Jean François Leclercq Department of Rythmology Private Hospital of Parly 2 - Le Chesnay F
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1 SECONDARY PREVENTION of Sudden Death: in which patients? Jean François Leclercq Department of Rythmology Private Hospital of Parly 2 - Le Chesnay F
2 Why an AID is effective? Because it stoppes a VT very quickly, almost always before its transformation into VF. before after Even better with ATP before Shock delivering
3 Class I: AID indications in France - Circulatory arrest by VF or VT, without acute or reversible cause proof level A - Spontaneous symptomatic sustained VT with heart disease impairing cardiac function proof level B - Nonsustained VT with old MI, LVEF<35% and VT/VF inducible proof level A JF Leclercq & S Lévy Arch Mal Cœur 2000;93:1227
4 AID indications in France Class II: Genetic disease with high risk of SD and no other efficient therapy proof level B Syncope without cause and VT/VF inducible proof level C Bad tolerated sustained VT in waiting list for heart transplant proof level C JF Leclercq & S Lévy Arch Mal Cœur 2000;93:1227
5 CONTROLLED STUDIES: Inclusion criteria: AVID Resuscitated VF (45% of cases) VT with syncope or bad tolerance and LVEF <40% 1,016 pts randomized 1/1 between AID and antiarythmics (amiodarone in 96% of cases) N Engl J Med 1997;337:1576
6 CONTROLLED STUDIES: AVID P< year survival: 75.4% (AID) vs 64.1% (amiodarone) i.e. a 31% decrease in mortality. N Engl J Med 1997;337:1576
7 CONTROLLED STUDIES: AVID Problem: more patients treated with betablockers in the AID group (42%) than in the amiodarone group (16.5%). However, the rate of appropriate shock delivered by AID is high: 64% during the 3- year F-U in the implanted group. The maximal benefit in survival was seen for LVEF between 20 and 34%.
8 CONTROLLED STUDIES: CASH Inclusion criteria: mainly resuscitated VF (84%) or syncopal VT (only 16%) by mobile care units. Randomization into 4 groups: AID Amiodarone Metoprolol Propafenone Kuck & al Circulation 2000;102:748
9 CONTROLLED STUDIES: CASH The group randomized to propafenone had a much higher mortality and this arm was stopped very early by the survey comitee. The 3 other arms were continued for a very long period of inclusion (beginning in 1987, results in 1999). Many of AID implanted by thoracotomy. Kuck & al Circulation 2000;102:748
10 CONTROLLED STUDIES: CASH 288 pts, 10% without underlying heart disease, mean LVEF 46% (high percentage of primary ischaemic VF). Mean F-U: 4.7 years. Efficacy of amiodarone and metoprolol was similar By comparison to the 2 groups amiodarone & metoprolol, AID decreases total mortality of 23% (p=0.08) and sudden death of 60% (p<0.01) Kuck & al Circulation 2000;102:748
11 CONTROLLED STUDIES: CIDS 659 pts with VF, syncopal or sustained VT, or syncope and inducible VT, randomized between AID and amio p= 0.14 Decrease in total Mortality: 20% (NS) in sudden death : 33% (NS). The trial was stopped early after the publication of AVID. Connolly & al Circulation 2000;101:1297
12 CONTROLLED STUDIES: CIDS A single center prolonged F-U up to 5.6 years: the difference became significant despite the small number of pts (120). Benefit from AID Is not linear: it Increases with time. Bokhari & al Circulation 2004;110:112
13 CONTROLLED STUDIES: CIDS Subgroup analysis - 50% p= Sheldon & al Circulation 2000;101: parameters predict mortality in the amiodarone group: LVEF, age, and NYHA class. In the AID group, a decrease in mortality is obvious in the 4th quartile of pts classified according to these criteria (50% reduction). Mortality in the 3 other quartiles is similar. Authors conclude that AID may be useful in pts with 2 of these factors: - Age >70 yrs - LVEF <35% - class NYHA III or IV
14 CONTROLLED STUDIES: AVID Subgroup analysis Retrospective analysis of the AVID study using the same subgroup as in CIDS: In pts with 2 or 3 risk factors (age>70yrs, LVEF <35%, class NYHA III-IV), the benefit of AID was significant (RR=0.57, p<.01), whereas it is less in those with no or 1 risk factor (RR=0.70, p=.07). However, all deaths prevented by AID occured in pts with LVEF< Exner & al Am Heart J 2001;141:99
15 CONTROLLED STUDIES: Meta-analysis of the 3 studies (AVID, CIDS & CASH) Obvious benefit only for pts with LVEF < 35% Connolly et al Eur Heart J 2000;21:2071
16 CONTROLLED STUDIES: VT substrate MUSTT 704 pts with CAD, LVEF<40%, NSVT and inducible VT/VF Final trt: Class-I 26%, Amiodarone 10%, Sotalol 9%, AID alone 46% Buxton & al N Engl J Med :1882
17 CONTROLLED STUDIES: Syncope and VT substrate P= 0.04 VT/VF inducibility in DCM 54 pts with DCM & syncope: better survival with AID. Inducibility did not predict the occurrence of spontaneous VT/VF (47% vs 40% at 1 yr) So DCM with syncope requires AID implant without EPS. Brilakis & al. PACE 2001;24:1623
18 AID: particular indications Pts with non-compacted cardiomyopathy? 12 pts implanted for secondary prevention (7 VF, 5 VT) After 33±24 months, a recurrence was observed in 1/3 of cases. Caliskan & al J Cardiovasc Electrophysiol 2011;22:898
19 Cardiac event free survival Particular indications of AID: LQTS 1.0 Risk of events on beta-blocker therapy LQT1 LQT2 LQT Follow up (years) Priori et al. JAMA 2004
20 Particular indications of AID: PCVT Risk of SD on b-blocker: 24 to 27% Leenhardt & al Circulation 1995;91:1512 Scheinman & al Am J Cardiol 1995;75:687
21 Risk of SD after sustained VT High in CAD or DCM, even if VT is well tolerated Leclercq et al Am Heart J 1991;121:1685 AVID substudy Raitt & al Circulation 2001;103:244
22 Risk of SD after sustained VT High risk on optimal treatment (b-blocker + amio) Risk significant even in pts with LVEF>0.30 Leclercq et al Am Heart J 1991;121:1685
23 Risk of SD after sustained VT However, low risk of SD in pts with normal LV Idiopathic VT ARVD DCM CAD Leclercq et al Am Heart J 1991;121:1685
24 Risk of SD after sustained VT VT ablation is a good alternative therapy for idiopathic VT (fascicular of infundibular) It has a place for ARVD In CAD or DCM, it is difficult (complex substrate)
25 Syncope and VT/VF induction: primary or secondary prevention? 50 pts with Syncope and VT/VF inducibility (66% had underlying heart disease) High incidence of shocks Fast VT/VF and LP predictive Link & al J Am Coll Cardiol 1997;29:370
26 Predictors of appropriate shocks 250 pts (92% for 2ary prevention); PROFIT study Multivariate analysis: LVEF<40%, QRS>150ms, permanent AF. Klein & al Europace 2006;8:618
27 Primary and Secondary prevention of SD by AID: is it different? 2,134 pts implanted (61% for primary and 39% for secondary prevention). After 3.4 ± 2.8 years, 20% died. The 5-year incidence of mortality was identical: 25% for primary prevention patients and 23% for secondary prevention patients. Secondary prevention patients had an increased risk for appropriate therapy (HR=1.7; p<.001). A comparable risk for inappropriate shocks was observed (HR=1.0; p= 0.9) Van Welsenes et al Europace 2011;13:389
28 Class-I indications of AID Clinical status Cardiac arrest by VF/VT after exclusion of any totally reversible cause Spontaneous sustained VT with underlying heart disease, whatever the tolerance Syncope of unknown cause and VT/VF induction at EPS LVEF<35% & NYHA II or III, more than 40 days after MI LVEF<35% & NYHA II or III, non-ischaemic DCM LVEF<30% & NYHA I, more than 40 days after MI NSVT, LVEF< 40% post-mi, and VT/VF induction at EPS Proof A B B A B A B ACC/AHA/HRS 2008 Guidelines Circulation 2008;117:2820 JACC 2008;51:2085
29 Class-II A indications of AID Clinical status Syncope of unknown cause and non-ischaemic DCM with LV dysfonction Spontaneous sustained VT without underlying heart disease LQTS and syncope or VT under b-blocker therapy CPVT and VT or syncope under b-blocker therapy Brugada syndrome and syncope or non-syncopal VT Patients at home waiting for heart transplantation HCM with 1 or more risk factor of SD ARVD with 1 or more risk factor of SD Proof C C B C C C C C ACC/AHA/HRS 2008 Guidelines Circulation 2008;117:2820 JACC 2008;51:2085
30 VF due to transient or correctable cause: AID not indicated? AVID registry (4,450 pts). «Transient» VT/VF in 278, caused mainly by ischemia. Survival egal or worse than in other pts. Wyse & al J Am Coll Cardiol 2001;38:1718
31 VF due to transient or correctable cause: AID not indicated? It depends probably of the cause: OK for proarrhythmic effect of drugs Other causes, especially ischaemia??? Wyse & al J Am Coll Cardiol 2001;38:1718
32 VF due to transient or correctable cause: AID not indicated? 38 pts with CAD and resuscitated VF, free of antiarrhythmic drugs before event. 22 during documented ischaemia (acute MI), 16 without pain or ECG changes. Only pts with ischaemic VF and without LP have good prognosis Leclercq & all Arch Mal Cœur 1994;87:57
33 Conclusions AID indications increased with time, of course for primary but also for secondary prevention. It could still increase. It is logical, because it seems preferable to stop a VT as soon as possible. VT ablation represents more a combined treatment than an alternative: implant first, but think after
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