Indication and Timing for ICD and CRT

Transcription

1 Ischemic Cardiomyopathy: Indication and Timing for ICD and CRT Dr. Yahya Al Hebaishi Electrophysiology Division/Heart Failure Unit PSCC, Riyadh 1. Introduction 2. SCA in Ischemic Cardiomyopathy 3. Secondary Prevention of SCA 4. Primary Prevention of SCA 5. CRT in Ischemic Cardiomyopathy 6. Summary 1

2 Introduction Ischemic cardiomyopathy is the leading cause of HF in developed country Increasing prevalence in developing countries Associated with significant mortality and morbidity 1 He J, Ogden LG, Bazzano LA,et al. Arch Med 2001; 161: Mstewart S, Wilkinson D et al. Circulation 2008; 118:2360. SCA Relationship to HF and Reduced LVEF Reduced left ventricular ejection fraction (LVEF) remains the single most important risk factor for overall mortality and SCD 1 1 Prior SG, et al. Eur Heart J. 2001;22: MERIT-HF Study Group. Lancet. 1999;353: Sweeney MO, PACE. 2001;24:

3 Control Group Mortality % at 2 years % Sudden Cardiac Deaths 3/31/2015 SCD Rates in Ischemic CM Total Mortality Arrhythmic Mortality TRACE CAPRICORN EMIAT MADIT MUSTT Inducible MUSTT Registry MADIT II Total Mortality ~20 to 30%; SCD accounts for ~50% of Total Deaths Relation of LVEF to Risk of SCA % 5.1% LVEF Note: 56.5% of all SCA victims had an LVEF > 30% 2.8% 1.4% 0-30% 31-40% 41-50% > 50% devreede-swagemakers JJ, et al. J Am Coll Cardiol. 1997;30:

4 Underlying Arrhythmias of SCA Polymorphic VT 13% Bradycardia 17% Monomorphic VT 62% Primary VF 8% Bayés de Luna A, et al. Am Heart J. 1989;117: Severity of Heart Failure Modes of Death NYHA II 12% 24% 64% CHF Other Sudden Death (N = 103) NYHA III 26% 59% 15% CHF Other Sudden Death (N = 103) NYHA IV 33% 56% 11% CHF Other Sudden Death (N = 27) SCA Pump Failure NYHA Class II 64% 12% NYHA Class III 59% 26% NYHA Class IV 33% 56% MERIT-HF Study Group. Lancet.1999;353:

5 SCA Relationship to Ischemic CM In people who ve had an MI and have HF, SCD occurs at 4 times the rate of the general population. Adabag AS, et al. JAMA. 2008;300: SCA Relationship to Ischemic CM Myerburg et al, Circulation

6 SCA Relationship to Ischemic CM Circ Imaging 2012 Jul;5(4): SCA Relationship to Ischemic CM Kwon HD et al, Heart Feb;100(3):

7 SCA Chain of Survival Statistics Even in the best EMS/early defibrillation programs, it is difficult to achieve high survival times due to any SCA events not being witnessed and the difficulty of reaching victims within 6-8 minutes. 48% to 58% SCAs not witnessed 1,2 85% SCAs occur at home/non-public 1 4.6% to 8% estimated SCA out-of-hospital survival 1,2 1 Nichol G, et al. JAMA. 2008;300: Chugh SS, et al. J Am Coll Cardiol. 2004;44: Secondary Prevention of Sudden Cardiac Arrest 7

8 Patient Case #1 History 47 y.o. Saudi male 3V CAD s/p CABG 2011 NYHA Class I LVEF 45% per echo Smoker; has COPD Stable on optimal medical therapy Syncopal episodes; with documented episodes of VT Patient Case #1 Prevention of SCD: Should this patient be referred for an ICD evaluation? Why? 8

9 % Arrhythmic Death 3/31/2015 Arrhythmic Death in VT/VF Patients AVID Results in Non-ICD Arm % 11% 8% 1 Year 2 Years 3 Years Pratt CM. Circulation. 1998;98(suppl I): Randomized Clinical Trials ICD Therapy for the Secondary Prevention of SCA Mortality (%) Trial N Mean Age (yrs) Mean LVEF (%) Follow-up (mos) Control Therapy Control ICD P AVID ± ± 12 Amiodarone or sotalol CIDS ± Amiodarone CASH ± ± 34 Amiodarone or metoprolol The AVID Investigators. N Engl J Med. 1997;337: Kuck KH, et al. Circulation. 2000;102: Connolly SJ, et al. Circulation. 2000;101:

10 % Mortality Reduction w/ ICD Rx 3/31/2015 Secondary Prevention Trials: Reduction in Mortality with ICD Therapy % 58% Overall Death Arrhythmic Death % 23%* 20%* 33% 0 AVID CASH CIDS Non-significant results. 1 The AVID Investigators. N Engl J Med. 1997;337: Kuck Kh, et al. Circulation. 2000;102: Connolly SJ, et al. Circulation. 2000;101: ACC/AHA/HRS Class I ICD Secondary Prevention Guidelines for the Management of Ventricular Arrhythmias 1. History of SCA, VF, hemodynamically unstable sustained VT (exclude reversible causes) 2. Structural heart disease and spontaneous sustained VT, whether hemodynamically stable or unstable 3. Syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at EP study 4. Non-sustained VT due to prior MI, LVEF < 40% and inducible VT at EP study Epstein AE, et al. Circulation 2008;117:e

11 Primary Prevention of Sudden Cardiac Arrest Patient Case #2 History 66 y.o. saudi female Type II DM, mild renal dysfunction 6 months post-mi, successfully revascularized NYHA Class III LVEF is 32% (echo) Compliant with meds: antiplatelet, beta blocker, ACE-I, diuretics, statin, DM regimen 11

12 Patient Case #2 Prevention of SCD: Should this patient be referred for an ICD evaluation? Is there anything else you d want to know before making the decision? Randomized Clinical Trials Supporting Device Therapy ICD and CRT-D for the Primary Prevention of SCA Trial N Mean Age (yrs) Mean LVEF (%) Mean Follow-up (mos) Control Therapy SCD-HeFT 1,2 2, Optimal Medical Therapy COMPANION 3 1, months Optimal Medical Therapy MUSTT No EP-guided Therapy MADIT II 5 1, Optimal Medical Therapy Mortality (%) Control ICD P (CRT-D) Bardy GH, et al. N Engl J Med. 2005;352: Packer DL. Heart Rhythm. 2005;2:S38-S39 3 Bristow MR, et al. N Engl J Med. 2004;350: Buxton AE, et al. N Engl J Med. 1999;341: Moss AJ, et al. N Engl J Med. 2002;346:

13 % Mortality Reduction w/ ICD Rx 3/31/2015 Primary Prevention Post-MI and HF Trials Reduction in Mortality with ICD or CRT-D Therapy Overall Death Arrhythmic Death , SCD-HeFT COMPANION MUSTT MADIT-II 1 Bardy GH, et al. N Engl J Med. 2005;352: Packer DL. Heart Rhythm. 2005;2:S38-S39 3 Bristow MR, et al. N Engl J Med. 2004;350: Buxton AE, et al. N Engl J Med. 1999;341: Moss AJ, et al. N Engl J Med. 2002;346: Cardiac Resynchronization Therapy (CRT-D/P) 13

14 Cardiac Resynchronization Therapy (CRT-D/P) Left Bundle Branch Block More Prevalent with Impaired LV Systolic Function Preserved LVSF (1) 8% Impaired LVSF (1) 24% Moderate/Severe HF (2) 38% Cardiac Resynchronization Therapy (CRT-D/P) 45 months mortality One year mortality 11% QRS < 120 msec 16% QRS > 120 msec 34% QRS < 120 msec 49% QRS > 120 msec Baldasseroni S, et al. Eur Heart J 2002;23: N=5,517 Luliano et al, AHJ 2002; 143:

15 Cardiac Resynchronization Therapy (CRT-D/P) PATH-CHF I & II N 200 MUSTIC N 60 PAVE N 360 INSYNC ICD N 103 VECTOR N 201 RHYTHM ICD N REVERSE MADIT-CRT RAFT VIGOR CHF N 84 INSYNC I, II, III N 600 MIRACLE N 536 MIRACLE ICD N 1000 CONTAK CD N 1100 CARE HF N 800 COMPANION N 2200 Cardiac Resynchronization Therapy Timing? Patient selection? 15

16 Cardiac Resynchronization Therapy Timing? Patient selection? ICD and CRT-D Treatment Algorithms 16

17 ICD and CRT Treatment Algorithms Does patient have history of cardiac arrest, VF, or symptomatic VT? PATIENT NYHA Class I CHF NYHA Class II or III CHF Note: Pathway only begins after optimal medical therapy & coronary evaluation / intervention as appropriate YES 40 days post MI with EF 30% Is patient on optimal medical therapy? NO Optimize therapies or consult HF specialist Consult EP for possible ICD Consult EP for possible ICD YES Determine EF EF > 35% EF 35% 1. Consider referral to HF Specialist or HF Program. Ischemic Non-Ischemic Class III or IV CHF and QRS > 120 ms 2. Repeat diagnostics with change of symptoms. 40 days post MI OR 3 months post revascularization 3 months post diagnosis Consult EP for possible CRT-D Consult EP for possible ICD Consult EP for possible ICD Summary 17

18 Summary 1.SCA is a leading cause of death in patient with Ischemic Cardiomyopathy. 2.ICD is the only effective treatment for SCA. 3.Predictors of SCD: low LVEF, HF, prior MI and prior SCA or VT/VF event. Summary 4.CRT-D/P improves mortality and morbidity in properly selected patients with Ischemic CM 5.Surface ECG is the primary selection tool for CRT candidate 18

19 THANK YOU 19