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5o ΠΑΝΕΛΛΗΝΙΟ ΑΡΡΥΘΜΙΟΛΟΓΙΚΟ ΣΥΝΕΔΡΙΟ

5o ΠΑΝΕΛΛΗΝΙΟ ΑΡΡΥΘΜΙΟΛΟΓΙΚΟ ΣΥΝΕΔΡΙΟ. Εκτίμηση του αρρυθμιολογικού κινδύνου και διαχείριση των ασθενών με KA Κλινικά διλήμματα και πρακτικές απαντήσεις. Evaggelismos Hospital, Athens. Sotirios Xydonas , MD, PhD, FESC, FHFA Heart Failure Unit Electrophysiology and Pacing Laboratory

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5o ΠΑΝΕΛΛΗΝΙΟ ΑΡΡΥΘΜΙΟΛΟΓΙΚΟ ΣΥΝΕΔΡΙΟ

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  1. 5o ΠΑΝΕΛΛΗΝΙΟΑΡΡΥΘΜΙΟΛΟΓΙΚΟΣΥΝΕΔΡΙΟ Εκτίμηση του αρρυθμιολογικού κινδύνου και διαχείριση τωνασθενών με KA Κλινικά διλήμματα και πρακτικέςαπαντήσεις Evaggelismos Hospital, Athens Sotirios Xydonas, MD, PhD, FESC, FHFA Heart Failure Unit Electrophysiology and Pacing Laboratory Cardiology Department, Evaggelismos Hospital, Athens

  2. Conflict of Interest Honoraria for lectures: Bayer, Boehringer-Ingelheim, Novartis, Pfizer, Servier Honoraria for advisory boards: Boehringer-Ingelheim, Novartis, Servier • This presentation is intended for non-promotional scientific purposes only and may contain information on products or indications currently under investigation and/or that have not been approved by the regulatory authorities. • This presentation represents exclusively the views of the speaker. • This presentation is accurate at the time of presentation. • Any data about non-Novartis products are based on publicly available information at the time of presentation.  

  3. Anatomic substrate and pathophysiology of Arrhythmias and SCD in HFrEF J Clin Med 2018;7:436.

  4. Secondary Prevention

  5. Secondary prevention trials ↓↓↓ 50% ↓↓↓28% Meta-analysis: ICD vs Amiodarone AVID, CASH, CIDS CAD 75-83% AVID, CASH, CIDS Eur Heart J 2000;21:2071–2078.

  6. Recommendations for ICD in patients with HF Eur Heart J 2015;36:2793–2867. Eur Heart J 2016;37:2129–2200.

  7. Primary Prevention

  8. Primary Prevention Eur Heart J 2016;37:2129-200. Eur Heart J 2015;36:2793–2867. Eur Heart J 2016;37:267–315. Eur Heart J 2018;39:119–177. Eur Heart J 2015;36:2793–2867. Eur Heart J 2016;37:267–315. Eur Heart J 2018;39:119–177.

  9. MADIT-II IHD N Engl J Med 2002;346:877-83.

  10. SCD-HeFT IHD vs. NIHD 52% ↓↓↓ 21% shock only N Engl J Med 2005;352:225-37.

  11. SCD-HeFT NYHA N Engl J Med 2005;352:225-37.

  12. RCTs evaluating the role of ICD in primary prevention of patients with NIDCM Eur Heart J Suppl. 2019;21:B5–B6. doi:10.1093/eurheartj/suz005

  13. Eur J Heart Fail. 2019 May 26. doi: 10.1002/ejhf.1531. [Epub ahead of print]

  14. Eur J Heart Fail. 2019 May 26. doi: 10.1002/ejhf.1531. [Epub ahead of print]

  15. 2-year cause-specific mortality and non-fatal vascular events Conceptual representation of Absolute and Relative risk JGF Cleland et al. Eur Heart J 2019;40:2128–2130.

  16. NYHA and Sudden Cardiac Death NYHA II benefit more from ICD than NYHA III Am Heart J 2017;191:21–29.

  17. NT-proBNP and ICDs Wet patients do not appear to benefit from ICDs JGF Cleland et al. Eur Heart J 2019;40:2128–2130.

  18. Sudden Death in HF Where are we now? Lancet 1999;353: 2001-07. Eur Heart J 2015;36:1990–1997.

  19. Declining Risk of Sudden Death in HF Over a period of 19 years the rate of sudden death has declined by 44%. N Engl J Med 2017;377:41-51.

  20. Declining Risk of Sudden Death in Heart Failure Annual Rates and Cumulative Incidence Rates of Sudden Death N Engl J Med 2017;377:41-51.

  21. Eur J Heart Fail. 2019 May 26. doi: 10.1002/ejhf.1531. [Epub ahead of print]

  22. Changes in Use and Dose οf GDMT over 12m among pts with HFrEF Contemporary US Outpatient Practice Epub: 2019 Mar 29, J Am Coll Cardiol 2019;73:2365-83.

  23. Remodeling Arrhythmia episodes reduction Clin Res Cardiol 2019;108:1074-1082.

  24. Mortality benefit Episodes reduction Shocks VT / NSVT Heart Rhythm 2018;15:395-402.

  25. Ventricular Repolarization in HFrEF ECG ventricular repolarization indices Acta Cardiol. 2018 Dec 4:1-6. doi: 10.1080/00015385.2018.1535818. [Epub ahead of print]

  26. Risk Stratification Circulation 2017;136:215–231.

  27. Risk Stratification Manolis AS. Expert Rev Cardiovasc Ther. 2017;15:315-325.

  28. CMR – LGE and Ventricular events J Am Coll CardiolImg 2016;9:1046–55.

  29. Midwall CMR – LGE and Sudden Cardiac Death Circulation 2017;135:2106–2115.

  30. Risk Stratification in HFrEF • Non Invasive Risk Factors (NIRF) • presence of late potentials (≥2/3 criteria) • frequent PVCs (≥30/hr) • NSVT (≥1/24 hr) • Abnormal HR turbulence (onset ≥0% and slope≤2.5 ms) • positive T wave alternans (≥65 μV) • reduced deceleration capacity (≤4.5 ms) • decreased HRV (SDNN<70 ms) • prolonged QTc interval (>460 ms in males and >480 ms in females) Gatzoulis KA, Sideris A, Kanoupakis E, Sideris S, Nikolaou N, Antoniou CK, Kolettis TM. Ann Noninvasive Electrocardiol. 2017;22:e12430.

  31. Case • Γυναίκα, 53 ετών • Καρδιακή ανεπάρκεια LVEF=30%, NYHA I • Διατατική Μυοκαρδιοπάθεια, από 10ετίας • ΗΚΓ = SR, PR 190ms, IVCD, QRS 144ms, 65/min • Holter ρυθμού: PVCs έως 5.600, NSVT: 0 • SAECG: 1 στα 3 θετικό • Νοσηλεία για αίσθημα παλμών • Φαρμακευτική αγωγή χωρίς αλλαγές από 12/2018 Ramipril 5mg od, Bisoprolol 5mg od, Spironolactone 50mg od, Frusemide 40mg bd

  32. Case Πιθανές προσεγγίσεις • Αύξηση α-ΜΕΑ • Αύξηση β-αναστολέα • Αύξηση σπειρονολακτόνης • Προσθήκη αμιοδαρόνης • Προσθήκη Ιβαμπραδίνης • Αντικατάσταση α-ΜΕΑ με ARNI • Εμφύτευση CRT-P ή CRT-D ή τίποτα • 53ετών • 104/70 mmHg • 62 bpm • NT-proBNP442pg/ml • Κ 4,6mEq/L • e-GFR 92ml/min/1,73m2 • Ramipril 5mg od • Bisoprolol 5mg od • Spironolactone 50mg od • Frusemide 40mg bd X Χ X X X v ? • Late potentials (≥2/3 criteria) • PVCs (≥30/hr) • NSVT (≥1/24 hr) • abnormal HR turbulence (onset ≥0% and slope≤2.5 ms) • positive T wave alternans (≥65 μV) • reduced deceleration capacity (≤4.5 ms) • decreased HRV (SDNN<70 ms) • prolonged QTc interval (>460 ms in males and >480 ms in females)

  33. CRT Eur Heart J 2016;37:2129–2200.

  34. Cardiac and non-Cardiac Death in CRT patients Cardiac Death & non-LBBB Cardiac Death & LBBB Non - Cardiac Death & LBBB Non-Cardiac Death & non-LBBB Europace 2015;17:1816-1822.

  35. Non LBBB and PR interval Death or Heart Failure Circ Heart Fail 2016;9:e002667.

  36. Take home messages • ICD therapy for LVEF≤35% for primary prevention is under consideration especially in NIDCM. • An unmet need for use of non-invasive risk stratification has emerged and various Risk algorithms are under evaluation. • The evidence of CRT benefit in patients with non LBBB is weak, particularly in patients with QRS<150ms and NYHA I-II.

  37. Take home messages Awaiting for robust SCD risk score algorithms from RCTs in HFrEF patients, we should keep in mind that: • ICDs are most effective at preventing sudden arrhythmic death for patients who have some increased risk of arrhythmias but, more importantly are otherwise at low risk. • Rather than trying to identify patients at high risk of sudden death, clinicians should be selecting patients at low risk of death for any other reason.

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