Pattarapong Makarawate MD, FHRS Assistant Professor. Division Of Cardiology Faculty of Medicine, Khon Kaen University
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1 Pattarapong Makarawate MD, FHRS Assistant Professor. Division Of Cardiology Faculty of Medicine, Khon Kaen University
2 1. Important and impact of ICD in primary prevention 2. Risk stratification for ICD therapy 3. Appropriate use of ICD primary prevention therapy 4. Rarely appropriate co morbid for ICD primary prevention therapy ICD indication
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6 Incidence of SCD in unselected adult population- only 2 per 1000 p/yr Currently : LVEF- 1⁰ factor for ICD LVEF- most consistent & powerful predictor of all-cause & cardiac mortality in IHD & DCM Others : SAECG, ventricular arrhythmia, T alternans, autonomic function, EP study
7 Prolonged QRS duration (usually 120 ms) is independent predictors of SCD Prolonged QTc (> 500 ms in long-qt synd) and familial short- QTc ( 300 ms) indicate an risk of SCD
8 IHD - inducibility of sustained VT during EPS well-established marker of SCD Limitations- Relatively high number of false negative Non-inducibility of VT may not imply low risk DCM-value of EPS- controversial
9 LVEF- most consistent & powerful predictor of all-cause & cardiac mortality in IHD & DCMP NYHA- Despite subjective, imprecise- simple bedside potent risk-stratification tool Degree of NYHA class- Not linearly related NYHA classes II & III - much more likely arrhythmia than class IV Pts with NYHA IV - mortality from progressive pump failure Primary prevention ICD trials have excluded pts with NYHA IV
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13 I IIa IIb III I IIa IIb III NYHA Class III/IV I IIa IIb III ICD therapy is recommended for primary prevention of SCD to reduce total mortality in selected patients with nonischemic DCM or ischemic heart disease at least 40 days post-mi with LVEF of 35% or less, and NYHA class II or III symptoms on chronic GDMT, who have reasonable expectation of meaningful survival for more than 1 year. CRT is indicated for patients who have LVEF of 35% or less, sinus rhythm, left bundle-branch block (LBBB) with a QRS duration of 150 ms or greater, and NYHA class II, III, or ambulatory IV symptoms on GDMT. NYHA Class II
14 I IIa IIb III ICD therapy is recommended for primary prevention of SCD to reduce total mortality in selected patients at least 40 days post-mi with LVEF less than or equal to 30%, and NYHA class I symptoms while receiving GDMT, who have reasonable expectation of meaningful survival for more than 1 year. I IIa IIb III CRT can be useful for patients who have LVEF of 35% or less, sinus rhythm, a non-lbbb pattern with a QRS duration of 150 ms or greater, and NYHA class III/ambulatory class IV symptoms on GDMT.
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20 Original Article Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure Lars Køber, M.D., D.M.Sc., Jens J. Thune, M.D., Ph.D., Jens C. Nielsen, M.D., D.M.Sc., Jens Haarbo, M.D., D.M.Sc., Lars Videbæk, M.D., Ph.D., Eva Korup, M.D., Ph.D., Gunnar Jensen, M.D., Ph.D., Per Hildebrandt, M.D., D.M.Sc., Flemming H. Steffensen, M.D., Niels E. Bruun, M.D., D.M.Sc., Hans Eiskjær, M.D., D.M.Sc., Axel Brandes, M.D., Anna M. Thøgersen, M.D., Ph.D., Finn Gustafsson, M.D., D.M.Sc., Kenneth Egstrup, M.D., D.M.Sc., Regitze Videbæk, M.D., Christian Hassager, M.D., D.M.Sc., Jesper H. Svendsen, M.D., D.M.Sc., Dan E. Høfsten, M.D., Ph.D., Christian Torp-Pedersen, M.D., D.M.Sc., Steen Pehrson, M.D., D.M.Sc., for the DANISH Investigators N Engl J Med Volume 375(13): September 29, 2016
21 DANISH : Study Overview In a randomized trial, more than 1100 patients with nonischemic heart failure (left ventricular ejection fraction 35%) were assigned either to receive or not to receive an ICD. At a median of 67.6 months, there was no significant difference in mortality between the two groups.
22 Time-to-Event Curves for Death from Any Cause, Cardiovascular Death, and Sudden Cardiac Death. Køber L et al. N Engl J Med 2016;375:
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29 In syncope patients - incidence of SCD 45%, V/S incidence 12% in pts with no history of syncope (p< )
30 Developed in Collaboration with the American College of Emergency Physicians and Society for Academic Emergency Medicine Endorsed by the Pediatric and Congenital Electrophysiology Society American College of Cardiology Foundation, American Heart Association, and the Heart Rhythm Society
31 Brugada Syndrome COR LOE Recommendations IIa IIb III: No Benefit Inheritable Arrhythmic Conditions B-NR B-NR B-NR ICD implantation is reasonable in patients with Brugada ECG pattern and syncope of suspected arrhythmic etiology. Invasive EPS may be considered in patients with Brugada ECG pattern and syncope of suspected arrhythmic etiology. ICD implantation is not recommended in patients with Brugada ECG pattern and reflex-mediated syncope in the absence of other risk factors.
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34 Short-QT Syndrome COR LOE Recommendation IIb C-EO ICD implantation may be considered in patients with short-qt pattern and syncope of suspected arrhythmic etiology.
35 Long-QT Syndrome COR LOE Recommendations I IIa B-NR B-NR Beta-blocker therapy, in the absence of contraindications, is indicated as a first-line therapy in patients with LQTS and suspected arrhythmic syncope. ICD implantation is reasonable in patients with LQTS and suspected arrhythmic syncope who are on beta-blocker therapy or are intolerant to beta-blocker therapy.
36 Catecholaminergic Polymorphic Ventricular Tachycardia COR IIa IIa LOE C-LD B-NR Recommendations Flecainide is reasonable in patients with CPVT who continue to have syncope of suspected VA despite betablocker therapy. ICD therapy is reasonable in patients with CPVT and a history of exercise- or stress-induced syncope despite use of optimal medical therapy or LCSD.
37 Early Repolarization Pattern COR LOE Recommendations IIb C-EO ICD implantation may be considered in patients with early repolarization pattern and suspected arrhythmic syncope in the presence of a family history of early repolarization pattern with cardiac arrest.
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40 1. Important and impact of ICD in primary prevention 2. Risk stratification for ICD therapy 3. Appropriate use of ICD primary prevention therapy 4. Rarely appropriate co morbid for ICD primary prevention therapy ICD indication
41 Thank you for your attention.
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abstract n engl j med 375;13 nejm.org September 29,
The new england journal of medicine established in 1812 September 29, 2016 vol. 375 no. 13 Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure Lars Køber, M.D., D.M.Sc., Jens
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