Aug 2026· Heart· pp. heartjnl-2026-327792· 0 citations· 24 references
Medicine
TL;DR
This is the first meta-analysis reviewing post-MI patients with LVEF 36-50 with a clinically relevant unmet need for patients who carry a substantial burden of SCD despite being outside current ICD eligibility criteria.
Abstract
Background
AND
Objectives
Implantable cardioverter defibrillator (ICD) therapy is indicated following a myocardial infarction (MI) to curtail the risk of sudden cardiac death (SCD) in patients who are classified as high-risk, defined by a left ventricular ejection fraction (LVEF) ≤35%. The understanding of risk in patients with ischaemic injury who do not meet these criteria is limited. This study aims to assess the burden of SCD in patients' post-MI with LVEF 36-50%.
Methods
Articles reporting mortality and SCD outcomes for participants with LVEF 36-50% post-MI without additional risk stratification or intervention were included. Medline, Embase and Cochrane databases were searched from index entries until the present. Data were synthesised using a random-effects model. Competing risk adjusted number needed to treat (NNT) for ICD implantation was calculated. This study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Results
7435 records were identified, five studies with 9345 patients were included. The pooled annual rate of SCD in patients with LVEF 36-50% post-MI was 1.74% (95% CI 1.02 to 2.95); a higher annual rate of 6.34% was observed for LVEF≤35% (p=0.03) while a lower yearly rate of 0.55% was observed for LVEF >50% (p=0.02). The proportion of mortality due to SCD was similar across all LVEF strata (p=0.79). Very high between-study heterogeneity was observed (I2=89.9% for SCD and I2=96.8% for all-cause mortality). During exploratory modelling, the primary prevention ICD NNT for patients with LVEF 36-50% was 19 when applying the MADIT-II ICD treatment effect (HR 0.33, 95% CI 0.20 to 0.53) and extrapolation to a 5-year device lifespan.
Conclusion
This is the first meta-analysis reviewing post-MI patients with LVEF 36-50%. These findings highlight a clinically relevant unmet need for patients who carry a substantial burden of SCD despite being outside current ICD eligibility criteria. Further study is needed to improve risk stratification within this population and determine whether suitable intervention is beneficial.
PROSPERO REGISTRATION NUMBER
CRD42024551830.
BACKGROUND AND AIM
Randomized trials conducted in the early 2000s established the survival benefit of primary prevention implantable cardioverter-defibrillator (ICD) therapy in patients with reduced left ventricular ejection fraction (LVEF) after myocardial infarction. However, management of myocardial infarction and heart failure has substantially evolved since that time. We investigated whether the estimated association between primary prevention ICD implantation in post-myocardial infarction patients with reduced LVEF and mortality reduction has changed over time.
METHODS
We analyzed individual participant data from 32,214 patients with LVEF ≤35% after myocardial infarction included in the PROFID pooled cohort, comprising 7,477 patients carrying a primary prevention ICD (ICD patients) and 24,737 patients without an ICD (non-ICD patients). The primary endpoint was all-cause mortality. Propensity scores were estimated using multivariable logistic regression including age, sex, LVEF, renal function, and diabetes, and overlap weighting was applied to balance treatment groups. Time period-specific analyses were performed across three prespecified time periods defined by inclusion year: 1995-2004, 2005-2014, and 2015-2020. Weighted cumulative mortality curves were generated for each time period. Temporal changes in the estimated association between ICD implantation and mortality reduction were assessed using a weighted Cox proportional hazards model.
RESULTS
A total of 12,097 deaths occurred during a mean follow-up of 43.7 months. The estimated association between ICD implantation and mortality changed significantly across time (P for interaction <0.001). In weighted time period-specific analyses, the estimated mortality reduction associated with ICD implantation progressively decreased over more recent periods. The hazard ratio for ICD versus non-ICD patients was 0.54 (95% CI 0.47-0.62; P<0.001) in 1995-2004, 0.67 (95% CI 0.62-0.72; P<0.001) in 2005-2014, and 0.89 (95% CI 0.73-1.07; P=0.221) in 2015-2020, with negligible separation of the weighted cumulative mortality curves in the most recent time period.
CONCLUSIONS
In this analysis including a large cohort of post-myocardial infarction patients with reduced LVEF, the estimated mortality reduction associated with primary prevention ICD implantation progressively decreased over time.
A. Sepehri Shamloo, T. Chiba, J. G. Tijssen et al.· European Heart Journal· 0 citations
The occurrence of NOAF was associated with increased in-hospital mortality, which was 2–3 times higher in patients with arrhythmia, and most NOAF prediction models developed specifically in STEMI cohorts undergoing PCI demonstrated higher discriminative ability.
R. L. Pak, B. I. Geltser, E. Kokarev et al.· Siberian Journal of Clinical...· 0 citations
Beta-blockers improve outcomes after myocardial infarction (MI) in patients with reduced left ventricular ejection fraction (LVEF), but their benefit in patients with preserved ejection fraction (pEF) or mildly reduced ejection fraction (mrEF) remains unclear in the era of modern reperfusion and optimized therapy. This study evaluates the long-term impact of beta-blockers in this population.
Following a systematic search of four databases, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) in post–myocardial infarction patients with LVEF ≥40%, comparing long-term beta-blocker therapy with usual care. Primary outcomes were all-cause mortality and recurrent MI; secondary outcomes included cardiovascular (CV) mortality, heart failure hospitalization (HFH), malignant ventricular arrhythmias, ischemic stroke, and unplanned coronary revascularization. Data were pooled using random-effects models.
Four multicenter RCTs (9892 patients in the beta-blocker group and 9934 in the control group) conducted between 2017 and 2024 were included, with a median follow-up of 3.5–3.7 years. Beta-blocker therapy was not associated with a significant reduction in all-cause mortality (hazard ratio [HR]: 0.98, confidence intervals [CI] 0.85–1.12) or recurrent MI (HR: 0.88, CI 0.74–1.05). No benefit was observed for secondary outcomes, including CV mortality, HFH, malignant arrhythmias, ischemic stroke, or unplanned revascularization. Heterogeneity was low to moderate, and study quality was moderate overall, with high certainty for primary outcomes.
In contemporary reperfusion-era populations with pEF or mrEF, long-term beta-blocker therapy after MI does not confer significant reductions in mortality or recurrent MI. These findings challenge the historical paradigm of universal post-MI beta-blockade and support a more selective, individualized approach guided by LVEF.
Emídio Mata, Bernardo Resende, A. M. Pinto et al.· Journal of Cardiac Critical...· 0 citations
Abstract Introduction Cardiovascular disease is a leading cause of death worldwide, of which coronary artery disease is the most common form. Sudden cardiac death (SCD) is a serious complication following acute myocardial infarction (MI), accounting for the highest percentage of all deaths in this population. Currently implantable cardioverter-defibrillators (ICDs) provide an acceptable method of primary prevention of SCD. However, the current literature is heterogeneous with regard to studies evaluating the benefits of ICDs for the primary prevention of SCD after MI, particularly relating to the timing of ICD implantation, risk stratification of patients for ICD implant selection and reporting non-rhythmic deaths after ICD implantation. Methods and analysis A meta-analysis will be performed to estimate the pooled effect size of randomised controlled trials (RCTs) examining the relationship between prophylactic transvenous ICD (TV-ICD) implantation and other medical therapies for primary prevention of SCD after MI. A comprehensive literature search and review will be performed using electronic medical databases including Scopus, Ovid MEDLINE, EMBASE (Ovid Platform), Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, ProQuest (Health and Medicine) and CINAHL (EBSCO) from January 1980 to June 2025. The literature search will be limited to peer-reviewed original studies carried out in human subjects and published in English. Type of study design will be limited to RCTs. The systematic review and meta-analysis will be developed according to the Joanna Briggs Institute Manual for Evidence Synthesis (2024 edition) and conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 guidelines. Data analysis will be performed according to a structured and predetermined analysis plan. The primary outcome of the study will be all-cause-mortality, for which Hazard Ratios (HRs) will be reported as a measure of effect with 95% CI. Based on data availability, subgroup analysis will be carried out. The effect sizes will be reported based on a random effects model. Expected study outcomes and dissemination This systematic review and meta-analysis will evaluate and provide primary evidence for the effectiveness of prophylactic implantation of TV-ICDs on all-cause mortality in patients who experienced MI, aiming for primary prevention of SCD after MI. The primary prevention of SCD after MI is an important goal to reduce community incidence of out-of-hospital cardiac arrests, improving patient survival rates and their quality of life after MI. Out-of-hospital cardiac arrests currently have a survival rate of less than 10% and could result in long-lasting neurological damage in those who survive. PROSPERO registration CRD42023456995.
A. Amarasekera, Anoja W. Gunaratne, J. Kovoor et al.· BMJ Open· 0 citations
Background: Heart failure (HF) is a global health burden with high mortality. Sudden cardiac death (SCD) remains a major complication, highlighting the need for accurate risk prediction. Methods: We conducted a systematic review and meta-analysis, guided by the Population, Intervention, Comparator, Outcome, Timing, and Setting framework, to identify risk factors for SCD in HF and assess prediction models. Searches across 8 databases yielded eligible studies. Data extraction, risk of bias assessment using the Prediction Model Risk of Bias Assessment Tool, and statistical analyses were performed. Results: Twelve studies met inclusion criteria, with 8 included in the meta-analysis. New York Heart Association classification and left ventricular ejection fraction emerged as the most robust predictors of SCD. Additional significant factors included age, sex, ischemic etiology, diabetes, heart rate, sodium, potassium, creatinine, estimated glomerular filtration rate, and hemoglobin. Considerable heterogeneity was observed among studies. Conclusion: New York Heart Association class and left ventricular ejection fraction are key predictors of SCD in HF, while demographic, etiological, and laboratory factors further refine risk assessment. Current models show limitations due to heterogeneity and lack of external validation. Future work should integrate refined predictors, treatment responses, and diverse populations to improve the accuracy and clinical utility of SCD risk stratification in HF.
Abstract Background Left ventricular thrombus (LVT) is a significant complication in ischemic cardiomyopathy (ICM). However, factors associated with LVT have mainly been reported in patients with recent myocardial infarction (MI), while data in chronic ICM remain limited. This study aimed to identify factors associated with CMR-detected LVT in patients with chronic ICM (left ventricular ejection fraction [LVEF] < 50% of ischemic etiology, >40 days post-MI), develop a CMR-based risk score, and evaluate the prognostic implications of LVT on major adverse cardiovascular events (MACE). Methods This study included 790 patients with ICM who underwent CMR at an academic hospital in Thailand between 2016 and 2023. Factors associated with LVT were identified using logistic regression analyses. A CMR-based risk score was developed and validated, with discriminative performance assessed by the area under the receiver operating characteristic curve (AUC-ROC). MACE, defined as a composite of cardiovascular death, ischemic stroke, transient ischemic attack, systemic embolism, nonfatal MI, or heart failure hospitalization, was also evaluated. Factors associated with MACE were assessed using Cox regression analysis. Results The mean age was 66.9 ± 11.3 years, and 75.3% were male. LVT was detected in 116 patients. Independent factors associated with LVT included apical aneurysm, apical late gadolinium enhancement (LGE), and the number of LGE segments. The CMR-LVT Score, incorporating these variables, demonstrated an AUC of 0.73 (95%CI, 0.68–0.77;p < 0.001) in the derivation cohort and 0.79 (95%CI, 0.69–0.90;p < 0.001) in the validation cohort. During a median follow-up of 3.2 years (IQR, 1.6–5.5), 150 MACE occurred. Baseline LVT was independently associated with MACE (adjusted HR 2.38, 95%CI 1.31–4.30;p = 0.004). Conclusions In patients with ICM undergoing CMR, apical aneurysm, apical LGE, and LGE extent were independently associated with LVT. The CMR-LVT Score demonstrated acceptable discriminative performance for identifying higher-risk patients who may benefit from more intensive follow-up. LVT was also independently associated with MACE.
Chayathorn Aramcharoen, P. Buraphat, Thidanan Wanitanantakun et al.· Annals medicus· 0 citations