Vest Prevention of Early Sudden Death Trial - VEST
Contribution To Literature:
A WCD does not reduce SCD, but reduces all-cause mortality up to 90 days among patients with moderate to severe LV dysfunction immediately post-MI compared with controls.
The goal of the trial was to compare the efficacy of a wearable cardioverter-defibrillator (WCD) in reducing sudden cardiac death (SCD) among post-myocardial infarction (MI) patients with left ventricular ejection fraction (LVEF) ≤35%.
Immediate post-MI patients with low EF were randomized in a 2:1 fashion to either WCD + optimal medical therapy (OMT) (n = 1,524) vs. OMT alone (n = 778).
- Total number screened: 13,774
- Total number of enrollees: 2,302
- Duration of follow-up: 90 days
- Mean patient age: 61 years
- Percentage female: 27%
- ≤7 days of hospital discharge for acute MI
- EF ≤35% assessed:
- ≥8 hours after MI
- ≥8 hours after percutaneous coronary intervention (PCI)
- ≥48 hours after coronary artery bypass grafting (CABG)
- Existing implantable cardioverter-defibrillator (ICD)
- Significant valve disease
- Unipolar pacing system
- Chronic hemodialysis
- Chest too small/large for WCD
- Discharge to skilled nursing facility for >7 days
- Prior MI 25%, prior CHF 18%
- Mean LVEF: 28.2%
- During index MI hospitalization, PCI: 84%, thrombolytics: 8%, CABG: 1%
- Cardiac arrest/ventricular fibrillation: 10%
- Cardiogenic shock: 10%
Other salient features/characteristics:
The primary outcome, SCD + ventricular tachyarrhythmia death, for WCD + control, was 1.6% vs. 2.4%, p = 0.18.
- Nonsudden death: 1.4% vs. 2.2%, p = 0.15, including stroke death: 0% vs. 0.5%, p = 0.01
- All-cause mortality: 3.1% vs. 4.9%, p = 0.04
- All-cause rehospitalization: 31% vs. 33%, p = 0.51
In the WCD group, hours/day WCD worn: 14.1; appropriate shocks: 1.4%, inappropriate shocks: 0.6%, aborted shocks: 4.6%.
The results of this trial indicate that a WCD does not reduce SCD up to 90 days among patients with moderate to severe LV dysfunction immediately post-MI compared with controls. However, there was a significant reduction in all-cause mortality with WCD use during this time frame. There was a fairly high rate of cross-over (~20%) and compliance with WCD use diminished with time. With the caveats of this being an open-label trial with a negative primary endpoint, it seems reasonable to consider WCD use among eligible patients based on the reduction observed in all-cause mortality in this trial.
It will be helpful to understand the cost-effectiveness of this strategy, as well as methods to risk-stratify the patients most likely to benefit from WCD use (e.g., patients presenting with cardiac arrest, severe LV dysfunction, nonsustained ventricular tachycardia in the hospital, etc.).
Olgin JE, Pletcher MJ, Vittinghoff E, et al., on behalf of the VEST Investigators. Wearable Cardioverter–Defibrillator After Myocardial Infarction. N Engl J Med 2018;379:1205-15.
Editorial: Field ME, Page RL. Another Shock for Sudden Death Prevention After Myocardial Infarction. N Engl J Med 2018;379:1274-5.
Presented by Dr. Jeffrey E. Olgin at the American College of Cardiology Annual Scientific Session (ACC 2018), Orlando, FL, March 10, 2018.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS
Keywords: ACC18, ACC Annual Scientific Session, Acute Coronary Syndrome, Arrhythmias, Cardiac, Coronary Artery Bypass, Cost-Benefit Analysis, Death, Sudden, Cardiac, Defibrillators, Heart Failure, Myocardial Infarction, Percutaneous Coronary Intervention, Secondary Prevention, Stroke, Stroke Volume
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