Predicted benefit of an implantable cardioverter-defibrillator: The MADIT-ICD benefit score

Arwa Younis, Jeffrey J. Goldberger, Valentina Kutyifa, Wojciech Zareba, Bronislava Polonsky, Helmut Klein, Mehmet K. Aktas, David Huang, James Daubert, Mark Estes, David Cannom, Scott McNitt, Kenneth Stein, Ilan Goldenberg

Research output: Contribution to journalArticlepeer-review


Aims: The benefit of prophylactic implantable cardioverter-defibrillator (ICD) is not uniform due to differences in the risk of life-threatening ventricular tachycardia (VT)/ventricular fibrillation (VF) and non-arrhythmic mortality. We aimed to develop an ICD benefit prediction score that integrates the competing risks. Methods and results: The study population comprised all 4531 patients enrolled in the MADIT trials. Best-subsets Fine and Gray regression analysis was used to develop prognostic models for VT (≥200 b.p.m.)/VF vs. non-arrhythmic mortality (defined as death without prior sustained VT/VF). Eight predictors of VT/VF (male, age < 75 years, prior non-sustained VT, heart rate > 75 b.p.m., systolic blood pressure < 140 mmHg, ejection fraction ≤ 25%, myocardial infarction, and atrialarrhythmia) and 7 predictors of non-arrhythmic mortality (age ≥ 75 years, diabetes mellitus, body mass index < 23 kg/m2, ejection fraction ≤ 25%, New York Heart Association ≥II, ICD vs. cardiac resynchronization therapy with defibrillator, and atrial arrhythmia) were identified. The two scores were combined to create three MADIT-ICD benefit groups. In the highest benefit group, the 3-year predicted risk of VT/VF was three-fold higher than the risk of non-arrhythmic mortality (20% vs. 7%, P < 0.001). In the intermediate benefit group, the difference in the corresponding predicted risks was attenuated (15% vs. 9%, P < 0.01). In the lowest benefit group, the 3-year predicted risk of VT/VF was similar to the risk of non-arrhythmic mortality (11% vs. 12%, P = 0.41). A personalized ICD benefit score was developed based on the distribution of the two competing risks scores in the study population ( Internal and external validation confirmed model stability. Conclusions: We propose the novel MADIT-ICD benefit score that predicts the likelihood of prophylactic ICD benefit through personalized assessment of the risk of VT/VF weighed against the risk of non-arrhythmic mortality.

Original languageEnglish
Pages (from-to)1676-1684
Number of pages9
JournalEuropean Heart Journal
Issue number17
StatePublished - 1 May 2021
Externally publishedYes


  • ICD benefit
  • Implantable cardioverter-defibrillator
  • Non-arrhythmic mortality
  • Primary prevention
  • Risk score
  • Sudden cardiac death
  • Ventricular tachyarrhythmia
  • Ventricular tachycardia


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