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Prevention de la Mort Subite Treatment of Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death

Prevention de la Mort Subite Treatment of Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. S. Nasr, M.D. Clinical Cardiac Electrophysiologist. Association Franco-Libanaise de Cardiologie 11 Mai 2007 - Beirut, Liban. Cause of Death.

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Prevention de la Mort Subite Treatment of Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death

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  1. Prevention de la Mort Subite Treatment of Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death S. Nasr, M.D. Clinical Cardiac Electrophysiologist Association Franco-Libanaise de Cardiologie 11 Mai 2007 - Beirut, Liban

  2. Cause of Death Total Mortality: Contribution from Sudden Cardiac Death % Zheng et al., Circulation 2001

  3. Sudden Cardiac Death Holter recordings from 157 cases with fatal arrhythmias Brady- arrhythmias 17% Primary VF 9% 62% VT VF 13% Torsade de Pointes Bayes de Luna et al. Am Heart J 1989

  4. Sudden Cardiac Death Huikuri et al. NEJM 2001

  5. Implantable Defibrillator

  6. Sudden Cardiac Death Incidence Events per Year Adult population CAD History of a coronary event Heart failure Resuscitation Resuscitation with previous MI 0 1 2 5 10 20 30 0 100 200 300 (x 1000) (% per year) Myerburg et al., Circulation 1992

  7. Sudden Cardiac Death • Secondary Prevention • Primary Prevention

  8. ICD Trials -Secondary prophylaxis Dutch trial VF, cardiac arrest CASH CIDS AVID sustained VT 10 20 30 40 60 LV-EF (%)

  9. Summary of 20 Prevention Trials Hazard ratio Other features Trial Name, Pub Year ● Aborted cardiac arrest N = 1016 AVID 0.62 1997 ● N = 191 Aborted cardiac arrest CASH 2000 0.83 ● Aborted cardiac arrest or syncope N = 659 CIDS 0.82 2000 p = 0.0023 ● Meta HR:0.73 (0.59,0.89) 1.8 0.4 0.8 1.0 1.2 1.4 1.6 0.6 ICDbetter

  10. Recommendations for 20 Prevention • Class I RecommendationsThe ICD is effective therapy to reduce mortality by a reduction in SCD in patients with LVD due to prior MI who present withhemodynamically unstable sustained VT, who are receiving chronic optimal medical therapy, and who have reasonableexpectation of survival with a good functional status for more than 1 year(Level of Evidence: A)An ICD should be implanted in patients withnon-ischemic DCM and significant LVD who have sustained VT or VF, who are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year (Level of Evidence: A)

  11. ICD Trials -Primary prophylaxis MADIT I MUSTT ns VT DEFINITE SCD-HeFT DINAMIT CAT High risk no VA MADIT II CABG-Patch 5 10 20 30 40 LV-EF (%)

  12. ICD 10 Prevention Trial Results Hazard Ratio CABG-Patch MUSTT CAD, MI MADIT I MADIT II DINAMIT CAD, NICM SCD-HeFT DEFINITE AMIOVIRT NICM CAT 0 0.5 1 1.5 2 2.5 ICD better No ICD better

  13. Risk stratification for sudden death in ICD trials  Ejection fraction (EF <30%, <35%, <40% + ...) Etiology of depressed EF (CAD vs DCM) EP study (inducible VT, VF) Timing of remote myocardial infarction (< 40 days, > 40 days / 1 month)  [HRV] NYHA class QRS duration

  14. Major ICD Secondary Prevention Trials

  15. LV-function as predictor of SCD LV-EF is considered as the best parameter for risk stratification after MI exponential increase of risk of SCD below EF 35-40% MUSST, MADIT, MADIT-2, SCD-HeFT DINAMIT, COMPANION, ……… risk LV-EF (%)

  16. MADIT II SCDHeFT DEFINITE 40 40 40 LVEF LVEF LVEF  35  35 35 35 35 310  20 285 > 30 ≤ 30 30 30 30 401 ≥ 25 1675 458 1232 25 25 25 25 23 831 1390 21 < 25 ≤ 30 20 20 20 < 20 15 15 15 0.2 0.4 0.6 0.8 1.0 1.2 1.4 0.2 0.4 0.6 0.8 1.0 1.2 1.4 0.2 0.4 0.6 0.8 1.0 1.2 1.4 Defibrillator Better Conventional Better Major ICD 10 Prevention Trials and LVEF 148

  17. LVEF LVEF 40 40 Class: IIb; LOE: B 35 35 Class: IIa; LOE: B 30 30 25 25 Class: 1 LOE: A Class: 1 LOE: A A B C Principle of Guidelines • EF difficult to measure • Multiple trials with EF < 30% • No trials of EF 30-35% or 35-40%

  18. LVEF CHD NICM 40 ≤ 30-40% ≤ 30-35% 35 30 Class: 1 LOE: A Class: 1 LOE: B 25 Examples of Guideline Recommendations

  19. Etiology of Heart Failure Aetiology n Ischaemic 884 Non-ischaemic 792 Ischaemic 506 Non-ischaemic 397 SCD HeFT COMPANION (ACM only) ICD better ICD not better 0.2 0.4 0.6 0.8 1 1.2 1.4

  20. Life expectancy >1 y 1.0 0.9 Defibrillator LY gained per device 0.8 Probability of Survival 0.7 Conventional 0.6 0.0 Salukhe TV et al, 2004 Year 0 1 2 3 4 MADIT II Moss AJ, 2002 Annual mortality rate, % 3.4 6.0 Mortality / 100py 3.5 1.5 DINAMIT Hohnloser SH et al, 2004 MADIT II Wilber DJ et al, 2004 ICD ≥40 days post MI Recommendation:

  21. SCD-HeFT NYHA II NYHA III Bardy G. et al., N Eng J Med 2005; 352: 225-37

  22. NYHA n I 461  I 771 I 99 II 263 III 96 II 1160 III 516 MADIT II DEFINITE SCD HeFT ICD not better ICD better 0 0.4 0.8 1.2 1.6 2 2.4 NYHA Functional Class

  23. Class 1 Recommendation: ICD therapy is recommended for primary prevention to reduce total mortality by a reduction in SCD in patients with non-ischemic DCM who have an LVEF ≤ 30% to 35%, are NYHA functional class II or III receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year (Level of Evidence: B) Class 1 Recommendation: ICD therapy is recommended for primary prevention to reduce total mortality by a reduction in SCD in patients with LVD due to prior MI who areat least 40 days post-MI, have an LVEF ≤ 30% to 40%,are New York Heart Association (NYHA) functional class II or III, are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year (Level of Evidence: A) Recommendations for 10 Prevention

  24. NYHA Functional Class 1 and LVD MADIT II DEFINITE NYHA n I 461  I 771 I 99 II 263 ICD not better ICD better 0 0.4 0.8 1.2 1.6 2 2.4 “The writing committee struggled with this issue since guidelines are meant to summarize current science and not take into account economic issues or the societal impact of making recommendations. However the committee recognizes that the economic impact and societal issues will clearly modulate how these recommendations are implemented”

  25. NYHA Class I Recommendations Class IIb Placement of an ICD might be considered in patients who have non-ischemic DCM, LVEF ≤ 30% to 35%, are NYHA functional class I receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year(Level of Evidence: C) Class IIa Implantation of an ICD is reasonable in patients with LVD due to prior MI who are at least 40 days post-MI, have an LVEF of ≤ 30% to 35%, are NYHA functional class I on chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year(Level of Evidence: B)

  26. Guidelines for the management of patients at risk of sudden death • ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult • ESC 2005 Guideline Update for the Diagnosis and Treatment of Chronic Heart Failure • ACC / AHA 2004 Guidelines for the management of Patients with ST-Elevation Myocardial Infarction • ACC / AHA / NASPE 2002 Guidelines Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices

  27. ICD Indications Comparison between Guidelines

  28. ICD Indications Comparison between Guidelines

  29. ICD Indications Comparison between Guidelines

  30. Summary and Conclusions VA&SCD Guidelines focus on management of actual and threatened ventricular tachyarrhythmias, and • Build on others that have preceded them - some recommendations have not changed. • Introduce many new and some potentially controversial recommendations • Favour the ICD and extend its indications: Class I CHF / little or no LV dysfunction / wider range of ejection fraction / non-ischemic cardiomyopathy • Acknowledge that not all those who might benefit from ICD therapy can accept or can receive such treatment - alternative treatment is recommended for those who do not receive an ICD

  31. Guidelines and Controversy You can please all the people some of the time, and some of the people all the time, but you cannot please all the people all the time." Abraham Lincoln

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