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Εμφυτεύσιμοι Απινιδωτές και Αιφνίδιος Καρδιακός Θάνατος : Η Δική μας Εμπειρία PowerPoint PPT Presentation


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Εμφυτεύσιμοι Απινιδωτές και Αιφνίδιος Καρδιακός Θάνατος : Η Δική μας Εμπειρία. Κων/νος Π. Πολυμερόπουλος, FACC, FESC Δρ Ιατρικής ΑΠΘ Επιμελητής Β`, Α` Καρδιολογική Κλινική Π.Ν.Θ. «Γ. Παπανικολάου». Αιφνίδιος Καρδιακός Θάνατος (ΑΚΘ).

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Εμφυτεύσιμοι Απινιδωτές και Αιφνίδιος Καρδιακός Θάνατος : Η Δική μας Εμπειρία

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    Myerburg R. In: Braunwald E, Heart Disease, 1997:742-749


Magnitude of sca in the us

Magnitude of SCA in the US

* Range: 166,200 to 310,000

1 Vital Statistics of the U.S., Data Warehouse, National Center for Health Statistics.4 Department of Health and Human Services. Centers for Disease Control and Prevention.

2 Chugh SS, et al. J Am Coll Cardiol. 2004;44:1268-1275.5 Avert Organization: www.avert.org.

3 Nichol G, et al. JAMA. 2008;300:1423-1431. 6 2008 Heart and Stroke Statistics Update. American Heart Association.


Sca chain of survival statistics

SCA Chain of Survival Statistics

Even in the best EMS/early defibrillation programs it is difficult to achieve high survival times due to many SCA events not being witnessed and the difficulty of reaching victims within 6-8 minutes.

  • 48 - 58% SCA events are not witnessed1,2

  • 85% SCA events occur at home/non-public locations1

  • 4.6 - 8% estimated SCA out-of-hospital survival1,2

1Nichol G. JAMA 2008;300:1423-1431

2 Chugh S. JACC 2004;44:1268-1275


Profile of an scd victim

Profile of an SCD Victim

  • 90% have blockage in 2 or more major coronary arteries

  • 66% have scarring from a prior heart attack

  • Structural abnormalities are often present when the victim is young

  • Intense physical exertion can produce adrenaline which can trigger SCD in susceptible people

  • Legal and illegal drugs can be pro-arrhythmic


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People whove had a heart attack have a sudden death rate thats 4-6 times that of the general population

American Heart Association. Heart Disease and Stroke Statistics2003 Update


Scd survivors

SCD Survivors

  • Few attempts at resuscitation are successful after 10 minutes

  • Survivors of one potentially life-threatening ventricular arrhythmia are at increased risk of having a second such arrhythmia


Sca resuscitation success versus time

100

90

80

70

60

50

40

30

20

10

0

1

2

3

4

5

6

7

8

9

SCA Resuscitation Success versus Time

Chance of success reduced 7-10% each minute

% Success

*Non-linear

Time (minutes)

Cummins RO. Ann Emerg Med. 1989;18:1269-1275


Coronary heart disease

5% Other*

15%Cardiomyopathy

80%Coronary Heart Disease

Coronary Heart Disease

  • An estimated 13 million people had CHD in the U.S. in 2002. 1

  • Sudden death was the first manifestation of coronary heart disease in 50% of men and 63% of women. 1

  • CHD accounts for at least 80% of sudden cardiac deaths in Western cultures.3

Etiology of Sudden Cardiac Death2,3

* ion-channel abnormalities, valvular or congenital heart disease, other causes

1 American Heart Association. Heart Disease and Stroke Statistics2003 Update. Dallas, Tex.: American Heart Association; 2002.

2 Adapted from Heikki et al. N Engl J Med, Vol. 345, No. 20, 2001.

3 Myerberg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6th ed. P. 895.


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ipes D. Circulation 1998;98:2334-51


Underlying arrhythmias of sca

Underlying Arrhythmias of SCA

Polymorphic VT 13%

Bradycardia17%

Monomorphic VT62%

Primary VF8%

Bays de Luna A. AmHJ. 1989;117:151-159


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  • irowski 1976

    irowskiM. Heart Lung 1973;2:867-69

    irowskiM. NEJM 1980;303:322-24


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ICD

  • : ,

  • -(): . ,

Gilkson M. Lancet 2001;357:1107-17


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68-90 gr

30-45 cm


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ICD

  • Single chamber (VVI)

  • Dual chamber (DDD)

  • CRT-ICD


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ICD

  • ()

  • (P- shock)

  • - A

  • ()


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  • , ,

  • : (10-25%, SVT, ST) (5-10%)

    Kadish A. NEJM 2004;350:2151-58

    Gradaus R. PACE 2003;26:1511-18


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ICD

  • -

  • - VT-VF


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M


Meta analysis of avid cash cids trial cumulative risk of fatal events

Meta-analysis of AVID/CASH/CIDSTrial Cumulative Risk of Fatal Events

Death

Arrhythmic death

60

60

27%

50

50

Amiodarone

40

40

50%

%

%

30

30

Amiodarone

20

20

ICD

10

10

ICD

0

0

0

1

2

3

4

5

6

0

1

2

3

4

5

6

Years

Years

Connolly S. Eur Heart J 2000;21:2071-8


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  • ( )


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Time Dependenceof Mortality Risk Post-MIPrediction of Sudden Cardiac Death After Myocardial Infarction in the Beta-Blocking Era1

  • 700 post-MI patients; ~95% on beta blockers two years after discharge

  • The epidemiologic pattern of SCD was different from that reported in previous studies

    • Arrhythmia events or SCDs did not concentrate early after the index event,but most of them occurred more than 18 months post-MI

Huikuri H. JACC 2003; 42: 652-8


Time dependence of mortality risk post mi

Time Dependence of Mortality Risk Post-MI

  • Maastricht Circulatory Arrest Registry:

    • In 224 sudden cardiac arrest victims, only 4% (10 cases) were due to an acute MI

    • The median time from MI to sudden cardiac arrest was 9.0 years in 92 patients (41% of total)

Gorgels A. EurHJ 2003;24:1204-1209


Scd rates in post mi patients with lv dysfunction

SCD Rates in Post-MI Patients with LV Dysfunction

32

Total Mortality

30

28

Arrhythmic Mortality

28

21

19.8

20

20

18

16

16

14

Control Group Mortality % at 2 years

12

10

9.4

10

7

0

TRACE

CAPRICORN

EMIAT

MADIT

MUSTT

MUSTT

MADIT II

Registry

Inducible

Total Mortality ~20 to 30%; SCD accounts for ~50% of Total Deaths


M i km

M (I KM)


Primary prevention post mi trials reduction in mortality with icd therapy

Primary Prevention Post-MI Trials:Reduction in Mortality with ICD Therapy

55%

48%

39%

% Mortality

27%

24%

24%

20%

16%

14%

2

3

1

4,5

27 Months

39 Months

20 Months

32 Months

1 Bigger JT. N Engl J Med. 1997;337(22):1569-1575.

2 Moss AJ. N Engl J Med. 1996;335:1933-40.

3 Buxton AE. N Engl J Med. 1999;341:1882-90.

4 Moss AJ. N Engl J Med. 2002;346:877-83.

5 Moss AJ. Presented before ACC 51st Annual Scientific Sessions,Late Breaking Clinical Trials, March 19, 2002.


Primary prevention post mi trials reduction in mortality with icd

Primary Prevention Post-MI TrialsReduction in Mortality with ICD

Overall Death

80

73

Arrhythmic Death

64

62

55

60

% Mortality Reduction w/ ICD Rx

40

31

23

20

0

1,2

3

4

SCD-HeFT

MUSTT

MADIT-II

1Bardy GH, et al. N Engl J Med. 2005;352:225-237.

2 Packer DL. Heart Rhythm. 2005;2:S38-S39

3 Buxton AE, et al. N Engl J Med. 1999;341:1882-1890.

4 Moss AJ, et al. N Engl J Med. 2002;346:877-883.


Post mi icd trials conclusions

Post-MI ICD Trials Conclusions

  • Post-MI patients with LV dysfunction are at an increased risk of SCA

  • ICD therapy in these patients results in significant reductions in overall mortality (31-55%) over antiarrhythmics or conventional therapy

  • ICD mortality reductions in post-MI trials (primary prevention) are equal to or greater than the mortality reductions achieved in VT/VF trials (secondary prevention, e.g., AVID)

  • ICD therapy in MADIT-II patients provided significant survival benefit in patients who were on optimal drug therapies


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M ( )


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  • 44% 50% ( - )

    Lee D. JACC 2003;41:1573-82


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M

  • HOCM, ARVC, Long QT, Short QT, . Brugada,

  • ,


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Goldschlager N. Clin Card 2006;29:189-94


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ICD


Crt d

CRT - D

  • QoL, , (CONTACT, MIRACLE-ICD, MADIT-CRT)

  • NYHA III/IV (COMPANION)


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Camm J. EHJ 2007;28:392-97


Number needed to treat to save a life

Number Needed to Treat To Save a Life

NNTx years = 100 / (% Mortality in Control Group % Mortality in Treatment Group)

Drug Therapies

50

45

37

40

CRT-D

CRT

35

Amiodarone

28

30

26

ICD

25

Simvastatin

20

20

14

14

Metoprolol

15

11

10

9

10

Captopril

5

0

MADIT II

COMPANION

AVID

SCD-HeFT

CARE-HF

SAVE

Merit-HF

4S

Amiodarone

Meta-Analysis

(3 Yr)

(3 Yr)

(4 Yr)

(1 Yr)

(2.5 Yr)

(3.5 Yr)

(1 Yr)

(6 Yr)

(2 Yr)


2 007 2010

` (2007-2010)

51 , 43 , 66 11,

10,4 (1-34), 7 ICD


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(17 )


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  • 108,5 43,3 min ( CRT-D)

  • 15,89,8 min

  • 2,3 0,8 ( )


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12/51- 24%


8 51 15 0 8 1 19

8/51 (15%) 0,8 (1-19)

6/30(20%) 2ary

2/21 (9,5%) 1ary


3 51 6 3 3 1 5

3/51 (6%) 3,3 (1-5)


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