Bo Yang Renmin Hospital of Wuhan University

1. Ischemic cardiomyopathy with cardiac dysfunctionICD/CRTD:WhenandWho Bo Yang Renmin Hospital of Wuhan University

2. CHD induced HF • Most important risk factor for HF:CHD • 1/3 patients to HF after MI 7-8 years • Primary cause of hospitalization in HF Nat Rev Cardiol. 2011;8:30-41

3. SCD rate in HF 45 months 13 months 41.4 months 27 months 16 months 6 months 12 months Total mortality 15~40% SCD 50%

4. NYHA III NYHA IV 26% 56% 33% 59% 15% 11% n = 103 n = 27 MERIT-HF NYHA II 12% 64% 24% n = 103 Sudden Other CHF Death MERIT-HF Study Group, LANCET 1999

5. MADIT II MulticenterAutomaticDefibrillator ImplantationTrial II 1.232 pts. - prior MI (1 month) - LVEF 30 % R 3:2 ratio 742 pts. Implantable Defibrillator 490 pts. Medical Therapy primary end point: death from any cause Moss et al., NEJM 2002

6. MADIT II Death from any cause p = 0.007 HR 0.69 31% reduction in mortality Moss et al., NEJM 2002

7. ICD Trail CIDS CASH Secondary Prevention AVID MADIT 心梗后高危 MUSTT Primary Prevention MADIT-II DEFINITE 心衰高危 SCD-HeFT 80’ 85’ 90’ 95’ 2000’

8. Results: secondary prevention 56% 59% % Mortality Reduction w/ ICD Rx 33% 31% 28% 20% 5 7 6 3 Years 3 Years 3 Years 5 The AVID Investigators. N Engl J Med. 1997;337:1576-83. 6 Kuck K. Circ. 2000;102:748-54. 7 Connolly S. Circ. 2000:101:1297-1302.

9. Results: primary prevention 75% 73% 55% 61% 54% % Mortality Reduction w/ ICD Rx 31% 1 2 3, 4 27 Months 39 Months 20 Months 1 Moss AJ. N Engl J Med. 1996;335:1933-40. 2 Buxton AE. N Engl J Med. 1999;341:1882-90. 3 Moss AF. N Engl J Med. 2002;346:877-83. 4 Moss AJ. Presented before ACC 51st Annual Scientific Sessions, Late Breaking Clinical Trials, March 19, 2002.

10. Comparison:results from secondary and primary prevntion 75% 76% 55% 61% 54% % Mortality Reduction w/ ICD Rx 31% ICD一级预防应用死亡率下降超过二级预防 1 2 3, 4 27 months 39 months 20 months 59% 56% 1 Moss AJ. N Engl J Med. 1996;335:1933-40. 2 Buxton AE. N Engl J Med. 1999;341:1882-90. 3 Moss AJ. N Engl J Med. 2002;346:877-83 4 Moss AJ. Presented before ACC 51st Annual Scientific Sessions, Late Breaking Clinical Trials, March 19, 2002. 5 The AVID Investigators. N Engl J Med. 1997;337:1576-83. 6 Kuck K. Circ. 2000;102:748-54. 7 Connolly S. Circ. 2000:101:1297-1302. % Mortality Reduction w/ ICD Rx 33% 31% 28% 20% 5 6 7 3 Years 3 Years 3 Years

11. Prevention of SCD Clinical Trail: The same importance of primary prevention anf sencondary prevention

12. One-year Total Mortality After Acute MI P = 0.008 Rouleau et al. JACC 1996; 27: 1119

13. CARE-HF, COMPANION, SCD-HeFT: SCD-HeFT (45.5mth) CARE-HF (29.4mth) COMPANION (16.6mth) JM Cleland JGF. N Engl J Med. 2005;352:1539-49. Bristow MR. N Engl J Med. 2004;350:2140-50. Packer DL. Heart Rhythm 2005. May;2 (1suppl):AB20-2. Bardy GH. N Engl J Med. 2005;352:225-237.

14. MADIT-CRT Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy N Engl J Med,2009,361,1329–1338

15. Methods • LVEF≤30% • QRS≥130ms • CRTD : ICD = 3 : 2 Eur H J,2011,32,1614-1621

16. ICM 1820 ( NYHA I / II ) Documented MI 704 No documented MI 237 • No ICM 774 ( NYHA II ) Eur H J,2011,32,1614-1621

17. Results MI 3M-8Y: same risk for HF/death among ICD and CRTD patients Eur H J,2011,32,1614-1621

18. Results MI>8Y: CRTD patients had a significantly better outcome than ICD Eur H J,2011,32,1614-1621

19. Results No documented MI: CRTD patients had a significantly better outcome than ICD Eur H J,2011,32,1614-1621

20. Results Patients≥75 years old: CRTD patients had a significantly better outcome than ICD J Cardiovasc Elecr, 2011,22,892-897

21. Results Patients 60-74 years old: CRTD patients had a significantly better outcome than ICD J Cardiovasc Elecr, 2011,22,892-897

22. Results Patients < 60 years old: same risk among ICD and CRTD patients J Cardiovasc Elecr, 2011,22,892-897

23. Results CRTD women had a significantly better outcome than CRTD men or ICD patients JACC,2011,57, 813–820

24. Conclusion • CRTD benefit for Remote MI • CRTD benefit for No documented MI with progressive adverse remodeling • CRTD benefit in older patients(≥60 years) • Especially for elderly patients(≥75 years) • CRTD women had a significantly better outcome than CRTD men or ICD patients

25. CHD with NYHA I ICD (CLASS I A ) • NYHA I • LVEF ≤ 30% • MI > 40 days JACC. 2008;51:e1-e62

26. CHD with NYHA II-III ICD (CLASS I A ) • NYHA II-III • LVEF ≤ 35% • MI > 40 days JACC. 2008;51:e1-e62

27. CHD with NYHA III–IV ICD/CRTD (CLASS I A ) • NYHA III–IV • LVEF ≤ 35% • QRS≥120ms • Sinus rhythm • Optimal medical therapy JACC. 2008;51:e1-e62

28. CHD with NYHA III–IV ICD/CRTD (CLASS IIa B) • AF • NYHA III–IV • LVEF ≤ 35% • QRS≥120ms • Optimal medical therapy Ablation of AV node JACC. 2008;51:e1-e62

29. CHD with NYHA I–IV ICD (CLASS I B) • No sustained VT due to prior MI • LVEF ≤ 40% • Inducible VF or sustained VT at EP JACC. 2008;51:e1-e62

30. CHD with NYHA I ICD (CLASS IIa C) • Sustained VT • Normal or near-normal ventricular function JACC. 2008;51:e1-e62

31. CHD with NYHA I–II CRT (CLASS IIb C) • With ICD for anticipated frequent ventricular pacing • Optimal medical therapy • NYHA I–II • LVEF ≤ 35% JACC. 2008;51:e1-e62

32. CHD with NYHA III–IV CRT (CLASS IIa C) • Frequent dependence on ventricular pacing • Optimal medical therapy • NYHA III–IV • LVEF ≤ 35% JACC. 2008;51:e1-e62

33. Summary • Patients with Ischemic cardiomyopathy with cardiac dysfunction are at high risk of SCD • ICD/CRTD is to lower the risk of SCD for selected patient in this group • Plus with optical medical thereary, and PCI in partial patients are the reasonable strategy

34. Thank you