Title of Trial
CASH (Randomized Comparison of Antiarrhythmic Drug Therapy With Implantable Defibrillators in Patients Resuscitated From Cardiac Arrest: The Cardiac Arrest Study Hamburg)

Date and Citation of Primary Publication(s) or References
Circulation. 2000;102:748-754.

Purpose of the Trial
Survivors of cardiac arrest, due to ventricular arrhythmias, are at a high risk for another sudden cardiac death. This study was designed to evaluate impact of two different treatment modalities, the ICD and antiarrhythmic drugs (amiodarone, metoprolol, propafenone), on overall survival rates in this patient population. The propafenone group was discontinued early (3/92) due to an increased mortality rate.

Study Categories
ICD, Ventricular arrhythmias/Sudden Death

Patient Population
Survivors of a cardiac arrest secondary to ventricular arrhythmias.

Inclusion Criteria
History of a cardiac arrest secondary to documented sustained ventricular arrhythmias.

Exclusion Criteria
Cardiac arrest occurring within 72 hours of an acute myocardial infarction, cardiac surgery, electrolyte abnormalities, or a proarrhythmic drug effect

Study Design
Prospective, multicenter, randomized study

Primary Endpoint
All-cause mortality

Secondary Endpoints
Sudden death; recurrence of cardiac arrest

Baseline Characteristics
Number of patients: 288 pts: 99 pts (ICD); 92 pts (amiodarone); 97 pts (metoprolol)
Mean age: years ICD group=58 ± 11 years; amiodarone group=59 ± 10 years; metoprolol=56 ± 11 years
Gender: % female; =21%; 18%; 21% (ICD, amiodarone, metoprolol groups, respectively)
Other characteristics: LVEF: 0.46 (ICD); 0.44 (amiodarone); 0.47 (metoprolol); CAD: 73% (ICD); 77%(amiodarone); 70% (metoprolol); NYHA Class II : 59% (ICD); 57% (amiodarone); 55% (metoprolol)

Years Follow-up: 57 ± 34 months

Results
All-cause mortality rates were 36.4% in the ICD group and 44.4% in the amiodarone/metoprolol group (1-sided p=0.081). Between the amiodarone and metoprolol groups, there was no significant difference in the all-cause mortality rate (43.5% vs 45.4% respectively; p=0.845). The sudden death rate was 13% for ICD group and 33% for the amiodarone/metoprolol group (1-sided p=0.005). There was no significant difference in the sudden death rate between the amiodarone and the metoprolol groups (29.5% vs 35.1%, respectively; p=0.467).

Conclusion
A 23% reduction (statistically nonsignificant) in the all-cause mortality rate was seen in the ICD group compared with the amiodarone/metoprolol group. There is a 61% reduction in the sudden death rate in the ICD group compared with the amiodarone/metoprolol group. No significant difference in the all-cause mortality rate or the sudden death rate was found between the amiodarone and the metoprolol group.

Trial Status: Completed

Review written by Sung Chun, M.D.