ACC/AHA/HRS 2. 00. Guidelines for Device- Based Therapy of Cardiac Rhythm Abnormalities. Indications for ICDs have evolved considerably from initial implantation exclusively in patients who had survived 1 or more cardiac arrests and failed pharmacological therapy. Multiple clinical trials have established that ICD use results in improved survival compared with antiarrhythmic agents for secondary prevention of SCD. Large prospective, randomized, multicenter studies have also established that ICD therapy is effective for primary prevention of sudden death and improves total survival in selected patient populations who have not previously had a cardiac arrest or sustained VT. Electrophysiologic Testing Fogoros Pdf MergeResumen Se presentan las conclusiones consensuadas de un panel de arritm. El manuscrito se ha dividido. Il flutter atriale (flutter in inglese significa battito rapido, movimento rapido) Amiodarone was initially developed 3 decades ago for angina. On the basis of the number of prescriptions filled in retail pharmacies, amiodarone was the most-often-prescribed antiarrhythmic agent, accounting for 24.1% of the. Patients who survive life-threatening ventricular arrhythmias are at risk for recurrent arrhythmias. They can be treated with either an implantable cardioverter–defibrillator or antiarrhythmic drugs, but the relative. We acknowledge that the “ACC/AHA/ESC 2. Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death”1. LVEF of less than 4. ICD implantation for primary prevention of SCD. The LVEF used in clinical trials assessing the ICD for primary prevention of SCD ranged from less than or equal to 4. MUSTT (Multicenter Unsustained Ventricular Tachycardia Trial) to less than or equal to 3. MADIT II (Multicenter Automatic Defibrillator Implantation Trial II). Two trials, MADIT I (Multicenter Automatic Defibrillator Implantation Trial I)3. SCD- He. FT (Sudden Cardiac Death in Heart Failure Trial),3. LVEFs of less than or equal to 3. We examined the causes of death in patients previously resuscitated from out-of-hospital ventricular fibrillation. In 51 months, 234 patients were successfully resuscitated, hospitalized and discharged home. En sus inicios, el flutter. Implantable Cardioverter-Defibrillator Therapy for Secondary Prevention of Cardiac Arrest and Sustained Ventricular Tachycardia. Specific Disease States and Secondary Prevention of Cardiac Arrest or. Electrophysiologic Testing Fogoros Pdf995
The present writing committee reached the consensus that it would be best to have ICDs offered to patients with clinical profiles as similar to those included in the trials as possible. Having given careful consideration to the issues related to LVEF for these updated ICD guidelines, we have written these indications for ICDs based on the specific inclusion criteria for LVEF in the trials. Because of this, there may be some variation from previously published guidelines. We also acknowledge that the determination of LVEF lacks a “gold standard” and that there may be variation among the commonly used clinical techniques of LVEF determination. All clinical methods of LVEF determination lack precision, and the accuracy of techniques varies amongst laboratories and institutions. Given these considerations, the present writing committee recommends that the clinician use the LVEF determination that they believe is the most clinically accurate and appropriate in their institution. Patient selection, device and lead implantation, follow- up, and replacement are parts of a complex process that requires familiarity with device capabilities, adequate case volume, continuing education, and skill in the management of ventricular arrhythmias, thus mandating appropriate training and credentialing. Training program requirements for certification programs in clinical cardiac electrophysiology that include ICD implantation have been established by the American Board of Internal Medicine and the American Osteopathic Board of Internal Medicine. Individuals with basic certification in pediatric cardiology and cardiac surgery may receive similar training in ICD implantation. In 2. 00. 4, requirements for an “alternate training pathway” for those with substantial prior experience in pacemaker implantation were proposed by the HRS with a scheduled expiration for this alternate pathway in 2. Fifteen percent of physicians who implanted ICDs in 2. ICD registry that they had no formal training (electrophysiology fellowship, cardiac surgical training, or completion of the alternate pathway recommendation). The options for management of patients with ventricular arrhythmias include antiarrhythmic agents, catheter ablation, and surgery. The “ACC/AHA/ESC 2. Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death” have been published with a comprehensive review of management options, including antiarrhythmic agents, catheter ablation, surgery, and ICD therapy. Secondary Prevention of Sudden Cardiac Death. Implantable Cardioverter- Defibrillator Therapy for Secondary Prevention of Cardiac Arrest and Sustained Ventricular Tachycardia. Secondary prevention refers to prevention of SCD in those patients who have survived a prior sudden cardiac arrest or sustained VT. Evidence from multiple randomized controlled trials supports the use of ICDs for secondary prevention of sudden cardiac arrest regardless of the type of underlying structural heart disease. In patients resuscitated from cardiac arrest, the ICD is associated with clinically and statistically significant reductions in sudden death and total mortality compared with antiarrhythmic drug therapy in prospective randomized controlled trials. Trials of the ICD in patients who have been resuscitated from cardiac arrest demonstrate survival benefits with ICD therapy compared with electrophysiologically guided drug therapy with Class I agents, sotalol, and empirical amiodarone therapy. A large prospective, randomized secondary prevention trial comparing ICD therapy with Class III antiarrhythmic drug therapy (predominantly empirical amiodarone) demonstrated improved survival with ICD therapy. Unadjusted survival estimates for the ICD group and the antiarrhythmic drug group, respectively, were 8. Estimated relative risk reduction with ICD therapy was 3. CI 1. 9% to 5. 9%) at 1 year, 2. CI 6% to 4. 8%) at 2 years, and 3. CI 1. 0% to 5. 2%) at 3 years. Two other reports of large prospective trials in similar patient groups have shown similar results. The effectiveness of ICDs on outcomes in the recent large, prospective secondary prevention trials—AVID (Antiarrhythmics Versus Implantable Defibrillators),3. CASH (Cardiac Arrest Study Hamburg),3. CIDS (Canadian Implantable Defibrillator Study)3. Specifically, the ICD was associated with a 5. Thus, the secondary prevention trials have been robust and have shown a consistent effect of improved survival with ICD therapy compared with antiarrhythmic drug therapy across studies. Some individuals are resuscitated from cardiac arrest due to possible transient reversible causes. In such patients, myocardial revascularization may be performed when appropriate to reduce the risk of recurrent sudden death, with individualized decisions made with regard to the need for ICD therapy. Sustained monomorphic VT with prior MI is unlikely to be affected by revascularization. Myocardial revascularization may be sufficient therapy in patients surviving VF in association with myocardial ischemia when ventricular function is normal and there is no history of an MI. Unless electrolyte abnormalities are proven to be the sole cause of cardiac arrest, survivors of cardiac arrest in whom electrolyte abnormalities are discovered in general should be treated in a manner similar to that of cardiac arrest survivors without electrolyte abnormalities. Patients who experience sustained monomorphic VT in the presence of antiarrhythmic drugs or electrolyte abnormalities should also be evaluated and treated in a manner similar to patients with VT or VF without electrolyte abnormalities or antiarrhythmic drugs. Specific Disease States and Secondary Prevention of Cardiac Arrest or Sustained Ventricular Tachycardia. The majority of patients included in prior prospective randomized trials of patients resuscitated from cardiac arrest have had coronary artery disease with impaired ventricular function. Patients with other types of structural heart disease constitute a minority of patients in the secondary prevention trials. However, supplemental observational and registry data support the ICD as the preferred strategy over antiarrhythmic drug therapy for secondary prevention for patients resuscitated from cardiac arrest due to VT or fibrillation with coronary artery disease and other underlying structural heart disease. Coronary Artery Disease. Patients with coronary artery disease represent the majority of patients receiving devices in prior reports of patients surviving cardiac arrest. Evidence strongly supports a survival benefit in such patients with an ICD compared with other therapy options. Between 7. 3% and 8. AVID, CASH, and CIDS trials had underlying coronary artery disease. The mean LVEF ranged from 3. MI in the majority of patients. Multiple analyses have supported the notion that patients with reduced LV function may experience greater benefit with ICD therapy than with drug therapy. All patients undergoing evaluation for ICD therapy should be given optimum medical treatment for their underlying cardiovascular condition. Patients experiencing cardiac arrest due to VF that occurs more than 4. MI may be at risk for recurrent cardiac arrest. It is recommended that such patients be evaluated and optimally treated for ischemia. If there is evidence that directly and clearly implicates ischemia immediately preceding the onset of VF without evidence of a prior MI, the primary therapy should be complete coronary revascularization. If coronary revascularization is not possible and there is evidence of significant LV dysfunction, the primary therapy for patients resuscitated from VF should be the ICD. Patients with coronary artery disease who present with sustained monomorphic VT or VF and low- level elevations of cardiac biomarkers of myocyte injury/necrosis should be treated similarly to patients who have sustained VT and no documented rise in biomarkers. Prolonged episodes of sustained monomorphic VT or VF may be associated with a rise in cardiac troponin and creatine phosphokinase levels due to myocardial metabolic demands that exceed supply in patients with coronary artery disease. Evaluation for ischemia should be undertaken in such patients. However, when sustained VT or VF is accompanied by modest elevations of cardiac enzymes, it should not be assumed that a new MI was the cause of the sustained VT. Without other clinical data to support the occurrence of a new MI, it is reasonable to consider that such patients are at risk for recurrent sustained VT or VF. An error occurred while setting your user cookie. Please set your. browser to accept cookies to continue. This cookie stores just a. ID; no other information is captured. Accepting the NEJM cookie is.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. Archives
December 2016
Categories |