Time dependence of mortality risk and defibrillator benefit after myocardial infarction

Background - Prophylactic implantable defibrillators (ICDs) improve survival in patients with impaired ventricular function after myocardial infarction (MI), but it is uncertain whether mortality risk and survival benefit depend on the elapsed time from MI. Methods and Results - The Multicenter Automatic Defibrillator Implantation Trial II examined the impact of ICDs on survival in post-MI patients with ejection fractions less than or equal to 30%. In 1159 patients, mean time from most recent MI to enrollment was 81 +/- 78 months. Patients were randomized to an ICD ( n = 699) or conventional care ( n = 460) in a 3: 2 ratio. Mortality rates ( deaths per 100 person-years of follow-up) in both treatment groups were analyzed by time from MI divided into quartiles ( < 18, 18 to 59, 60 to 119, and ≥ 120 months). In conventional care patients, these rates increased as time from MI increased (7.8%, 8.4%, 11.6%, 14.0%; P = 0.03). Mortality rates in ICD patients were consistently lower in each quartile and showed minimal increase over time (7.2%, 4.9%, 8.2%, 9.0%; P = 0.19). Covariate-adjusted hazard ratios for risk of death associated with ICD therapy were 0.97 ( 95% CI, 0.51 to 1.81; P = 0.92) for recent MI ( < 18 months) and 0.55 ( 95% CI, 0.39 to 0.78; P = 0.001) for remote MI ( greater than or equal to 18 months). Conclusions - Mortality risk in patients with ejection fractions less than or equal to 30% increases as a function of time from MI. The survival benefit associated with ICDs appears to be greater for remote MI and remains substantial for up to greater than or equal to 15 years after MI.