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ICD pro

  1. 1. ICD in prevenzione primariaDott. Brunacci MicheleDott. Bianco Daniele
  2. 2. The Problem: Sudden Cardiac Death► In the United States, accounts for 325,000 deaths per year.► Often the first presentation of heart disease.► More often than not, occur in people with structural heart or coronary disease.► Out of hospital cardiac arrests are unlikely to survive (rates from 1.4 - 20%). Those who do survive are often not neurologically intact.
  3. 3. Epidemiologia della Morte Improvvisa• In Italia i dati disponibili provengono dallo studio MONICA, condotto in Brianza, in cui è stata riportata un’incidenza di MCI di 0.95/1000 abitanti/anno, pari a 40-50 000 nuovi eventi ogni anno .• Evidenze più recenti sono offerte da uno studio basato su dati ISTAT del 2001, secondo cui la MCI rappresenterebbe il 10% della mortalità totale2, mentre elaborazioni CUSAS su dati ISTAT 2006 e Ministero della Salute portano questa percentuale al 10.84% 3 .
  4. 4. Dr. Mirowski (1924 – 1990)
  5. 5. Road to ICDs
  6. 6. Linee Guida
  7. 7. Implantable Cardioverter- Defibrillators I IIa IIb III ICD therapy is not indicated for patients who do not have a reasonable expectation of survival with an acceptable functional status for at least 1 year, even if they meet ICD implantation criteria specified in the Class I IIa IIb III I, IIa, and IIb recommendations above. ICD therapy is not indicated for patients with incessant VT or VF. I IIa IIb III ICD therapy is not indicated in patients with significant psychiatric illnesses that may be aggravated by device implantation or that may preclude systematic follow-up. I IIa IIb III ICD therapy is not indicated for NYHA Class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or cardiac resynchronization therapy defibrillators (CRT-D).All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation ofsurvival with good functional capacity for more than 1 year.
  8. 8. Implantable Cardioverter- Defibrillators I IIa IIb III ICD therapy is not indicated for syncope of undetermined cause in a patient without inducible ventricular tachyarrhythmias and without structural heart disease. ICD therapy is not indicated when VF or VT is amenable I IIa IIb III to surgical or catheter ablation (e.g., atrial arrhythmias associated with the Wolff-Parkinson-White syndrome, RV or LV outflow tract VT, idiopathic VT, or fascicular VT in the absence of structural heart disease). I IIa IIb III ICD therapy is not indicated for patients with ventricular tachyarrhythmias due to a completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma).All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation ofsurvival with good functional capacity for more than 1 year.
  9. 9. ICD as primary prevention: Ischemic Cardiomyopathy
  10. 10. I TRIALS : Multicenter Automatic Defibrillator Implantation Trial196 pz Risultati sulla sopravvivenzaCADFE ≤ 35% 1.0 Probabilità di sopravvivenzaTVNS asinTV SEF Defibrillatore 0.8 0.6 0.4 Terapia convenzionale 0.2 Valore P = 0,009 0.0 0 1 2 3 4 5 N. pazienti Anno Defibrillatore 95 80 53 31 17 3 Terapia convenzionale 101 67 48 29 17 0Moss AJ. N Engl J Med. 1996;335:1933-40.
  11. 11. I TRIALS : Multicenter Automatic Defibrillator Implantation Trial II 1232 pz 1.0 Risultati sulla sopravvivenza CAD >1 mese FE≤ 30% 0.9 sopravvivenza Probabilità di Defibrillatore 0.8 0.7 Terapia convenzionale P = 0,007 0.6 0.0 0 1 2 3 4 N. a rischio Anno Defibrillatore 742 503 (0,91) 274 (0,94) 110 (0,78) 9 Terapia convenzionale 490 329 (0.90) 170 (0,8) 65 (0,69) 3Moss AJ. N Engl J Med. 2002;346:877-83.
  12. 12. I TRIALS : Multicenter UnSustained Tachycardia Trial • 351 pazienti ischemici con TVNS asintomatiche e FE 40% • randomizzati a terapia antiaritmica SEF-guidata od ICD 0.5 I 3 gruppi di pazienti sono inducibili al SEF: Terapia AA SEF guidata efficace (NO ICD) Frequenza di eventi 0.4 No Terapia AA, NO ICD Terapia AA SEF guidata inefficace ICD 0.3 p < 0.001 0.2 0.1 0 0 1 2 3 4 5 Tempo successivo all’arruolamento (Anni)
  13. 13. I TRIALS : Sudden Cardiac Death in Heart Failure Trial2521 pzFE ≤35% Enpoint Primario : Mortalità per tutte le causeNYHA II/ III Mortality by Intention-to-treat52 % CAD48% idiop 23% Riduzione della Mortalità per tutte le cause per la Terapia con ICD (p-value 0.007) Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl. J Med. 2005; 352:225-237. © 2005 Massachusetts Medical Society. All rights reserved.
  14. 14. ICD as primary prevention: Non ischemic Cardiomyopathy
  15. 15. IDCM - Incidence and Prognosis• Prevalence is 36 per 100,000 population• Third most common cause of heart failure• Most frequent cause of heart transplantation• DCM accounts for approximately 10,000 deaths and 46,000 hospitalizations per year in the US• Complete recovery is rare
  16. 16. Cardiomiopatia dilatativa idiopatica Anni“ The NATURAL history of of idiopathic dilated cardiomyopathy ”Am J Cardiol 1981; 47:525
  17. 17. I TRIALS : Defibrillators In Non-Ischemic CardiomyopathyTreatment Evalutation 458 pz FE ≤ 30% TVNS-PVC Solo non CAD Alan Kadish, Alan Dyer, James P. Daubert et al

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