 ratio to WCD or standard care. Arrhythmic death occurred in 1.6% of patients in the WCD group and in 2.4% of the control patients (relative risk 0.67 with no statistical difference between the groups). Death from any cause was a secondary outcome and demonstrated a benefit in the WCD treated patients (relative risk 0.64, P = 0.04). These data were discussed thoroughly in the writing group of the consensus document group, and we felt that the current scientific evidence does not merit a general recommendation of WCD in post-acute myocardial infarction patients.

We certainly agree with Sebastian Reif that there is a need to identify the post-MI patients at risk of SCD before ICD implantation⁴, who would benefit from a WCD before a potential ICD should be implanted and encourage the scientific field to plan a RCT to lower the burden of SCD. Overall the need for better prediction and prevention of SCD in the general population is warranted.⁵ Based on the VEST trial, currently, we do not recommend WCD in post-MI patients with ejections fraction below 35%.

Conflict of interest: E.J-P., M.M. - consultant fees from Medtronic, Biotronik, Abbott and Boston Scientific; TP - none; G.A.D. speaker fees from Boehringer-Ingelheim, Bayer, Pfizer, Servier, Sanofi, Amgen; C.S.: Boston Scientific, Biotronik, Medtronic, Microport, Bayer; E.D.M. received consultant fees from Biotronik and Boston Scientific; J.H.S. received unrestricted research grants from Medtronic, speaker fees from Medtronic and in addition he is member of an advisory board in Medtronic. J.H.S. also has received unrestricted research grant from Gilead.

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