Opinions on the Results of the VEST Trial
Dr. Caudle: So, could you briefly summarize for us the current role of wearable defibrillators?
Dr. Zipes: The wearable defibrillator is a substitute for an implanted device. It’s used in patients who have a transient risk in multiple situations. The vest study that was very capably done by Jeff Olgin was for patients after an acute myocardial infarction who had a reduced dejection fraction of 35% or less. And they demonstrated that there was a reduction in overall mortality but not in sudden death mortality, which was a disappointing outcome because that was their primary objective. But nevertheless, the vest, I think, is still appropriately used in transient risk situations and there are multiple.
One, as Jeff demonstrated in his study, is the month or 3 months after an acute myocardial infarction when we know patients are at risk for dying sudden death as well as non-sudden death. But there are at least two other situations. One is in a patient who has an ICD that’s become infected and has to be removed. And the infection has to be cleared before a new device is implanted. And I can see the vest used in that patient during that transient period when they’re receiving antibiotics that cure up the infection prior to another ICD implantation.
Another situation is a patient who is a potential transplant candidate. They are at risk for death and sudden death, and I could see a vest being used while waiting for a new heart. So, although the vest trial outcomes were not as positive as we might want, in no way would I toss the vest out the window.
I think it still has application in multiple situations, but one has to be very choosy and work this out with the patient to decide who should have the vest.
Dr. Caudle: Fair enough. You talked a little bit about this in your first answer, but if you could just reiterate what questions did the vest trial seek to answer?
Dr. Zipes: Well, it sought to answer whether the high mortality after acute myocardial infarction in patients with reduced cardiac function might be reduced by wearing the vest. And, as I said, they demonstrated a reduction in overall mortality, but not sudden death mortality. And the reality is these patients die post-infarct from multiple causes and not necessarily a ventricular tachyarrhythmia.
Dr. Caudle: And how do you feel the trial will impact clinical practice?
Dr. Zipes: I think it’ll make physicians think twice about who should receive the vest, but as I indicated, I think there are clear clinical situations where, in the judgment of the physician, the patient is at risk for sudden death generally from a ventricular tachyarrhythmia where the vest could and should be used.
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