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1、Who Should Receive a Defibrillator in 2009?Primary and Secondary Prevention of Sudden Cardiac Death,Yong-Mei Cha,MD Mayo ClinicDalian,2009,CP1270808-8,400,000 sudden deaths/year in USA,Other causesStroke160,000Lung cancer 90,100Breast cancer 40,200Automobile accident 50,000AIDS 16,000Fires 4,000,Pat
2、hophysiology and Epidemiology of Sudden Death from Cardiac Causes,Huikuri et al:NEJM 345(20):1473,2003,Secondary prevention trialsall patients had aborted cardiac arrest or syncope,ICDControlTrial(no.)(no.)RR(95%CI)-AVID1997 80/507 122/5090.66(0.51-0.85)CASH200036/99 84/1890.82(0.60-1.11)CIDS 2000 8
3、3/328 98/3310.85(0.67-1.10)Subtotal199/934 304/1,0290.76(0.65-0.89),AVID Antiarrhythmics Versus Implantable Defibrillatorssecondary sudden death prevention trial,Entry Criterion:VFVT with syncopeVT with EF 40%,CHF,or near syncopeN:1,016Therapy:ICD versus amiodarone or sotalolEndpoint:Total mortality
4、Findings:ICD reduced overall mortality by 34%,Antiarrhythmic-drug group,Defibrillator group,AVID:NEJM,1997,P0.02,ICD Primary Prevention,ICD implantation to reduce mortality in patients without a history of:Aborted cardiac arrest,Life-threatening VT,or Unexplained syncope with work-up suggesting a hi
5、gh probability that a ventricular tachyarrhythmia was the cause of the syncope.,Zipes Circulation e408 2006,MADIT II Multicenter Automatic Defibrillator Implantation Trial,Entry Criterion:Post MI 1 month EF 30%,NYHA I-III Exclusion:MI within 1 month of enrollment CABG/PCI within 3 monthsN:1,232Thera
6、py:ICD versus optimal medical therapy Endpoint:Total mortality,MADIT II:Survival with ICD vs Conventional Therapy,Probabilityofsurvival,Follow-up(mo),ICD742503 274 110 9Conventional490329 170 65 3,ICD,Conventional,P=0.007,14.2%,19.8%,Inclusion:recent MI(6-40 days)LVEF 35%depressed HRV(SDNN 70 msec o
7、r 24 h mean RR 750 msec)Exclusion:CABG/PCI expected within 4 weeks after randomizationN:674Therapy:Conventional vs.ICDPrimary outcome:mortality from all causes,DINAMITProphylactic Use of an ICD after Acute MI,CP1242180-13,DINAMIT:N Engl J Med 351:2481,2004,Cumulative risk ofdeath from any cause,Mont
8、hs after randomization,No.at riskICD3152992582111721238225Control3183052722171721247931,ICD group,Control group,P=0.66,DINAMIT death from any cause,SCD-HeFT Amiodarone or an ICD for Congestive Heart Failure,CP1145214-12,DCM or ICMEF 35%NYHA class II or III,R,Bardy et al:ACC,2004,N=2,521,No.at riskPl
9、acebo847797724505304 89Amiodarone845772715484280 97ICD therapy829778733501304103,Mortalityrate,Kaplan-Meier Estimates of Death from Any Cause,CP1186510-8,SCD-HeFT,Bardy GH:NEJM,2005,Follow-up(mo),Hazard ratio(97.5%CI)PAmiodarone 1.06(0.86-1.30)0.53vs placeboICD therapy 0.77(0.62-0.96)0.007vs placebo
10、,5-yr eventrateDeathsPlacebo0.361244Amiodarone0.340240ICD therapy0.289182,Kaplan-Meier Estimates of Death from Any Cause,SCD-HeFT,Bardy GH:NEJM,2005,CP1186510-9,Mortality rate,Follow-up(mo),No.at riskPlacebo45341537024415248Amiodarone42638434622713046ICD therapy43139536524414448,39438235426115241419
11、3883692571505139838336825716055,Hazard ratio(97.5%CI)PAmiodarone 1.05(0.81-1.36)0.66vs placeboICD therapy0.79(0.60-1.04)0.05vs placebo,Ischemic CHF,0.50.40.30.20.10,Follow-up(mo),Hazard ratio(97.5%CI)PAmiodarone 1.07(0.76-1.51)0.65vs placeboICD therapy0.73(0.50-1.07)0.06vs placebo,Nonischemic CHF,5-
12、yr eventratePlacebo0.432Amiodarone0.417ICD therapy0.359,5-yr event ratePlacebo0.279Amiodarone0.258ICD therapy0.214,10 ICD Primary Prevention Randomized Trials,Trialyearcause of CMPN RR-MADIT 1996 ischemic 1960.41CABG-Patch 1997 ischemic9001.08MUSTT 1999ischemic6590.46MADIT II 2002 ischemic12320.71CA
13、T 2002 non-ischemic1040.83AMIOVIRT 2003non-ischemic1030.87DEFINITE 2004non-ischemic4580.70DINAMIT 2004ischemic6741.10COMPANION 2004both15200.83SCD-HeFT 2005both25210.76-Total0.75,total nmortality-Non-ICD therapy3,72326.4%ICD therapy3,53018.5%Absolute mortality reduction 8%Relative mortality reductio
14、n 25%,10 ICD Primary Prevention Randomized Trials,ICD efficacy in risk subgroups,Widened QRS duration provide no significant benefit with ICD therapyICD therapy is associated with an equivalent reduction of mortality in elderly 75(MADIT II)ICD efficacy is similar in both genderRenal dysfunction is a
15、ssociated with higher mortality(non-arrhythmic death),and less ICD benefit.An inverse relationship between BP and risk of SD.ICD benefits more in patients with low BP.(MADIT II),In ICD primary prevention of sudden death trials,patients with NYHA class IV were excluded.,Reprinted with permission from
16、 Elsevier Science(The Lancet,1999;353:2001-2007).MERIT-HF study group.Effect of metoprolol CR/XL in chronic heart failure:metoprolol CR/XL randomized intervention trial in congestive heart failure(MERIT-HF).LANCET.1999;353:2005.,SCDa prominent mode of death,SCD in Heart Failure,ICD indication.Class
17、I,Survivors of cardiac arrest due to VF,VTHeart disease with sustained VTSyncope of undetermined origin,inducible VT/VFIschemic cardiomypathy,LVEF 40 daysOr nonischemic CardiomyopathyPrior MI,nonsustained VT,LVEF 40%,inducible VT/VF,ICD indication.Class III,Who have an expectation of survival 1 year
18、 even if they meet ICD criteriaWho have incessant VT or VFWho have drug refractory NYHA IV HF,not candidates for CRT or cardiac transplantVT or VF is amenable to surgical or catheter ablationVT or VF due to drugs,electrolyte imbalance,or trauma,Causes of Death in HCM744 Patients 125 Deaths,Maron:Cir
19、c,2000,CP1123516-5,Hypertrophic Cardiomyopathy,Class I for secondary prevention of SD:Sustained VT/VFClass IIa for primary prevention of SD:one or more major risk factor Family history of prematured SD Unexplained syncope Septal thickness 30mm Non-sustained VT abnormal BP response,A 30 yo male with
20、a FH sudden death and LVH 27mm,received a ICD4-month later.,Arrhythmogenic Right Ventricular Cardiomyopathy,SD can be the first manifestation of ARVCAnnual incidence of SD from 1%to 9%Class I:secondary prevention of SD in patients with history of sustained VT/VFClass IIa:primary prevention of SD in
21、high risk patients with one or more risk factor Extensive disease with LV involvement Family history of SD Unexplained syncope,ICD for special populationsGuideline 2008,Case#1,68 yo man had anterior STEMI 4 days ago and underwent emergent PCI with a drug-eluting stent placed in the proximal LAD.The
22、LVEF is 25%.Would you consider an ICD for primary prevention of sudden death before dismiss?A.YesB.noMADIT II:exclude patients with PCI/CABG 3 months,What would you do next?,Medical management:beta blocker,ARB,statinFollow-up in 3-6 months,If LVEF 35%,recommend ICD,Case#2,58 yo female had anterior M
23、I 10 years ago and had LAD angioplasty.Echo indicates a LVEF of 30%.She is in NYHA class I.Holter shows rare PVCs.Would you recommend an ICD?A.YesB.no,MADIT II candidate,Case#3,A 62 yo female had a diagnosis of dilated cardiomyopathy for 5 years.Despite optimal medical treatment,her LVEF remains under 35%.She is in NYHA class II,no palpitations or syncope.Holter shows rare PVCs.QRS duration is 112ms.Would you recommend an ICD?A.YesB.No,
