ICD Guidelines: who benefits from an ICD? Matthew Bennett Cardiac Electrophysiologist Vancouver Coastal Health, Device Lead Associate Professor, UBC Matthew.bennett@vch.ca
Disclosures I have research collaborations with Medtronic, SJM, Boston Scientific and Sorin I implant ICDs
Objectives Review the current ICD guidelines Review the benefit of an ICD in non- ischemic CM Review the factors that increase or decrease the mortality benefit of an ICD
What is an ICD?
CRT Biventricular Pacing
Who benefits from an ICD? High risk of dying from VF/VT that would be terminated by an ICD Low risk of dying from a non- arrhythmic cause Low risk of dying from VF/VT that would not be terminated by an ICD The time it takes to see the benefit depends on these competing risks
60 yo woman EF=25% Dx: 9 months ago Case 1 Carvedilol 25mg po bid, Entresto, spironolactone, ivabradine Narrow QRS
70 yo woman EF=20% Dx: 12 months ago Case 2 Carvedilol 25mg po bid, Entresto, spironolactone, ivabradine LBBB
AMIOVIRT EF<=35% Non-ischemic NYHA I-IV Spontaneous NSVT N=103, randomized to ICD or amiodarone JACC, 2003
DEFINITE EF<=35% Non-ischemic NYHA I-III Spontaneous NSVT or >=10 PVCs/24hr N=458, randomized to ICD or Rx Mean F/U=29.0months NEJM, 2004
Summary ICDs may improve arrhythmia- free survival but not overall survival
CAT EF<=30% Non-ischemic NYHA II-III New onset (CHF<=9 months) N=104, randomized to ICD or Rx Mean F/U= 22.8 mo s Circulation, 2002
Summary ICDs may improve arrhythmia- free survival but not overall survival ICDs don t improve survival early after CM diagnosis
SCD-HeFT EF<=35% NYHA II-III (>3 mo s) >30 days post MI or PCI >30days post CABG N=2521, randomized to CHF Rx, CHF Rx+amiodarone or CHF Rx + ICD 1211 non-ischemic CM NEJM 2005; 352:225-37
Summary ICDs may improve arrhythmia- free survival but not overall survival ICDs don t improve survival early after CM diagnosis 27% reduction in mortality with ICD (p=0.06)
CARE- HF 813 patients 18yrs or older, greater than 6 weeks of CHF, NYHA III or IV despite standard therapy, LVEF 35%, Lvedd 30mm (indexed to height), and QRS duration 120msec. If QRS 120-149msec had to have 2 of aortic preejection delay of >140 msec, an interventricular mech delay of >40 msec or delayed activation of the post- lat LV wall Randomized to CRT- P vs medical therapy NEJM 352; 2005
COMPANION LVEF 35% QRS 120 msec NYHA class III or IV due to either ischemic(>60 days post MI or CABG) or non-ischemic cardiomyopathy N=1520, randomized in a 1:2:2 ratio to protocol mandated Rx, Rx and CRT or Rx, CRT and ICD At 12 months, Rx: 19%; CRT: 15%, CRT+ICD: 12% NEJM 2004; 350: 2140-50
Summary ICDs may improve arrhythmia- free survival but not overall survival ICDs don t improve survival early after CM diagnosis 27% reduction in mortality with ICD (p=0.06) CRT- Ds and CRT- Ps reduce mortality in patients with CM
DANISH N=1116 Non- ischemic cardiomyopathy Randomized to ICD vs Usual care Median follow up: 67.6 months With CRT=645 DANISH, NEJM, 2016
DANISH DANISH, NEJM, 2016
Summary ICDs improves arrhythmia- free survival but not overall survival ICDs don t improve survival early after CM diagnosis 27% reduction in mortality with ICD (p=0.06) CRT- D reduces mortality in patients with CM ICDs improve survival patients with non- ischemic CM younger than 68 yrs old
Forest plot of all-cause mortality among patients with nonischemic cardiomyopathy randomly assigned to ICD and CRT-D versus optimal medical therapy for primary prevention of sudden cardiac death. Harsh Golwala et al. Circulation. 2017;;135:201-203 Copyright American Heart Association, Inc. All rights reserved.
Case 1 60 yo woman EF=25% Dx: 9 months ago Carvedilol 25mg po bid, Entresto, spironolactone, ivabradine Narrow QRS ICD
Case 2 70 yo woman EF=25% Dx: 9 months ago Carvedilol 25mg po bid, Entresto, spironolactone, ivabradine LBBB CRT- P vs CRT- D?
Striking a balance Diuretic use Older age Increased NYHA class HTN AFIB Increased QRS duration No Beta- blocker Low Na Chronic lung dz PVD DM Renal dz Reduced EF Increased NYHA class Inducible VT Ischemic heart disease
Who benefits from an ICD? High risk of dying from VF/VT that would be terminated by an ICD Low risk of dying from a non- arrhythmic cause Low risk of dying from VF/VT that would not be terminated by an ICD The time it takes to see the benefit depends on these competing risks