Innehållet i denna fil får endast användas för privat bruk. Kopiering eller annan användning kräver tillstånd från Frieder Braunschweig, Karolinska

Transcription

1 Innehållet i denna fil får endast användas för privat bruk. Kopiering eller annan användning kräver tillstånd från Frieder Braunschweig, Karolinska Universitetssjukhuset

2 ICD i själ och hjärta Omhändertagande av ICD-patienter efter chock Frieder Braunschweig MD PhD FESC Karolinska University Hospital Stockholm, Sweden

3 Evolution of ICD therapy Worldwide ICD implants (estim # per Year) First Human Implant FDA Approval CRT-D SCD HeFT Dual- Chamber COMPANION ICDs Transvenous Leads MADIT-II Biphasic Waveform MUSTT AVID CASH MADIT CIDS MADIT-CRT

4 Patient with ICD shock (s) New clinical picture Increasing incidence Symptoms with a broad range of severity Other medical conditions may be involved Causes psychological distress and anxiety Barrier to ICD implantation

5 Who gets involved? ICDspecialist EP ICD-nurse - Pacemaker Family practitioner technician Patient with CRT ICD Patient shock(s) HF General nurse/ cardiologist coordinator Internist Emergency Imaging medicine specialist Ambulance personal

6 Types of shock 1) Appropriate shocks - VF, VT 2) Unnecessary shocks - Haemodynamically tolerated NSVT - Haemodynamically tolerated VT sensitive for ATP 3) Inappropriate shocks - Supraventricular tachycardia (AF!) - Signal misinterpretation (EMG, interference, device failure) 4) Phantom shocks

7 How common? (%) Shocks (total) appropriate inappropriate Annual shock rate appr 10% (appr), 7.5% (inappr) AVID MADIT II DEFINITE SCD-HeFT COMPANION PREPARE n=492 n=719 n=227 n=811 n=594 n=700 24/12M 22M 29M 45M 16M 12M Secondary Primary Primary Primary Primary Primary ICM + DCM ICM DCM ICM + DCM ICM + DCM ICM + DCM ICD ICD ICD ICD (single lead) CRT-D ICD + CRT-D

8 Predictors of shock TOVA study: cohort study, n=1140 ICD, 95% secondary prevention Whang et al, Circulation. 2004;109:

9 Predictors of appropriate therapy MADIT II Probability of first appropriate ICD therapy for VT or VF n= VT terminated by ATP (147 pts) 305 VT terminated by shock (108 pts) 115 VF terminated by shock (36 pts) Moss et al, Circulation. 2004;110:

10 Predictors of appropriate therapy MADIT II Patients receiving 1 or more device therapies VT therapies VF therapies VF therapies 25 VT therapies First Therapy: VT First Therapy: VF 54% of repeat episodes occurring within 24 h, 67% within 1 w, 93% within 6 M Further predictors of electrical therapy: Higher NYHA-class Interim MI was no predictor Moss et al, Circulation. 2004;110:

11 Predictors of inappropriate shocks MADIT II Inappropriate shocks over time (11.5% of pts) AF (44%) SVT (36%) Inappr sensing (20%) Predictors of inappropriate shock Daubert et al JACC 2008;51:

12 Prognosis after ICD therapies MADIT II (ICD group analysis) Probability of CHF hospitalization 1.0 Probability of CHF hospitalization Post VF Therapy Post VT Therapy Prior to Therapy Years p< Patients at risk Post VF therapy (0.31) 1 (0.48) Post VT therapy (0.26) 29 (0.29) 8 (0.36) Prior to therapy (0.19) 165 (0.25) 53 (0.31) Moss et al, Circulation. 2004;110:

13 Prognosis after ICD therapies MADIT II (ICD group analysis) Probability of survival 1.0 Prior to Therapy Survival Years Post VT Therapy Post VF Therapy p< Patients at risk Prior to therapy (0.94) 206 (0.89) 76 (0.83) Post VT therapy (0.82) 29 (0.74) 8 (0.74) Post VF therapy (0.80) 3 (0.49) 1 (0.32) Moss et al, Circulation. 2004;110:

14 Prognosis after ICD shock (s) COMPANION (CRT-D group analysis) Free from All-cause Mortality (%) Free from Pump Failure Death and HF Hospitalization (%) Saxon et al, Circulation. 2006;114:

15 Prognosis after ICD shock (s) SCD-HeFT (ICD group analysis) n=811 (269 pts received shocks: 128 only appr, 87 only inappr, 54 both) Adjusted for baseline prognostic factors Death due to progressive HF: 42.9% Poole JE and al N Engl J Med 2008;359:

16 Poor prognosis after shock Possible explanations Ventricular arrhythmia = harbinger of end stage heart failure Atrial arrhythmia (inappr) = risk marker of heart failure Cellular damage and negative inotropic effects, activation of signaling pathways in the molecular cascade of HF Post traumatic stress

17 How the ICD works Patient management in the acute setting Electrical Storm General measures Drug therapy Device programming Catheter ablation Long-term and remote follow-up Anxiety and depression

18 Acute setting Patients experiencing one or more ICD shocks: Due to possible clinical instability and the potential severity of symptoms, we recommend that patients be evaluated by a clinical expert in due course

19 Acute setting: out of hospital chamber Single shock or 2 shocks delivered in a short sequence Multiple shocks (delivered within minutes to hours) Persisting severe symptoms? (e.g. shortness of breath, rapid palpitations, confusion, significant anxiety or distress) NO YES Contact the ICD clinic within the next working day Immediate medical evaluation Emergency Dept. or ICD clinic

20 Acute setting: emergency dept/ambulance Cardiac arrest: ECG: Clinical assessment: Contact with ICD clinic: Routine CPR Continuous monitoring, 12-lead ECG History, status, haemodynamics, Clear algorithm in place Tachycardia with haemodynamic compromise: External DC shock (ap) or iv amiodarone and /or beta-blockers Tachycardia without haemodynamic compromise: Drugs ICD reprogramming? Delivery of ATP? Repetitive ICD shocks in the absence of tachycardia or tachycardia that is haemodynamically well tolerated: Magnet!! Laboratory tests: Electrolytes, biomarkers, renal function, respiratory insufficiency, drug intoxication

21 Acute setting: device-realated issues Programmer: Real-time telemetry Device interrogation: Assess appropriateness of therapies Re-evaluate tachyarrhythmia settings Pay attention to warnings Check shock and pacing lead impedance Assess capture thresholds and sensing values Consider provocative manoeuvres Consider radiography (lead fracture)

22 Acute setting: assessment of stress Psychological reactions should be assessed! Shock Acute stress reaction Chronic anxiety Posttraumatic stress Depression Imbalance in autonomic tone May lower arrhythmia threshold

23 Acute setting: assessment of stress Easy things to do: - Ask for perception / interpretation of the shock - Ask for feelings of anxiety, helplessness or panic - Ask for sources of support (family, friendship, medical system) In traumatized patients: - Benzodiazepines - Consultation of a mental health expert

24 Electrical storm Definition: 3 or more distinct VT/VF episodes within 24 h More common in secondary (10-40%) vs primary prevention No apparent cause in majority of cases Potential triggering factors: - Drugs (pro-arrhythmia, non-compliance) - Worsening HF - Myocardial ischaemia - Emotional stress and anger - Alcohol excess - Electrolyte abnormalities - Early postoperative period

25 Electrical storm management (I) Reversible cause? Correct drug side effects Electrolyte disturbances Akut hjärtsvikt Myocardial ischaemia Drugs: iv amiodarone (or sotalol) Class I anti-arrhythmic drugs only on exception Lidocaine may be beneficial (ischaemia) Cave: increased cycle length of the arrhythmia (amiodarone)

26 Electrical storm management (II) Polymorphic VT Iv magnesium sulfate, potassium Overdrive pacing Isoproterenol (long QT syndrome) Betablockers, revascularization (ischaemia) Catheter ablation Other measures General anesthesia Mechanical circulatory support

27 VT ablation

28 General measures Evaluation of underlying heart disease Myocardial ischaemia Angiography Revascularization Catheter ablation Heart failure Disease progression? Therapy optimization (β-blocker) Optimize device (RV-, BiV-pacing) Check device diagnostics AV-junctional ablation (AF)

29 General measures Drug therapy for shock prevention Beta-blockers Amiodarone Sotalol Class IA or IC in selected cases Upstream therapy ACE-I Statins Aldosterone blockers Driving Treatment termination

30 General measures Optimal device programming Remote follow-up Upcoming talks

31 Device programming Individualized VT/VF detection zones ATP (up to 250bpm) Time to detection and therapy (up to 30/40)

32 Psychological distress * * Mark et al N Engl J Med 2008;359:

33 Psychological distress Mark et al N Engl J Med 2008;359:

34 Continuum of coping and distress C O N T I N U U M Coping Distress Feelings, thoughts and behaviours Optimism Active coping Faith in doctors Depressive coping Distraction /Denial Catastrophizing Resignation Reassurance Successful adjustment Realistic fear Adjustment disorder Shock phobia Moderate depression Generalized anxiety PTSD / personality change Severe / recurrent depression ICD as guardian angel ICD doesn t bother me ICD may fail Uncertain if ICD keeps me safe Avoid activities that might trigger shocks Avoid any activities, lose interest / confidence in life, permanent worry Permanent threat and arousal Wanting to be dead Modified from Sears and Conti, Heart. 2002;87:488-93

35 Vicious circle of stress and arrhythmia Autonomic imbalance HR HRV Inflammation Distress (Anxiety / Depression) Tachyarrhythmia / shock Increased perception, dysfunctional appraisal, maladaptive coping Personality Pre-existing distress Social support

36 Psychological distress Psychological symptoms and maladaptive coping should be identified early, preferably even before ICD implantation. ICD clinic Trustful physician-patient relationship Easy access to support and advice Merely listening to patient concerns may reduce their worries!! (Even a few minutes more can make a difference ) Providing information about disease, the ICD and how it works Complete self-report forms Family support Support groups Internet forums

37 Psychological distress: treatment Maintain or resume normal life as soon as possible in order to prevent phobic avoidance behaviour Cognitive behavioural therapy Relaxation Telephone counselling Exercise Selective serotonin receptor inhibitors (SSRIs) Data on treatment of distress in ICD patients are limited Mental health expert should be involved

38 Summary I The ICD patient with shock has become a frequent picture in cardiology and emergency medicine. Comprehensive knowledge about the management of ICD patients with shock(s) is required throughout the chain of care to provide appropriate treatment.

39 Summary II ICD shocks may occur in the context of severe cardiovascular conditions, are associated with an increased risk for subsequent events and may cause acute and chronic distress. Therefore it is important that patients who received one or multiple shocks are thoroughly assessed and to take all possible measures to prevent unnecessary or inappropriate shock delivery.

40