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July 17, 2003 — There seems to be no end to the "good news" apropos the use of lipid-lowering assay (LLT), and a substudy from the Antiarrhythmic Versus Implantable Defibrillators (AVID) balloon now suggests that LLT may additionally accept antiarrhythmic benefits. [1] In patients with atherosclerotic affection ache (ASHD) advised for ventricular tachycardia/ventricular fibrillation (VT/VF) with implantable cardioverter defibrillators (ICDs), the use of statins and added lipid-lowering agents bargain the anticipation of VT/VF ceremony by 40%. LLT was additionally associated with cogent reductions in both cardiac bloodshed and all-cause afterlife in a beyond accomplice of patients advised with either ICDs or antiarrhythmic biologic therapy.
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Many apropos still abide apropos the mechanisms by which LLT was bent and assigned in AVID, nonetheless, the allegation announce that LLT may accept a able assurance contour in patients with acutely depressed myocardial action and a cardinal of comorbidities.
AVID was a prospective, randomized balloon that compared the use of antiarrhythmic drugs (sotolol or amiodarone) with ICD assay as a assay action for patients who survived life-threatening abiding VT/VF. The substudy assay was bound to AVID patients with ASHD who survived >= 1 ages afterwards randomization and who accustomed either constant and aboriginal LLT (ie, aural 6 months of follow-up) or no LLT. Investigators bent VT/VF-free adaptation by comparing the outcomes of LLT with non-LLT patients advised with ICD therapy. In addition, the access of the attendance or absence of LLT on cardiac-related afterlife and all-cause bloodshed was adjourned in all ASHD patients advised with either antiarrhythmics or ICD therapy.
LLT was assigned at the acumen of the primary affliction physician, and the authors appear that its use was recorded at acquittal and at aftereffect visits as "yes" or "no."
Detailed medical histories were taken from a sample of 237 of the absolute 1016 AVID patients, 26% of whom were reportedly on a lipid-lowering dieting (HMG-CoA reductase inhibitors, 79%; fibric acerbic derivatives, 19%; and acerbity acerbic resins, 3%). Lipid levels were not abstinent during the advance of the trial.
Significant accord acclaimed amid time to VT/VF ceremony and use of LLT
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A absolute of 362 patients accustomed ICDs during the AVID trial; of these, 279 patients were not advised with LLT and 83 patients accustomed aboriginal or connected LLT. In general, ICD patients who accustomed LLT were adolescent white males who were additionally added acceptable to accept abiding VT and beneath acceptable to accept VF than patients in the ICD accumulation not advised with LLT.
Univariate assay showed a trend advertence that LLT bigger VT/VF-event chargeless survival. Afterwards adjusting for added variables, however, there was a cogent accord amid time to VT/VF ceremony and use of LLT; use of LLT was associated with a 40% bargain accident of VT/VF ceremony (Table).
Univariate and multivariate analyses articulation LLT with cogent adaptation benefit
The all-embracing substudy accumulation consisted of 713 patients; 564 patients did not accept LLT and 149 patients were on LLT. In accession to actuality of hardly adolescent age, patients on LLT had a greater history of myocardial infarction and hypertension and were added acceptable to be absolved on angiotensin-converting agitator inhibitor therapy, digitalis, nitrate therapy, or aspirin/antiplatelet assay than were non-LLT patients. Non-LLT patients were beneath acceptable than LLT patients to accept undergone above-mentioned revascularization.
Both univariate and multivariate assay showed that the use of LLT was decidedly associated with lower ante of cardiac-related and all-cause deaths. LLT was associated with a 39% abridgement in accident of cardiac-related afterlife and a 36% abridgement in the accident of all-cause bloodshed (Table).
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ICD-10 Coding of Coronary Atherosclerosis of Unspecified Type of ... | ashd icd 10[/caption]
* P ethics announce account of LLT over no LLT
CI indicates aplomb interval; LLT, lipid-lowering therapy; RRR, about accident reduction; VF, ventricular fibrillation; VT, ventricular tachycardia
As acclaimed by advance columnist L. Brent Mitchell, MD, Foothills Hospital/University of Calgary (Calgary, Alberta, Canada), the adaptation account associated with the use of LLT was greater in patients already agreeable to VT/VF, compared with the adaptation account about appear in added analytic trials that evaluated patients with ASHD after VT/VF predisposition. "These observations abutment the achievability that absolute or aberrant antiarrhythmic furnishings of LLT contributed to a greater and beforehand account in patients with life-threatening VT/VF," the authors said.
In an accompanying editorial, Kelley P. Anderson, MD, Marshfield Clinic (Marshfield, Wisconsin) accustomed the "intriguing possibility" that LLT ability abate the accident of ventricular arrhythmias, but he acclaimed that there are a cardinal of affidavit to alternate afore jumping on the lipid-lowering bandwagon.
In accession to the actuality that the allegation were based on a posthoc nonrandomized design, there are still several uncertainties apropos the LLT regimens used, including the nonstandardized way in which they were assigned and the actuality that lipid levels were not measured, which makes the aftereffect of the LLT itself difficult to determine. Moreover, Dr. Anderson acicular out that any agitation about the allowances of LLT may be arguable because "application of accepted guidelines for LLT [already] authorization assay of best if not all patients with IHD agnate to those enrolled in the [overall] AVID study."
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Official Coding Guidelines ICD-10-CM and PCS - ppt download | ashd icd 10[/caption]
According to Dr. Anderson, added assay efforts should be adherent to free the mechanism(s) amenable for the abeyant antiarrhythmic furnishings of LLT, accurately the role of ischemia. He declared that pinpointing the apparatus amenable is "crucial" and added that "if LLT possesses an antiarrhythmic aftereffect absolute of ischemia, it ability account patients with nonischemic arrhythmia mechanisms."
Although the after-effects should be advised preliminary, Anderson believes that the substudy has served a bifold purpose. "[It] has not alone aloft the akin of acquaintance of this important abeyant account of LLT but additionally has provided important advance that LLT is safe in this citizenry of patients with acutely depressed myocardial action and abundant comorbid conditions," he said.
Mitchell LB, Powell JL, Gillis AM, et al. Are lipid-lowering drugs additionally antiarrhythmic drugs? An assay of the Antiarrhythmics Versus Implantable Defibrillators (AVID) trial. J Am Coll Cardiol. 2003;42:81-87.
Anderson KP. Lipid-lowering assay for blockage of ventricular tachyarrhythmias. J Am Coll Cardiol. 2003;42:88-92.
By Peggy PeckReviewer: Albert A. Del Negro, MD
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