New scientific documents from EHRA Management of patients with defibrillator shocks

Transcription

1 New scientific documents from EHRA Management of patients with defibrillator shocks Frieder Braunschweig MD PhD FESC Karolinska University Hospital Stockholm, Sweden

2 Evolution of ICD therapy Worldwide ICD implants (patients # per year) First Human Implant FDA Approval Dual- Chamber ICDs Transvenous Leads Biphasic Waveform MADIT AVID CASH CIDS CRT-D MADIT-II MUSTT SCD HeFT COMPANION MADIT-CRT

3 ICD shocks, a complex clinical issue Iatrogenic condition Caused by implanted device Occurs with or w/o arrhythmia Symptoms with a broad range of severity Different medical conditions may be involved Causes patient distress and anxiety Causes physician anxiety Frequent clinical issue

4 How common? (%) Shocks (total) appropriate inappropriate Annual shock rate ca 10% (appr.), 7.5% (inappr) AVID MADIT II DEFINITE SCD-HeFT COMPANION PREPARE n=492 n=719 n=227 n=811 n=594 n=700 24/12M 22M 29M 45M 16M 12M Secondary Primary Primary Primary Primary Primary ICM + DCM ICM DCM ICM + DCM ICM + DCM ICM + DCM ICD ICD ICD ICD (single lead) CRT-D ICD + CRT-D

5 Who gets involved? Devicespecialist EP ICD-nurse - Pacemaker Family practitioner technician Patient with CRT ICD Patient shock(s) HF General nurse/ cardiologist coordinator Internist Emergency Imaging medicine specialist Ambulance personal

6 Prognosis after ICD shock (s) SCD-HeFT (ICD group analysis) n=811 (269 pts received shocks: 128 only appr, 87 only inappr, 54 both) Adjusted for baseline prognostic factors Death due to progressive HF: 42.9% Poole JE and al N Engl J Med 2008;359:

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8 Document structure

9 Acute setting Patients experiencing one or more ICD shocks: Due to potential severity of symptoms and the possible clinical instability, we recommend that patients be evaluated by a clinical expert in due course

10 Acute setting: out of hospital chamber Single shock or 2 shocks delivered in a short sequence Multiple shocks (delivered within minutes to hours) Persisting severe symptoms? (e.g. shortness of breath, rapid palpitations, confusion, significant anxiety or distress) NO YES Contact the ICD clinic within the next working day Immediate medical evaluation Emergency Dept. or ICD clinic

11 Acute setting: emergency dept/ambulance Cardiac arrest: Routine CPR Tachycardia with haemodynamic compromise: External DC shock (ap) iv amiodarone and /or beta-blockers Tachycardia with stable haemodynamics: Drugs ICD re-programming? Delivery of ATP? Repetitive ICD shocks w/o tachycardia or tachycardia that is haemodynamically well tolerated: Magnet!! ECG: Continuous monitoring, 12-lead ECG Contact with ICD clinic: Clear algorithm in place

12 Acute setting: assessment of stress Psychological reactions should be assessed! Shock Acute stress reaction Chronic anxiety Posttraumatic stress Depression Imbalance in autonomic tone May lower arrhythmia threshold

13 Acute setting: assessment of stress Easy things to do: - Ask for perception / interpretation of the shock - Ask for feelings of anxiety, helplessness or panic - Ask for sources of support (family, friendship, medical system) In traumatized patients: - Benzodiazepines - Consultation of a mental health expert

14 Electrical storm management (I) Definition: 3 or more distinct VT/VF episodes within 24 h Reversible cause? Correct drug side effects Electrolyte disturbances Myocardial ischaemia Drugs: iv amiodarone (or sotalol) Class I anti-arrhythmic drugs only on exception Lidocaine may be beneficial (ischaemia) Cave: increased cycle length of the arrhythmia (amiodarone)

15 Electrical storm management (II) Polymorphic VT Iv magnesium sulfate, potassium Overdrive pacing Isoproterenol (long QT syndrome) Betablockers, revascularization (ischaemia) Catheter ablation Other measures General anesthesia Mechanical circulatory support

16 General measures Evaluation of underlying heart disease Myocardial ischaemia Angiography? Revascularization? Catheter ablation? Heart failure Disease progression? Therapy optimization (β-blocker) Optimize device programming (RV-, BiV-pacing) Check device diagnostics AV-junctional ablation (AF)

17 General measures Drug therapy for shock prevention Beta-blockers Amiodarone Sotalol Class IA or IC in selected cases Upstream therapy ACE-I Statins Aldosterone blockers Driving Treatment termination

18 Device programming Minimizing unnecessary shocks Detection zones Anti-tachycardia pacing (ATP) Time to detection and therapy Minimizing inappropriate shocks: Algorithms for discrimination of atrial and ventricular arrhythmia Inappropriate shocks due to signal misinterpretation. Device related causes of arrhythmia

19 VT ablation Catheter ablation of VT is recommended: 1. Symptomatic sustained monomorphic VT with frequent ICD therapies despite AAD therapy or when AADs are not tolerated or not desired. 2. Control of recurrent symptomatic or incessant monomorphic VT not suppressible by AAD therapy 3. Bundle branch re-entrant or interfascicular VTs 4. Recurrent polymorphic VT and VF refractory to AAD therapy when there is a suspected trigger that can be targeted by ablation. VT catheter ablation is contra-indicated 1. In the presence of a mobile ventricular thrombus (epicardial ablation may be considered) 2. For VT due to transient, reversible causes, such as acute ischaemia, hyperkalemia, or drug induced torsade de pointes.

20 Continuum of coping and distress C O N T I N U U M Coping Distress Feelings, thoughts and behaviours Optimism Active coping Faith in doctors Depressive coping Distraction /Denial Catastrophizing Resignation Reassurance Successful adjustment Realistic fear Adjustment disorder Shock phobia Moderate depression Generalized anxiety PTSD / personality change Severe / recurrent depression ICD as guardian angel ICD doesn t bother me ICD may fail Uncertain if ICD keeps me safe Avoid activities that might trigger shocks Avoid any activities, lose interest / confidence in life, permanent worry Permanent threat and arousal Wanting to be dead Modified from Sears and Conti, Heart. 2002;87:488-93

21 Psychological distress Psychological symptoms and maladaptive coping should be identified early, preferably even before ICD implantation. ICD clinic Trustful physician-patient relationship Easy access to support and advice Merely listening to patient concerns may reduce their worries!! (Even a few minutes more can make a difference ) Providing information about disease, the ICD and how it works Complete self-report forms Family support Support groups

22 Psychological distress: treatment Data on treatment of distress in ICD patients are limited Maintain or resume normal life as soon as possible to prevent phobic avoidance behaviour Telephone counselling Cognitive behavioural therapy Relaxation Exercise Selective serotonin receptor inhibitors (SSRIs) Mental health expert should be involved

23 Summary I The ICD patient with shock has become a frequent picture in cardiology and emergency medicine. Comprehensive knowledge about the management of ICD patients with shock(s) is required throughout the chain of care to provide optimal treatment.

24 Summary II ICD shocks may occur in the context of severe cardiovascular conditions, are associated with an increased risk for subsequent events and may cause acute and chronic distress. Therefore it is important that patients who received one or multiple shocks are thoroughly assessed and to take all possible measures to prevent unnecessary or inappropriate shock delivery.

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