Reducing unnecessary and inappropriate therapy in secondary prevention patients
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1 Reducing unnecessary and inappropriate therapy in secondary prevention patients Maurizio Gasparini, MD Chief of EP and Pacing Unit Humanitas Research Hospital, Rozzano-Milano Italy
2 Goals of Optimal ICD Programming! Ensure detection and effective therapy for life-threatening VT/VF.! " unnecessary shocks! "" inappropriate Rx for SVT.! "" inappropriate Rx for oversensing. Sorry! "" unecessary Rx for self-terminating VT.! Terminate VT/VF with ATP whenever possible.! Prevent proarrhythmia.
3 Are there specific features for secondary prevention patients? # SP pts : unique clinical characteristics with more arrhythmic profile # In the recent ICD era, implanted population moved from secondary indication to HF PP indication Very few studies on SP # Which strategies to " unncessary and inappropriate therapies in SP?
4 Possible strategies to " unnecessary and inappropriate therapies in SP 1. Choice of ICD 2. Choice of device programming
5 1. ICD : VVI versus DDD
6 No differences in inappropriate/appropriate shocks in DDD vs VVI ICD in secondary prevention
7 2. ICD : device programming * Included secondary prevention patients. Clinical Trials of Features to Minimize Shocks Rate Duration SVT vs. VT OS Rejection ATP Sensed Events Shock Faster Rate Longer Duration SVT-VT Discrimination Sensing Confirmation PREPARE (2008) X X (X) X RELEVANT (2009) X x X MADIT-RIT (2012) X X X X ADVANCE III (2013)* ATP X X X PROVIDE (2014) X X X X PAINFREE SST (2015)* X X X X X
8 (Heart Rhythm 2015;12: )
9
10 Extremely low incidence of inappropriate shocks 1.5%/yr 2.5%/yr # Absence of a control group in the general population! # Waiting for results in SP
11 Faste r Rate Longer Duration SVT-VT Discrimina tion Sensing Confirmat ion PREPARE (2008) X X (X) X RELEVANT (2009) X X X ATP Long detection proven to be effective in PP MADIT-RIT (2012) ADVANCE III (2013)* X X X X X X X PROVIDE (2014) X X X X PAINFREE SST (2015)* X X X X X Is long detection effective in SP too?
12
13 SP population is obviously more arrhythmic then HF
14 Results Time to 1 st therapy
15 Results Long detection in SP : " 25 % ALL therapy Long detection in SP : " 34 % SHOCKS
16
17 36% less shocks!! First time in the Secondary Prevention: # " overall therapies and shocks, # " APPROPRIATE and INAPPROPRIATE shocks
18 First time in the Secondary Prevention: " APPROPRIATE shocks in long detection In SP too a lot of SELF-TERMINATING TRUE VA!!! " " of APPROPRIATE but UNNECESSARY SHOCKS QOL $$
19 First time in the Secondary Prevention: " INAPPROPRIATE shocks in long detection In SP too a lot of SELF-TERMINATING SV ARRYTHMIAS!!! " " of INAPPROPRIATE SHOCKS QOL $$
20 Hypotetical problems long detection-related Sincopal episodes # Syncopal episodes rare, no difference between 2 arms
21 Definitively According to Programming and Testing Expert Consensus Statement (HRS/EHRA/APHRS/SOLAECE) Heart Rhythm 2015 in press Optimal Rate and Duration Longer Duration Primary Prevention 6-12 s or 30 intervals Class I Secondary Prevention 6-12 s or 30 intervals Class I Detection Rate bpm Class I < VT rate - 10 bpm*& < 200 bpm Class IIA *Or detection interval VT CL+ 40 ms For VT window programming: CONSIDER SLOWER CUT OFF RATES if concomitant antiarrhythmic drugs!
22 Definitively According to Programming and Testing Expert Consensus Statement (HRS/EHRA/APHRS/SOLAECE) Heart Rhythm 2015 in press Optimal Rate and Duration Longer Duration Primary Prevention 6-12 s or 30 intervals Class I Secondary Prevention 6-12 s or 30 intervals Class I Detection Rate bpm Class I < VT rate - 10 bpm*& < 200 bpm Class IIA *Or detection interval VT CL+ 40 ms SVT-VT Discrimination Algorithms Class I Program SVT-VT discrimination algorithms ON for rates up to 200 bpm, potentially up to 230 bpm, unless contraindicated.
23 Conclusions 1. Every effort should be made to unnecessary ICD therapies, especially shocks ( QOL and arrhytmogenic risk) 2. Long detection and high rate cut off are well known to reduce appropriate but UNNECESSARY and INAPPROPRIATE therapy in Primary Prevention (Relevant, MADIT RIT, PROVIDE, ADVANCE III ) 3. According to ADVANCE III results long detection programming allows dramatic UNNECESSARY and INAPPROPRIATE shock reduction in SP too 4. Long detection SHOULD BE FIRST- LINE CHOICE both in Primary and Secondary Prevention
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