• •MALIGNANT ARRHYTHMIAS / SUDDEN CARDIAC DEATH • •M. Kozák •Department of Medicine and Cardiology, University hospital Brno [USEMAP] • sudden unexpected death caused by loss of heart function (1 hour time window ) • • sudden collapse • no pulse • no breathing • loss of consciousness • •SCD [USEMAP] RBBB VT [USEMAP] LBBB VT [USEMAP] G:\EKGskripta\Tmp21.tif •FVT [USEMAP] E:\polyvticdj.bmp [USEMAP] •AVRT • • prevalence 3/1000 inhabitants C:\Dokumenty\My Pictures\reentry.tif C:\Dokumenty\My Pictures\reentry.tif •WPW sy [USEMAP] E:\wpw_type_Bj.bmp [USEMAP] •whole population •multirisk •coronary event •LVEF < 35 % •VT/VF •comb. • •SCD-HeFT • • • •AVID •CASH •MADIT •Number of events x 1000 •incidence % /year • •INCIDENCE / SCD TOTAL NUMBER •Myerburg et al., Circulation, 1998 [USEMAP] • •SCD - STATISTICS G:\Vanysek\vanysdefibhistory.jpg [USEMAP] • •SCD x AGE • incidence 1SCD/100.000 inhabitants < 35 (x 1/1000 u population > 35) • acute forms CAD 20-39 - 76% SCD Kuller et al. JAMA 1966,198:158 C:\Dokumenty\My Pictures\scdage.bmp •Kuisma et al, Resuscitation 1995, Steinberger et al Am J Cardiol 1996 [USEMAP] • •PARIS PROSPECTIVE STUDY • 7.079 man, age 43-52 years (1967-1972), follow-up 23 years C:\Dokumenty\My Pictures\parisstudy.bmp • • • • •Jouven X et al. Circulation. 1999;99:1978-1983 [USEMAP] •MUSTT • • • • • • • • • • • • •0.5 •0.6 •0.7 •0.8 •0.9 •1 •1 Year •2 Years •3 Years •4 Years •5 Years [USEMAP] • •MORTALITY – HISTORY x TODAY • • • • • • • •SCD 33,6% x 12,7% [USEMAP] •SCD 33,6% x 12,7% • •MORTALITY – HISTORY x TODAY [USEMAP] • • • [USEMAP] • •SCD/ PP • •ACEI (SOLVD - 23% NSS, V-HeFT - 31% NSS, CHFSTAT -52% NSS) • ACEI therapy – lower risk of SCD • more than 50% pts. treated ACEI can profit from SCD prophylaxis • • • • •amiodaron (CHFSTAT,CAMIAT, EMIAT) •Do not prolong survival with LV dysfunction •BB (CIBIS II, BEST, MERIT-HF) • downgrade risk of SCD • prolong survival of pts with CHF • • [USEMAP] •OPT + revascularization CADCHS) • •ICD / CRT ICD • •RFA • •Heart transplant • •Surgery of CHF (MVP, aneurysmectomy) • •SCD PREVENTION • • • • • [USEMAP] • •Profile of resuscitated patient •Cobb et al, Circulation, 1992 •Who? G:\Vanysek\vankprpraha.gif •50% •2001 •1996 [USEMAP] • •HISTORY • 1788 Ch. Kite •An Assay on the Recovery of the Apparently Dead G:\Vanysek\kite1defib.jpg [USEMAP] •Where? G:\VanII\vanaedakce.jpg •Becker et al. Circulation. 1998,97:2106-2109 • • airports • industrial zones • golf clubs • fitcenters • casinas •Incidence => 0.03 (30 places = 1 CA) •Atkins et al. Prehospital Disaster Med 1996, 11:47-49 [USEMAP] A:\Defík.jpg heart1.bmp 00029182 Macintosh HD ABA78158: • •ICD IN SECONDARY PREVENTION OF SCD •ČR -75/1mil G:\Vanysek\vanysbifvýboj.jpg [USEMAP] H:\Článek VL\Obrázky IEKG\obr22.bmp • •ICD IN SECONDARY PREVENTION OF SCD [USEMAP] •MI + NSVT + LV dysf. = 2 year mortality > 30% •MI + NSVT + LV dysf. + EPS + = 50% •1. Anderson. CIRC 1978 •2. Bigger. CIRC 1984 •3. Buxton. Am J C 1984 •4. Wilber CIRC 1990 • •Months •inducible/nonsupresible VT (Wilber et al) • •CAD + NSVT • •ICD - PRIMARY PREVENTION [USEMAP] For which patient? •A number of previous ICD studies* indicate patients are remarkably similar with respect to: –Age –Left Ventricular Ejection Fraction –Percentage with Coronary Artery Disease –NYHA classification • •Prophylactic patient is not different •*Sources: Moss, A, et al; N Engl J Med 1996; 335: 1933-40 •Buxton, A, et al; N Engl J Med 1999; 341: 1882-90 •AVID Investigators; N Engl J Med 1997; 337: 1576-83 [USEMAP] •MADIT • •ICD IN PRIMARY PREVENTION OF SCD [USEMAP] • •ICD - PRIMARY PREVENTION •Documented episodes of NSVT in CAD post MI patients and LVEF < 0.35, sustained VT inducible in EPS. nsvto [USEMAP] •MADIT II • •ICD IN PRIMARY PREVENTION OF SCD G:\Brno03\maditII.tif •Moss AJ et al, CEPR 2002, 6(4), 463-465 [USEMAP] •MADIT II • •ICD IN PRIMARY PREVENTION OF SCD G:\Brno03\maditIIpsk.tif •Moss AJ et al, CEPR 2002, 6(4), 463-465 • ICD group (N=742) 105 (14,2%) deaths • CONV therapy (N=490) 97 (19,8%) • 31% reduction of deaths in ICD group • 63% reduction of mortality - QRS > 120 ms [USEMAP] • 4.12.5. •CAD post MI, LV dysfunction, LVEF < 0.30, QRS > 120ms, NYHA II, 6 m post IM, standard pharmacotherapy (bb) C:\Dokumenty\My Pictures\icdlidi02.bmp C:\VSTASCAN\image\TMP14.BMP • •ICD IN PRIMARY PREVENTION OF SCD [USEMAP] • •ICD IN PRIMARY PREVENTION OF SCD - CZ • 2004 5,5% • 2005 7% • 2006 22,8% • 2007 34 % • 2008 39% • 2009 46% • •2010 – 2019 - 75% primary preventive implantation [USEMAP] • [USEMAP] mdticds1989_2000 • •COGNIS •TELIGEN • • •Objem (cm3) •32.5 •31.5 / 30.5* •Tloušťka (mm) •9.9 •9.9 •Hmotnost (g) •72.0 •71.0 • •ICD HARDWARE [USEMAP] C:\Dokumenty\blaf\M-03Heart faillure mgt.jpg [USEMAP] C:\Dokumenty\blaf\M-05CurrentTreatment.jpg [USEMAP] C:\presentations\ebelingvenogram1.tif U:\My documents on U\Heart faillure\Images\implant steps RAPIDO\OLay-9.jpg •CRT G:\bivICD02.JPG [USEMAP] • •CRT INDICATION • 4.10. HF, stand. Rx 6 months (NYHA II/ III 6 m, NYHA IV) • LVEF < 35%, QRS > 150 ms, 120-150ms, dyssynchrony C:\moje skripta\TMP13.TIF [USEMAP] • • • • •BIO • • • •MDT • • • • •SJM • • • BS • 2003 2004 2005 2006 2007 2008 2307gleich housecallplusremotefollowup_hr • carelink •Renewal/Inductive/Frontier •CareLink Network (’02) •Directo - CareLink Programmer & RemoteView •Home Monitoring (‘02) •Home Monitoring II •HouseCall •HouseCall Plus •HouseCall Plus •Frontier •CareLink Network • •UP TO DATE STATUS • E:\Info brožury\logo_lf_mu.gif [USEMAP] Cardiom+lade_links_9x15_RGB+al •Patient Device Cardio Messenger •BIOTRONIK Service Center •Implant with Home Monitoring Lexos_DR-T_10x8_RGB_LR+alpha •Cardio Report •Physician •Patient • •Home Monitoring • • • E:\Info brožury\logo_lf_mu.gif [USEMAP] •Anatomie nervus phrenicus • •ICD SOFTWARE [USEMAP] E:\obr seminář 07\Carto_KT_final.jpg E:\obr seminář 07\Carto_KT_Umapa_final.jpg •RFA VT [USEMAP] •FENOTYPE •GENOTYPE A:\sekvenace •Novotný, Vojtíšková, Semrád, et al. Cor Vasa 2000;42:260-2 • •PREVENTIVE PROGRAMMS • •LQTsy [USEMAP] •Prophylactic ICD patient is not different to the general ICD population • •NNT ratio is low and reduced in time • •ICD therapy is cost effective • •Prophylactic pts require a full featured device, just like any other pt • •CONCLUSION [USEMAP] • •CONCLUSION • No of PP ICD implantation is 75% • • Each fourth pt in CZ is implanted from secondary preventive reasons • The most frequent - combined indication PP ICD + CRT [USEMAP] It is now a scientifically proven fact that ICD therapy is the therapy of first choice for patients at high risk of life-threatening ventricular tachyarrhythmias. Summary of evidence-based medicine supporting this fact: •There are many large clinical series in patients resuscitated from VT/VF, and these cover a wide variety of cardiac disorders •The several large, randomized prospective trials (covered in this slide series) provide overwhelming evidence showing ICD superiority in terms of reduction in all-cause mortality, compared to “conventional” medical management. •A significant contribution to the accelerating acceptance of ICD therapy comes from the technological advances, which have reduced the morbidity and enhanced programming and diagnostics very similar to pacemaker therapy •Finally, the absence of any evidence from clinical trials supporting improved survival with antiarrhythmic drugs - with the significant exception of beta blockers - is another major reason in favor of ICD therapy. Antiarrhythmic drugs continue to serve an important adjunctive role in patients with VT/VF, but no longer as primary therapy. •Regarding costs, ICD therapy has also proven equally or more cost-effective than other already well-established medical interventions.