Appropriate Use Criteria for ICD/CRT Online Appendix Indications by Appropriate Use Ratings

Transcription

1 Appropriate Use Criteria for ICD/CRT Online Appendix Indications by Appropriate Use Ratings Table 1. Appropriate Indications (Median Score 7-9) Indication Appropriate Use Score (1-9) Section 1: Secondary Prevention CAD: VF or Hemodynamically Unstable VT Associated With Acute (<48 hours) MI (Newly Diagnosed, No Prior Assessment of LVEF) Total Revascularization Completed After Cardiac Arrest VF or polymorphic VT during acute (<48 hours) MI NSVT 4 days post MI Inducible VT/VF at EPS 4 days after revascularization VF or polymorphic VT during acute (<48 hours) MI NSVT 4 days post MI Inducible VT/VF at EPS 4 days after revascularization Obstructive CAD With Coronary Anatomy Not Amenable to Revascularization VF or polymorphic VT during acute (<48 hours) MI No EPS done CAD: VF or Hemodynamically Unstable VT <48 Hours (Acute) Post-Elective Revascularization No evidence for acute coronary occlusion, restenosis, preceding infarct, or other clearly reversible cause CAD: VF or Hemodynamically Unstable VT [No Recent MI ( 40 days) Prior to VF/VT and/or No Recent Revascularization ( 3 Months) Prior to VF/VT] No identifiable transient and completely reversible causes No need for revascularization identified by cath performed following VF/VT No identifiable transient and completely reversible causes No need for revascularization identified by cath performed following VF/VT No identifiable transient and completely reversible causes No need for revascularization identified by cath performed following VF/VT No revascularization performed (significant CAD present at cath performed following VF/VT, but coronary anatomy not amenable to revascularization) Page 1

2 No revascularization performed (significant CAD present at cath performed following VF/VT, but coronary anatomy not amenable to revascularization) No revascularization performed (significant CAD present at cath performed following VF/VT, but coronary anatomy not amenable to revascularization) Significant CAD identified at cath performed following VF/VT Complete revascularization performed after cardiac arrest Significant CAD identified at cath performed following VF/VT Complete revascularization performed after cardiac arrest Significant CAD identified at cath performed following VF/VT Incomplete revascularization performed after cardiac arrest Significant CAD identified at cath performed following VF/VT Incomplete revascularization performed after cardiac arrest Significant CAD identified at cath performed following VF/VT Incomplete revascularization performed after cardiac arrest CAD: VF or Hemodynamically Unstable VT During Exercise Testing Associated With Significant CAD No revascularization performed (significant CAD present at cath performed following VF/VT, but coronary anatomy not amenable to revascularization) No revascularization performed (significant CAD present at cath performed following VF/VT, but coronary anatomy not amenable to revascularization) No revascularization performed (significant CAD present at cath performed following VF/VT, but coronary anatomy not amenable to revascularization) Significant CAD identified at cath performed following VF/VT Complete revascularization performed after cardiac arrest Significant CAD identified at cath performed following VF/VT Incomplete revascularization performed after cardiac arrest Significant CAD identified at cath performed following VF/VT Incomplete revascularization performed after cardiac arrest Significant CAD identified at cath performed following VF/VT Incomplete revascularization performed after cardiac arrest Page 2

3 Dilated nonischemic cardiomyopathy Dilated nonischemic cardiomyopathy Dilated nonischemic cardiomyopathy No CAD: VF or Hemodynamically Unstable VT VF/Hemodynamically Unstable VT Associated With Other Structural Heart Disease 18. Myocardial sarcoidosis 20. Giant cell myocarditis Genetic Diseases with Sustained VT/VF 22. Congenital Long QT 23. Short QT 24. Catecholaminergic Polymorphic VT 25. Brugada syndrome 26. ARVC with successful ablation of all inducible monomorphic VTs 27. ARVC with unsuccessful attempt to ablate an inducible VT 28. ARVC without attempted ablation 29. Hypertrophic cardiomyopathy No Structural Heart Disease (LVEF 50%) or Known Genetic Causes of Sustained VT/VF Idiopathic VF With Normal Ventricular Function 32. No family history of sudden cardiac death 33. First degree relative with sudden cardiac death Syncope in Patients Without Structural Heart Disease Unexplained Syncope in a Patient With Long QT Syndrome 41. While on treatment with beta blockers 42. Not being treated with beta blockers Unexplained Syncope in a Patient With Brugada ECG Pattern 43. No EPS performed EPS performed No ventricular arrhythmias induced EPS performed Sustained VT/VF induced Unexplained Syncope in a Patient With Catecholaminergic Polymorphic VT 46. While on treatment with beta blockers Page 3

4 47. Not being treated with beta blockers Syncope in Patients With Coronary Artery Disease Unexplained Syncope With Prior MI and No Acute MI LVEF 36-49% 52. Electrophysiology study revealed inducible sustained VT/VF Unexplained Syncope With Prior MI and No Acute MI LVEF 35% 53. EPS not performed 54. Inducible VT/VF at EPS 55. Not inducible at EPS Syncope in Patients With Nonischemic Structural Heart Disease Unexplained Syncope in a Patient With Left Ventricular Hypertrophy Without Criteria for Hypertrophic Cardiomyopathy Left ventricular hypertrophy/hypertensive heart disease Unexplained Syncope in a Patient With Nonischemic Cardiomyopathy Nonischemic dilated cardiomyopathy Left ventricular non-compaction Left ventricular non-compaction 59. Hypertrophic cardiomyopathy 61. Tetralogy of Fallot with prior corrective surgery Unexplained Syncope in a Patient With Arrhythmogenic Right Ventricular Cardiomyopathy 62. No EPS performed 63. No inducible VT/VF at EPS Inducible VT/VF at EPS All inducible VTs successfully ablated Inducible VT/VF at EPS Ablation unsuccessful Sustained Hemodynamically Stable Monomorphic VT Associated With Structural Heart Disease CAD and prior MI CAD and prior MI CAD and prior MI Page 4

5 CAD and prior MI All inducible VTs successfully ablated CAD and prior MI Troponin elevation thought to be secondary to VT All inducible VTs successfully ablated CAD and prior MI Troponin elevation thought to be secondary to VT All inducible VTs successfully ablated Nonischemic dilated cardiomyopathy 69. Nonischemic dilated cardiomyopathy Nonischemic dilated cardiomyopathy Nonischemic dilated cardiomyopathy All inducible VTs successfully ablated Nonischemic dilated cardiomyopathy All inducible VTs successfully ablated Bundle branch reentry successfully ablated in a patient with nonischemic cardiomyopathy Bundle branch reentry successfully ablated in a patient with nonischemic cardiomyopathy Section 2: Primary Prevention Post Acute Myocardial Infarction ( 40 Days) LVEF 30% Revascularized After Acute MI EPS with inducible sustained VT (EPS performed after revascularization, within 30 days of MI) EPS with inducible sustained VT (EPS performed after revascularization, between 30 and 40 days after MI) Not Revascularized Obstructive CAD With Coronary Anatomy Not Amenable to Revascularization EPS with inducible sustained VT (EPS performed within 30 days of MI) EPS with inducible sustained VT (EPS performed between 30 and 40 days after MI) Post Acute Myocardial Infarction ( 40 Days) LVEF 31-40% Page 5

6 Revascularized for Acute MI EPS with inducible sustained VT (EPS performed after revascularization, within 30 days of MI) EPS with inducible sustained VT (EPS performed after revascularization, between 30 and 40 days after MI) Post Acute Myocardial Infarction ( 40 days) and Pre-Existing Chronic Cardiomyopathy ( 3 Months) LVEF 30% due to old infarction due to old infarction I-III due to nonischemic causes I-III Post Myocardial Infarction ( 40 days) and Need for Guideline-Directed Pacemaker Therapy Post MI (e.g., SSS, CHB, or Other Indications for Permanent Pacemaker) 94. Post Myocardial Infarction (>40 days) With Ischemic Cardiomyopathy No Recent PCI or CABG ( 3 Months) LVEF 30% LVEF 30% I LVEF 30% II LVEF 31-35% LVEF 31-35% I LVEF 31-35% II LVEF 36-40% Asymptomatic NSVT EPS with inducible sustained VT/VF Recent PCI or CABG ( 3 Months) Pre-existing documented cardiomyopathy on guideline-directed medical therapy >3 months prior to PCI/CABG Need for ppm post-revascularization (e.g., SSS, CHB, or other guideline-directed indications for permanent pacemaker) Page 6

7 Duration of Guideline-Directed Medical Therapy for Ischemic Cardiomyopathy Without Recent MI (Revascularization Not Indicated) On guideline-directed medical therapy <3 months NSVT EPS with inducible sustained VT On guideline-directed medical therapy 3 months LVEF 30% LVEF 30% I-III LVEF 31-35% LVEF 31-35% I-III Nonischemic Cardiomyopathy At Least 3 Months on Guideline-Directed Medical Therapy Recent Valve Surgery (i.e., Same Hospitalization or <3 Months) Which Included Incidental Bypass Graft Need for pacemaker and LV function not felt likely to improve Sarcoid heart disease Myotonic dystrophy Chagas disease Giant cell myocarditis Giant cell myocarditis LVEFF >35% Peripartum cardiomyopathy Persists >3 months postpartum Specific Etiologies Genetic Conditions (Excludes Syncope and Sustained VT, Covered in Section 1) 121. Hypertrophic cardiomyopathy with 1 or more risk factors 122. Arrhythmogenic right ventricular dysplasia/cardiomyopathy with no symptoms due to arrhythmia Congenital Long QT Syndrome With 1 or More Risk Factors Page 7

8 124. Receiving guideline-directed medical therapy Catecholaminergic Polymorphic VT With Nonsustained VT (Without Syncope) 125. Not receiving beta blockers, flecainide, or propafenone 126. Receiving beta blockers 127. Not tolerating or breakthrough nonsustained ventricular arrhythmias on beta blockers Incidentally Discovered Brugada by ECG (Type I ECG Pattern) In the Absence of Symptoms or Family History of Sudden Cardiac Death 129. Inducible VT or VF at EPS Familial Dilated/Nonischemic Cardiomyopathy (RV/LV) Associated With Sudden Cardiac Death 131. Evidence of structural cardiac disease but LVEF >35% 133. LV non-compaction with LVEF >35% Section 3: Comorbidities Special Conditions/Comorbidities in Patients for Primary Prevention (Meeting Indications of ICD Implant Related to HF Diagnosis With LVEF 30% on Guideline-Directed Medical Therapy >3 Months) Renal Disease Severe symptomatic peripheral vascular disease (e.g., peripheral interventions or clinical claudication) I Severe symptomatic peripheral vascular disease (e.g., peripheral interventions or clinical claudication) II Class IV Heart Failure 147. On waiting list for heart transplant Section 4: ICD Generator Replacement at ERI Primary Prevention ICD at Initial Implant No Clinically Relevant Ventricular Arrhythmias on ICD Since Implant Patient received primary prevention ICD when LVEF was 35% LVEF now unchanged No Clinically Relevant Ventricular Arrhythmias on ICD Since Implant (Now Has Prognosis <1 Year) Patient received primary prevention ICD Pacemaker dependent Replace with a pacemaker Clinically Relevant Ventricular Arrhythmias on ICD Since Implant Patient received primary prevention ICD when LVEF was 35% LVEF now unchanged Patient received primary prevention ICD when LVEF was 35% LVEF now 36-49% Patient received primary prevention ICD when LVEF was 35% LVEF now 50%% (normalized) Page 8

9 Patient received secondary prevention ICD No ventricular arrhythmia since initial implant Secondary Prevention ICD at Initial Implant Patient received secondary prevention ICD Had ventricular tachyarrhythmias in the monitor zone lasting >30 seconds, but no treated ventricular arrhythmias since initial implant Patient received secondary prevention ICD Had ventricular arrhythmias receiving ICD therapy since implant Primary Prevention at Initial Implant: Replacement of CRT-ICD for ERI Patient received a CRT-ICD when LVEF was 35% LVEF now unchanged (despite clinical improvement) Replace With CRT-ICD Patient received a CRT-ICD when LVEF was 35% LVEF now 36-49% Replace With CRT-ICD Patient received a CRT-ICD when LVEF was 35% LVEF now 50% (normalized) Replace With CRT-ICD Secondary Prevention at Initial Implant: Replacement of CRT-ICD for ERI Patient received a CRT-ICD when LVEF was 35% LVEF now unchanged (despite clinical improvement) Replace With CRT-ICD Patient received a CRT-ICD when LVEF was 35% LVEF now 36-49% Replace With CRT-ICD Patient received a CRT-ICD when LVEF was 35% LVEF now 50% (normalized) Replace With CRT-ICD Section 5: Dual Chamber ICD (As Opposed to Single Chamber ICD for Patients Who Meet Criteria for ICD Implantation) Conduction System Abnormalities Sinus Node Dysfunction Who Meets Criteria for ICD Sinus node dysfunction (includes sinus pauses, chronotropic incompetence, or marked sinus bradycardia that results from drug therapy required to treat other conditions) Symptomatic Resting sinus bradycardia (resting heart rate <50 bpm) Asymptomatic Conduction System Abnormalities AV Conduction Disease Who Meets Criteria for ICD (Narrow QRS <120 msec) Third degree AV block or advanced second degree AV block (Mobitz II AV block or high degree AV block) Symptomatic CRT not indicted Page 9

10 Third degree AV block or advanced second degree AV block (Mobitz II AV block or high degree AV block) Asymptomatic CRT not indicated Alternating RBBB and LBBB CRT not indicated Conduction System Abnormalities Bundle Branch Block Conduction System Abnormalities Acute MI or Ischemic Event Transient AV block thought to be secondary to ischemia Status post successful revascularization Chronic Wide QRS ( 120 msec) Transient AV block thought to be secondary to ischemia Not amenable to revascularization Chronic Wide QRS ( 120 msec) Conduction System Abnormalities Cardiac Valve Surgery 184. New LBBB and first degree AV block Tachyarrhythmias Atrial Arrhythmias or Supraventricular Tachycardia (SVT) and No Standard Pacing Indications 186. Paroxysmal atrial arrhythmias Slow Ventricular Arrhythmias Known Active patient Known slow VT that overlaps with sinus tachycardia rate Congenital Long QT Syndrome ICD for secondary prevention Congenital Long QT Syndrome ICD for primary prevention Genetic Disorders Section 6: CRT No Prior Implant Ischemic Cardiomyopathy LVEF 30% I II-amb IV Page 10

11 I II-amb IV II-amb IV Ischemic Cardiomyopathy LVEF 31-35% I II-amb IV I II-amb IV II-amb IV Nonischemic Cardiomyopathy LVEF 30% 206. I Page 11

12 II-amb IV I II-amb IV II-amb IV Nonischemic Cardiomyopathy LVEF 31-35% I II-amb IV I II-amb IV II-amb IV Pre-existing or Anticipated RV Pacing With a Clinical Indication for ICD or Pacemaker Implantation RV pacing anticipated >40% -II RV pacing anticipated >40% II-amb IV Intrinsic Narrow QRS, LVEF 35% Refractory Class III/IV CHF <3 Months Post Revascularization and/or 40 Days Post MI Page 12

13 No Other Indication for Ventricular Pacing LVEF 35% Table 2. May Be Appropriate Indications (Median Score 4-6) Indication Appropriate Use Score (1-9) Section 1: Secondary Prevention CAD: VF or Hemodynamically Unstable VT Associated With Acute (<48 hours) MI (Newly Diagnosed, No Prior Assessment of LVEF) Total Revascularization Completed After Cardiac Arrest Single episode VF or polymorphic VT during acute (<48 hours) MI Recurrent VF or polymorphic VT during acute (<48 hours) MI VF or polymorphic VT during acute (<48 hours) MI NSVT 4 days post MI Inducible VT/VF at EPS 4 days after revascularization No Revascularization Indicated (i.e., No Significant CAD) Single episode VF or polymorphic VT during acute (<48 hours) MI Recurrent VF or polymorphic VT during acute (<48 hours) MI Obstructive CAD With Coronary Anatomy Not Amenable to Revascularization VF or polymorphic VT during acute (<48 hours) MI No EPS done VF or polymorphic VT during acute (<48 hours) MI No EPS done CAD: VF or Hemodynamically Unstable VT <48 Hours (Acute) Post-Elective Revascularization No evidence for acute coronary occlusion, restenosis, preceding infarct, or other clearly reversible cause Page 13

14 No evidence for acute coronary occlusion, restenosis, preceding infarct, or other clearly reversible cause CAD: VF or Hemodynamically Unstable VT [No Recent MI ( 40 days) Prior to VF/VT and/or No Recent Revascularization ( 3 Months) Prior to VF/VT] Significant CAD identified at cath performed following VF/VT Complete revascularization performed after cardiac arrest CAD: VF or Hemodynamically Unstable VT During Exercise Testing Associated With Significant CAD Significant CAD identified at cath performed following VF/VT Complete revascularization performed after cardiac arrest Significant CAD identified at cath performed following VF/VT Complete revascularization performed after cardiac arrest VT/VF associated with cocaine abuse VT/VF associated with cocaine abuse No CAD: VF or Hemodynamically Unstable VT Severe Valvular Disease VT/VF <48 Hours After Surgical Repair or Replacement of Aortic or Mitral Valve No evidence of post-operative valvular dysfunction No evidence of post-operative valvular dysfunction No evidence of post-operative valvular dysfunction VF/Hemodynamically Unstable VT Associated With Other Structural Heart Disease 19. Myocarditis; not giant cell myocarditis 21. Takatsubo cardiomyopathy (stress induced cardiomyopathy, apical ballooning syndrome) 48 hours of onset of symptoms No Structural Heart Disease (LVEF 50%) or Known Genetic Causes of Sustained VT/VF Other Causes 34. Bradycardia dependent VT/VF Syncope in Patients With Coronary Artery Disease Unexplained Syncope With Prior MI and No Acute MI LVEF 36-49% 50. Electrophysiology study failed to define a cause of syncope Nonobstructive CAD; revascularization not indicated Page 14

15 51. Electrophysiology study failed to define a cause of syncope Obstructive CAD; not amenable to revascularization Syncope in Patients With Nonischemic Structural Heart Disease Unexplained Syncope in a Patient With Left Ventricular Hypertrophy Without Criteria for Hypertrophic Cardiomyopathy Left ventricular hypertrophy/hypertensive heart disease Unexplained Syncope in a Patient With Nonischemic Cardiomyopathy Nonischemic dilated cardiomyopathy Nonischemic dilated cardiomyopathy Left ventricular non-compaction 60. Cardiac amyloidosis Sustained Hemodynamically Stable Monomorphic VT Associated With Structural Heart Disease CAD and prior MI All inducible VTs successfully ablated CAD and prior MI All inducible VTs successfully ablated CAD and prior MI Troponin elevation thought to be secondary to VT All inducible VTs successfully ablated Nonischemic dilated cardiomyopathy All inducible VTs successfully ablated Bundle branch reentry successfully ablated in a patient with nonischemic cardiomyopathy Section 2: Primary Prevention Post Acute Myocardial Infarction ( 40 Days) LVEF 30% Revascularized After Acute MI EPS without inducible VT (EPS performed after revascularization, between 30 and 40 days after MI) Not Revascularized Obstructive CAD With Coronary Anatomy Not Amenable to Revascularization No EPS performed EPS without inducible VT (EPS performed within 30 days of MI) Page 15

16 84. EPS without inducible VT(EPS performed between 30 and 40 days after MI) Post Myocardial Infarction ( 40 days) and Need for Guideline-Directed Pacemaker Therapy Post MI (e.g., SSS, CHB, or Other Indications for Permanent Pacemaker) 95. LVEF 36-40% Post Myocardial Infarction (>40 days) With Ischemic Cardiomyopathy No Recent PCI or CABG ( 3 Months) LVEF 36-40% Asymptomatic NSVT No EPS LVEF 36-40% Asymptomatic NSVT EPS without inducible VT/VF No known pre-existing cardiomyopathy Recent PCI or CABG ( 3 Months) LVEF 36-40% Need for ppm post-revascularization (e.g., SSS, CHB, or other guideline-directed indications for permanent pacemaker) Duration of Guideline-Directed Medical Therapy for Ischemic Cardiomyopathy Without Recent MI (Revascularization Not Indicated) On guideline-directed medical therapy for <3 months LVEF 30% I-III Nonischemic Cardiomyopathy Treatment Since Diagnosis <3 Months Newly Diagnosed Cardiomyopathy With Narrow QRS At Least 3 Months on Guideline-Directed Medical Therapy 112. LVEF 36-40% Specific Etiologies Sarcoid heart disease LVEF >35% Myotonic dystrophy LVEF >35% Chagas disease LVEF >35% Amyloidosis with heart failure Amyloidosis with heart failure LVEF >35% Page 16

17 120. Peripartum cardiomyopathy Persists >3 months postpartum LVEF >35% Genetic Conditions (Excludes Syncope and Sustained VT, Covered in Section 1) Congenital Long QT Syndrome With 1 or More Risk Factors 123. Not receiving guideline-directed medical therapy Familial Dilated/Nonischemic Cardiomyopathy (RV/LV) Associated With Sudden Cardiac Death 132. Normal ECG and echo but carrying the implicated gene Section 3: Comorbidities Special Conditions/Comorbidities in Patients for Primary Prevention (Meeting Indications of ICD Implant Related to HF Diagnosis With LVEF 30% on Guideline-Directed Medical Therapy >3 Months) Life Expectancy 135. Noncardiac disease with life expectancy 1-2 years Elderly years old years old I years old II 90 years old I 90 years old II Cognitive Impairment Not able to understand or provide informed consent Health care proxy consents to ICD Renal Disease Severe symptomatic peripheral vascular disease (e.g., peripheral interventions or clinical claudication) Chronic kidney disease on dialysis Not a candidate for renal transplant Chronic kidney disease on dialysis Not a candidate for renal transplant I Chronic kidney disease on dialysis Not a candidate for renal transplant II Page 17

18 Chronic kidney disease with CrCl <30 cc, not yet on dialysis but candidate for dialysis Chronic kidney disease with CrCl <30 cc, not yet on dialysis but candidate for dialysis I Chronic kidney disease with CrCl <30 cc, not yet on dialysis but candidate for dialysis II Class IV Heart Failure 149. Patient with a VAD Section 4: ICD Generator Replacement at ERI No Clinically Relevant Ventricular Arrhythmias on ICD Since Implant Patient received primary prevention ICD when LVEF was 35% LVEF now 36-49% Patient received primary prevention ICD when LVEF was 35% LVEF now 50% (normalized) No Clinically Relevant Ventricular Arrhythmias on ICD Since Implant (Now Has Prognosis <1 Year) Patient received primary prevention ICD Pacemaker dependent Replace with ICD Clinically Relevant Ventricular Arrhythmias on ICD Since Implant Patient received primary prevention ICD Now has prognosis <1 year Primary Prevention at Initial Implant: Replacement of CRT-ICD for ERI Patient received a CRT-ICD when LVEF was 35% LVEF now 36-49% Replace with CRT-Pacemaker Patient received a CRT-ICD when LVEF was 35% LVEF now 50% (normalized) Replace with CRT-Pacemaker Section 5: Dual Chamber ICD (As Opposed to Single Chamber ICD for Patients Who Meet Criteria for ICD Implantation) Conduction System Abnormalities AV Conduction Disease Who Meets Criteria for ICD (Narrow QRS <120 msec) Mobitz Type I AV block Asymptomatic CRT not indicated First degree AV block (PR <300 msec) Asymptomatic First degree AV block (PR 300 msec) Asymptomatic Conduction System Abnormalities Bundle Branch Block Page 18

19 with normal PR interval CRT not indicated with first degree AV block CRT not indicated with normal PR interval Bifascicular block (RBBB/LAFB or RBBB/LPFB) CRT not indicated with first degree AV block Bifascicular block (RBBB/LAFB or RBBB /LPFB) CRT not indicated Conduction System Abnormalities Acute MI or Ischemic Event Transient AV block thought to be secondary to ischemia Status post successful revascularization Narrow QRS (<120 msec) Transient AV block thought to be secondary to ischemia Not amenable to revascularization Narrow QRS (<120 msec) Transient AV block Narrow QRS (<120 msec) with normal PR interval Asymptomatic Conduction System Abnormalities Cardiac Valve Surgery No Conduction Abnormalities Meets Criteria for ICD (Narrow QRS <120 msec) Tachyarrhythmias Atrial Arrhythmias or Supraventricular Tachycardia (SVT) and No Standard Pacing Indications Underlying structural heart disease (e.g., ischemic or nonischemic CM) No known paroxysmal atrial arrhythmias or SVT Structurally normal heart No known paroxysmal atrial arrhythmias or SVT Hypertrophic cardiomyopathy Narrow QRS (<120 msec) No standard bradycardia pacing indications Hypertrophic cardiomyopathy Wide QRS ( 120 msec) No standard bradycardia pacing indications Genetic Disorders Page 19

20 Section 6: CRT No Prior Implant Ischemic Cardiomyopathy LVEF 30% II-amb IV I Ischemic Cardiomyopathy LVEF 31-35% II-amb IV I Nonischemic Cardiomyopathy LVEF 30% 206. Page 20

21 II-amb IV I Nonischemic Cardiomyopathy LVEF 31-35% II-amb IV I LVEF >35% of Any Etiology (ICD Indicated) II-amb IV -II Page 21

22 II-amb IV II-amb IV LVEF 35% of Any Etiology NYHA Class IV On Intravenous Inotropic Support Pre-existing or Anticipated RV Pacing With a Clinical Indication for ICD or Pacemaker Implantation RV pacing anticipated 40% -II RV pacing anticipated 40% II-amb IV RV pacing anticipated 40% II-amb IV RV pacing anticipated >40% -II Intrinsic Narrow QRS, LVEF 35% Intrinsic Narrow QRS, LVEF >35% 227. RV pacing anticipated >40% II-amb IV Refractory Class III/IV CHF <3 Months Post Revascularization and/or 40 Days Post No Other Indication for Ventricular Pacing LVEF 35% No Other Indication for Ventricular Pacing LVEF 36-50% Page 22

23 Table 3. Rarely Appropriate Indications (Median Score 1-3) Indication Appropriate Use Score (1-9) Section 1: Secondary Prevention CAD: VF or Hemodynamically Unstable VT Associated With Acute (<48 hours) MI (Newly Diagnosed, No Prior Assessment of LVEF) Total Revascularization Completed After Cardiac Arrest Single episode VF or polymorphic VT during acute (<48 hours) MI Single episode VF or polymorphic VT during acute (<48 hours) MI Recurrent VF or polymorphic VT during acute (<48 hours) MI Recurrent VF or polymorphic VT during acute (<48 hours) MI No Revascularization Indicated (i.e., No Significant CAD) Single episode VF or polymorphic VT during acute (<48 hours) MI Single episode VF or polymorphic VT during acute (<48 hours) MI Recurrent VF or polymorphic VT during acute (<48 hours) MI Recurrent VF or polymorphic VT during acute (<48 hours) MI VT/VF associated with cocaine abuse No CAD: VF or Hemodynamically Unstable VT No Structural Heart Disease (LVEF 50%) or Known Genetic Causes of Sustained VT/VF Pharmacologically Induced Sustained VT/VF R (2) R (2) R (2) 30. Non-torsades de pointes VT/VF in the setting of antiarrhythmic drug use 31. Drug induced torsades de pointes R (2) Other Causes 35. WPW syndrome with VT/VF Pathway successfully ablated Structurally normal heart Syncope in Patients Without Structural Heart Disease R (2) Unexplained Syncope With No Structural Heart Disease or Genetically Transmitted Ventricular Arrhythmias 36. Normal ECG and structurally normal heart Family history of sudden death Page 23

24 Normal ECG and structurally normal heart No known family history of sudden death Unexplained Syncope in a Patient With RV or LV Outflow Tract Tachycardia (Idiopathic VT) With Normal LV and RV Function and Anatomy Documented sustained monomorphic VT (LBBB/inferior axis) at the time of syncope Ablation not yet attempted Documented history of sustained monomorphic VT (LBBB/inferior axis) but not recorded at the time of syncope Ablation not yet attempted Documented sustained monomorphic VT (LBBB/inferior axis) at the time of syncope Ablation successful Syncope in Patients With Coronary Artery Disease Unexplained Syncope With Coronary Heart Disease and No Acute MI LVEF 50% Electrophysiology study and noninvasive investigations failed to define a cause of syncope No prior MI Nonobstructive CAD; revascularization not indicated Electrophysiology study and noninvasive investigations failed to define a cause of syncope No prior MI Obstructive CAD; not amenable to revascularization Syncope in Patients With Nonischemic Structural Heart Disease R (2) R (2) R (2) R (2) Unexplained Syncope in a Patient With Left Ventricular Hypertrophy Without Criteria for Hypertrophic Cardiomyopathy 56. Left ventricular hypertrophy/hypertensive heart disease Section 2: Primary Prevention Post Acute Myocardial Infarction ( 40 Days) LVEF 30% Plan for Revascularization (Not Yet Performed) 72. No NSVT R (2) Revascularized After Acute MI 73. No NSVT R (2) No EPS performed EPS without inducible VT (EPS performed after revascularization, within 30 days after MI) Not Revascularized Obstructive CAD With Coronary Anatomy Not Amenable to Revascularization 79. No NSVT R (2) Post Acute Myocardial Infarction ( 40 Days) LVEF 31-40% Revascularized for Acute MI 85. No NSVT R (2) Page 24

25 No EPS performed EPS without inducible VT (EPS performed after revascularization, within 30 days of MI) EPS without inducible VT (EPS performed after revascularization, between 30 and 40 days after MI) LVEF 30% LVEF 31-35% LVEF 31-35% I-III Acute lymphocytic myocarditis Newly diagnosed (<3 months ago) Acute lymphocytic myocarditis Newly diagnosed (<3 months ago) LVEF >35% Nonischemic Cardiomyopathy Treatment Since Diagnosis <3 Months Newly Diagnosed Cardiomyopathy With Narrow QRS Specific Etiologies Genetic Conditions (Excludes Syncope and Sustained VT, Covered in Section 1) Incidentally Discovered Brugada by ECG (Type I ECG Pattern) In the Absence of Symptoms or Family History of Sudden Cardiac Death 128. No EPS 130. No inducible VT or VF at EPS Section 3: Comorbidities Special Conditions/Comorbidities in Patients for Primary Prevention (Meeting Indications of ICD Implant Related to HF Diagnosis With LVEF 30% on Guideline-Directed Medical Therapy >3 Months) Life Expectancy 134. Life expectancy <1 year from cardiac or noncardiac conditions Elderly years old NHYA Class I 139. Cognitive Impairment Not able to understand or provide informed consent No health care proxy can be identified Advanced Psychiatric Impairment Page 25

26 140. Significant psychiatric illnesses that may be aggravated by device implantation or that may preclude regular follow-up Other Comorbidities 144. IV drug abuse (ongoing) R (2) 145. Unresolved infection associated with risk for hematogenous seeding R (2) 146. Non-compliance with medical therapy and follow-up Class IV Heart Failure Not candidate for cardiac transplantation, CRT, or VAD Refractory symptoms on oral therapy Not a candidate for transplant or VAD Does not meet CRT criteria Planned outpatient continuous intravenous inotropic therapy for palliation R (2) R (2) Section 4: ICD Generator Replacement at ERI Primary Prevention ICD at Initial Implant No Clinically Relevant Ventricular Arrhythmias on ICD Since Implant (Now Has Prognosis <1 Year) Patient received primary prevention ICD Not pacemaker dependent Primary Prevention at Initial Implant: Replacement of CRT-ICD for ERI Patient received a CRT-ICD when LVEF was 35% LVEF now unchanged (despite clinical improvement) Replace with CRT-Pacemaker Secondary Prevention at Initial Implant: Replacement of CRT-ICD for ERI Patient received a CRT-ICD when LVEF was 35% LVEF now 36-49% Replace with CRT-Pacemaker Patient received a CRT-ICD when LVEF was 35% LVEF now 50% (normalized) Replace with CRT-Pacemaker R (2) Section 5: Dual Chamber ICD (As Opposed to Single Chamber ICD for Patients Who Meet Criteria for ICD Implantation) Tachyarrhythmias Atrial Arrhythmias or Supraventricular Tachycardia (SVT) and No Standard Pacing Indications 189. Long-standing persistent or permanent atrial fibrillation or atrial flutter No plans for cardioversion or rhythm control Section 6: CRT No Prior Implant Ischemic Cardiomyopathy LVEF 30% 195. QRS <120 msec Page 26

27 QRS <120 msec I QRS <120 msec II-amb IV I Ischemic Cardiomyopathy LVEF 31-35% QRS <120 msec QRS <120 msec I QRS <120 msec II-amb IV I Nonischemic Cardiomyopathy LVEF 30% QRS <120 msec QRS <120 msec I QRS <120 msec II-amb IV Page 27

28 I Nonischemic Cardiomyopathy LVEF 31-35% QRS <120 msec QRS <120 msec I QRS <120 msec II-amb IV I LVEF >35% of Any Etiology (ICD Indicated) QRS <120 msec -II QRS <120 msec II-amb IV -II -II II-amb IV R (2) Page 28

29 II Pre-existing or Anticipated RV Pacing With a Clinical Indication for ICD or Pacemaker Implantation RV pacing anticipated 40% -II Intrinsic Narrow QRS, LVEF >35% Refractory Class III/IV CHF <3 Months Post Revascularization and/or 40 Days Post MI No Other Indication for Ventricular Pacing LVEF 36-50% R (2) Page 29