Εκθορηίζεις απινιδωηή και θνηηόηηηα: μέθοδοι μείωζης ηων θεραπειών απινίδωζης

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1 Εκθορηίζεις απινιδωηή και θνηηόηηηα: μέθοδοι μείωζης ηων θεραπειών απινίδωζης Εμμ. Μ. Κανοσπάκης Καρδιολογική Κλινική Πανεπιζηημίοσ Κρήηης

2 Lessons from large trials Conditioning Rhythm and Electrical Therapy Type Hazard of Death MADIT-II SCD-HeFT Appropriate + inappropriate shock 4.08 ( ) ( ) Appropriate shock only 3.36 ( ) 5.68 ( ) Inappropriate shock only 2.29( ) 1.98( ) Appropriate ATP but not shock 0.41( ) N/A (all shocks) Inappropriate ATP but not shock 0.73( ) N/A (all shocks) Patients with shocked episodes have higher mortality than patients with neither Poole J et al, N Engl J Med 2008;359: Daubert J et al, J Am Coll Cardiol 2008;51:

3 The dilemma The shock(s) induce myocardial trauma and dysfunction that increase mortality? or The VTA and shocks are a marker of patients at increased risk?

4 Myocyte destruction by shocks In addition to chronic fibrosis (F), acute necrosis is present when recent shocks were delivered. Epstein A et al, Circulation 1998;98:

5 Acute hemodynamic effects of VF shocks in humans LV pump function declines after VF shocks, inversely related to VF shock strength. Tokano T et al. J Cardiov Electrophys 1998;9:

6 VF shocks and cardiac biomarkers release Patients with a recent MI and a mean DFE 18 J seem to be prone to ctni rise. Hurst T et al. J Am Coll Cardiol 1999;34:

7 DINAMIT: who are at risk? No No ICD ICD group ICD group Reduction in arrhythmic deaths was offset by parallel increases in non-arrhythmic deaths ICD + shock group Increased risk of non-arrhythmic deaths was confined to patients who received appropriate shocks Dorian P et al. Circulation. 2010;122:

8 Survival rates by rhythm and therapy type 2135 pts from PainFREE Rx I, PainFREE Rx II, EMPIRIC, PREPARE Survival among pts treated only with ATP was identical to that in pts with no VT, whereas survival among pts who received shocks was significantly worse. Sweeney M et al, Heart Rhythm 2010;7:

9 Ο ανηίλογος

10 Appropriate vs. other shocks A cohort evaluation of 1,372 patients Inappropriate shocks or for induced VA were not associated with an increased risk of mortality or HF hospitalization An appropriate shock for VT/VF represented an increased risk of mortality and HF hospitalization Bhavnani SP et al, Heart Rhythm 2010;7:

11 Uncoupling arrhythmia type & therapy type risk 2135 pts from 4 trials: PainFREE Rx I, PainFREE Rx II, EMPIRIC, PREPARE BUT Delayed time to therapy-increased time spent to VT No increase in mortality with inappropriate shocks Sweeney M et al, Heart Rhythm 2010;7;

12 ALTITUDE study 28,000 pts with pp ICD, f-up 5 years, 3809 received shocks Patients receiving shocks for VT and AF/AFL had an increased mortality because these patients have a higher burden of underlying cardiac disease than do those without. it's likely the substrate or arrhythmias, and not the shocks themselves, that are killing people." Powell B HRS 2011,

13 Heart Rhythm 2012, in press

14 ICD shocks: ένα αναγκαίο κακό Painful Psychosocial consequences Battery life Burden to health care system Mortality?

15 Methods to reduce Inappropriate shocks Supraventricular arrhythmias with rapid ventricular conduction Oversensing T-wave oversensing, noise, double counting Unnecessary shocks Appropriate shocks that could have been avoided using other means of terminating VTA Non-sustained arrhythmias

16 How to avoid inappropriate shocks? SVT discriminators

17 How to avoid inappropriate shocks? Algorithms to avoid shocks due to noise or T-wave oversensing

18 How to avoid unnecessary shocks?

19 PainFREE_Rx trial FVT (>188bpm) is common in ICD patients. 89% of FVTs were terminated by ATP with a low incidence of acceleration and syncope. Wathen M et al Circulation 2001;104:

20 PainFREE_Rx II trial Compared with shocks, empirical ATP for FVT is highly effective resulting in a 71% relative reduction in the proportion of shocked episodes, is equally safe, and improves quality of life. Wathen M, et al Circulation 2004;110:

21 Burst or ramp? The PITAGORA ICD Trial Bursts had a significantly higher success rate than ramps (72% vs. 52%) for fast VTs, with a trend toward less acceleration (2.3% vs. 7.4%) Gulizia M, et al Circ Arrhythmia Electrophysiol 2009;2:

22 ATP during charging To prevent shock delay in case of ATP failure

23 Quick convert ATP before charging

24 Distribution of ATP success by median CL of spontaneous VT episodes Schoels W et al Heart Rhythm 2007;4:879-85

25 How to program the ICD? ATP switched ON in the VT together with the FVT zone Wilkoff B et al, J Am Coll Cardiol 2006;48:330 9

26 The EMPIRIC experience Nearly all EMPIRIC arm pts were enabled to treat tachycardias >150 bpm, in marked contrast to pts in tailored programming. Nearly all EMPIRIC arm patients had ATP on up to 250 bpm, in marked contrast to a small proportion of tailored arm patients Wilkoff B et al, J Am Coll Cardiol 2006;48:330 9

27 How to avoid unnecessary shocks? Antitachycardia pacing even for fast VT

28 What are the properties of a VTA? Sustained? Symptomatic? Timing of Rx?

29 Prolong detection duration PREPARE programming vs. controls* VT/VF for rates 182 bpm, NID: 30 of 40 intervals. ATP as the first therapy for regular rhythms 182 to 250 bpm SVT discriminators ON for rhythms 200 beats/min Significant reduction of ICD shocks the 1 st year (9 vs. 17%) The incidence of untreated VT and arrhythmic syncope was similar *MIRACLE-ICD & EMPIRIC (phys tail arm) Wilkoff B et al, J Am Coll Cardiol 2008;52:541 50

30 RELEVANT trial Gasparini M et al, Europ Heart J 2009;30:

31 ADVANCE III trial The first prospective randomized trial Schwab J et al, JCE 2009;20:663 6

32 MADIT-RIT the value of high cut-off rates and longer detection delays

33 How to avoid unnecessary shocks? Antitachycardia pacing even for fast VT Prolong detection time / intervals

34 Antiarrhythmic drugs Suppress VTA Slow VT termination by ATP Suppress SVT avoid inappropriate shocks Amiodarone plus β-blocker is more effective than sotalol for preventing shocks but has an increased risk of drug-related adverse effects OPTIC trial Connolly et al, JAMA 2006;295:

35 V-TACH Prophylactic VT ablation before ICD implantation seemed to prolong time to recurrence of VT in patients with stable VT, previous myocardial infarction, and reduced LVEF Kuck et al, Lancet 2010;375:31-40

36 Take home messages No clear winner in the controversy: ICD shocks & mortality Beyond the reassurance of the patient that he or she is lucky wearing ICD, use the validated ICD technology to minimize or replace shocks to terminate VTA

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