ΕΜΦΤΣΕΤΙΜΟΙ ΑΠΙΝΙΔΩΣΕ ΚΑΙ ΑΙΦΝΙΔΙΟ ΚΑΡΔΙΑΚΟ ΘΑΝΑΣΟ. Κωνσταντίνος Γκατζούλης

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1 ΕΛΛΗΝΙΚΗ ΚΑΡΔΙΟΛΟΓΙΚΗ ΕΤΑΙΡΕΙΑ ΕΜΦΤΣΕΤΙΜΟΙ ΑΠΙΝΙΔΩΣΕ ΚΑΙ ΑΙΦΝΙΔΙΟ ΚΑΡΔΙΑΚΟ ΘΑΝΑΣΟ Κωνσταντίνος Γκατζούλης Αναπληρωηής Καθηγηηής Καρδιολογίας Υπεύθσνος εργαζηηρίοσ ηλεκηροθσζιολογίας «ΙΠΠΟΚΡΑΤΕΙΟ» Γ.Ν. ΑΘΗΝΩΝ ΣΕΜΙΝΑΡΙΑ ΟΜΑΔΩΝ ΕΡΓΑΣΙΑΣ ΦΕΒΡΟΥΑΡΙΟΣ 2012 ΘΕΣΣΑΛΟΝΙΚΗ

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4 Cumulative risk of fatal events in secondary SCD prevention trials (AVID, CIDS, CASH) Connoly SJ et al, EHJ 2000

5 M.R.Gold και S.Nisam, PACE 23(ptII):1981, 2000

6 Moss A et al, For the MADIT II, NEJM, 2002

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9 ICD prevention of SCD Secondary Primary Effectiveness moderate high Cost high lower Survival probability probably high (1st event) low Secondary trials Primary trials AVID, CIDS, CASH MADIT, MUSTT, MADIT II, CABG-PATCH

10 ICD primary prevention of SCD Disease LVEF Complex VAs LPs MADIT CAD/MI <35% NSVT? MUSTT CAD/MI <40% NSVT? MADIT II CAD/MI <30%? - CABG PATCH CAD/MI <35%? Yes

11 Camm AJ, Nisam S, EHJ 2000

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13 Concerns in primary ICD prevention Cost Health care system resources Periimplantation and long term complications Type of ICD Psychological problems encountered True effectiveness

14 Survival with AID-Limitations Severity of underlying heart disease Type of underlying heart disease Perioperative and long term complications Volume and weight of implanted devices Longevity of implanted devices Deterioration of arrhythmia substrate (ES)

15 CAD - Primary prevention Risk stratifiers Echocardiography (LVEF, aneurysm, LV dilatation) Electrocardiography lead ECG -- SAECG -- T wave alternans Holter monitor Programmed Ventricular stimulation

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18 Kαρδιακζς Παθήσεις, 2001

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20 ML. 64 M, OEM, LVaneurysm and Sust VT

21 Στεφανιαίοσ αςκενισ με υποτροπιάηουςα κοιλιακι ταχυκαρδία και αποκλειςμό του αριςτεροφ ςκζλουσ. Καρδιακζς Παθήσεις, 2001

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24 Circulation 69, No 2, , 1984

25 Η κετικι προγνωςτικι ακρίβεια για τθν εκδιλωςθ μειηόνων αρρυκμιολογικών ςυμβάντων κατά τθ μετεμφραγματικι περίοδο, βελτιώνεται ςθμαντικά όταν πολλαπλοί προγνωςτικοί δείκτεσ εμφανίηουν πακολογικά ευριματα Καρδιακζς Παθήσεις, 2001

26 174 post MI pts 98 pts with SVT All studied with SAECG, HM, CATH Kanovsky, Circ 1984

27 ΠΡΟΓΝΩΣΙΚΗ ΗΜΑΙΑ ΠΡΟΚΛΗΗ ΕΚΣ Ε ΜΕΣΕΜΦΡΑΓΜΑΣΙΚΟΤ ΑΘ φνολο μελ. Αςκ (+)ΕΚΣ (VT/VF) (-)ΕΚΣ (VT/VF) % 69.5% FU (arrhytmic events) 25.4% 5% Σροποποιθμζνο από Nacarella Current opinion in Cardiology 2000

28 Results Univariate analysis HIGH RISK (n=24) LOW RISK (n=90) p value LVEF (%) 27.9± ± QRS (ms) 120±33 125± fqrs (ms) 146±29 146± QTc (ms) 471±51 469± Heart Rate (bpm) 69.7±9 69.9±9 0.9 NSVT (episodes) 4.2± ± VPBs (number) 1483± ± VT/VF on PVS (nb/%) 18 (75%) 46 (51%) 0.03 Gatzoulis & Arsenos, 2011

29 What about ICDs in the early post MI period?

30 SDNN <70 and/or mean HR >80bpm

31 NSVT and/or resting HR >90bpm

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33 ΠΚΔ και ΔΜΚΠ Μικρζσ ςε αρικμό, μθ ελεγχόμενεσ, αναδρομικζσ? μελζτεσ Αντικρουόμενα αποτελζςματα Οι περιςςότερεσ δεν παρζχουν ενδείξεισ ότι θ πρόκλθςθ ΕΚΣ ςυνοδεφεται από ΑΚΘ Αυξανόμενθ ςυχνότθτα ΑΚΘ ςε αςκενείσ με δίχωσ πρόκλθςθ ΕΚΣ Αςυμπτωματικοί αςκενείσ παρουςιάηουν πρόκλθςθ ΕΚΣ ςε ποςοςτό 10-15%

34 BASELINE CHARACTERISTICS OF THE STUDY POPULATION Group I (n=44) Group II (n=114) P value Mean age, years 61.3 ± ± Male gender (%) Syncope (%) Complex ventricular tachyarrhythmias (%) NYHA 2.45 ± ± classification LV ejection 30.7 ± ± fraction (%) Diabetes mellitus (%) Hypertension (%) Medication ΑCE-inhibitors / ΑRBs (%) Diuretics (%) Digoxin (%) Beta-blocker (%) Gatzoulis et al., Submitted

35 THE PROGNOSTIC VALUE OF PVS IN DCM Gatzoulis et al., Submitted

36 THE PROGNOSTIC VALUE OF PVS IN DCM Gatzoulis et al., Submitted

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38 Διαστρωματωση κινδυνου αιυνιδιου καρδιακου θανατου Class I VTs, VF / ICD Class IIa Clinical Factors>2 ICD Class IIb High risk mutation ESC on SCD Aug 2001 Clinical factors LVWmax >3cm FSD - Syncope NSVT BP response Spirito, Maron et al NEJM2000 Elliott,Mckenna et al Lancet 2001 Braunwald et al Cicr 2002;106:1312

39 ICDs in HCM 45 patients with syncope or/and complex VAs underwent EPS Good correlation between non invasive RFs and results in EPS 14 patients with multiple RFs and induced SVT received an ICD During ~3 years (F/U), 6/14 had appropriate ICD therapies (42%) K.Gatzoulis et al, IGNA 2004

40 Marcus FI, Fontaine G. Pacing Clin Electrophysiol 1995, 18:

41 68 y/o M with NSVT, ARVC and inducible VT on EPS

42 ARVD patients with AICD (8/112: 7%) (IGNA 2001) K.Gatzoulis et al, 2001

43 ΑΚΘ σε ΣΚ TF D-Μετάθεση των μεγάλων αγγείων Στένωση ισθμού αορτής ΑΣ

44 RF in operated TOF patiens QRS duration (>180 msec) Age at repair Years after repair RV and LV hemodynamics NSVT? LPs? QT dispersion?

45 Middle aged operated TOF patient with NSVT

46 ESC GLs 2010

47 CRT-P vs CRT-D Risk stratification including EP testing Potential upgrading on replacement Cost effectiveness Both Companion as well as CARE HF data favor CRT-D

48 Kaplan Meier curves of survival free of appropriate implantable cardioverter defibrillator therapies over the 12-month follow-up. Dilaveris P et al. Europace 2009;11: Figure 4 Upper panel, left: solid line, no history of ventricular tachycardia or inducible ventricular tachycardia on electrophysiological study; dashed line, history of clinical ventricular tachycardia or inducible ventricular tachycardia on electrophysiological study; log-rank (Mantel Cox) ¼ 29.89; P ¼ Upper panel, right: solid line, no history of clinical ventricular tachycardia; dashed line: history of clinical ventricular tachycardia; log-rank (Mantel Cox) ¼ 5.37; P ¼ Lower panel: solid line, no inducible ventricular tachycardia on electrophysiological study; dashed line: inducible ventricular tachycardia on electrophysiological study; log-rank (Mantel Cox) ¼ 17.92; P ¼ It is obvious that the combination of the two parameters possesses incremental discriminating value.

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50 S.Sideris, K.Gatzoulis et al, Hellenic J Cardiol 2011

51 Limitations - LVEF Intra- and inter- observer variability Variability over time (surgery, PTCA, drugs, natural history) Stronger association with total mortality 2/3 of SCD in patients with LVEF 30%

52 SCD In Preserved LVEF 1041 post-mi with LVEF 40% (55 ± 10%) 32 ± 14 months F/U 18 SCD (1.8%) 18% (169 pts) with TWA, 12% (112 pts) with NSVT, 9% (81 pts) with LPs Ikeda et al, Predictive Value of Microvolt T-Wave Alternans for Sudden Cardiac Death in Patients With Preserved Cardiac Function After Acute Myocardial Infarction, J Am Coll Cardiol.2006 Dec 5; 48(11):

53 Ikeda et al, Predictive Value of Microvolt T-Wave Alternans for Sudden Cardiac Death in Patients With Preserved Cardiac Function After Acute Myocardial Infarction, J Am Coll Cardiol.2006 Dec 5; 48(11):

54 Ikeda et al, Predictive Value of Microvolt T-Wave Alternans for Sudden Cardiac Death in Patients With Preserved Cardiac Function After Acute Myocardial Infarction, J Am Coll Cardiol.2006 Dec 5; 48(11):

55 Ikeda et al, Predictive Value of Microvolt T-Wave Alternans for Sudden Cardiac Death in Patients With Preserved Cardiac Function After Acute Myocardial Infarction, J Am Coll Cardiol.2006 Dec 5; 48(11):

56 495 αςκενείσ με ICD Data under review μζςθ περίοδο 41.1 μθνών 442 άνδρεσ, 65.6 ετών, 68.9% ICM ΚΕΑΚ 35% (n=422) ΚΕΑΚ >35% (n=73). 69 cardiac deaths (6 SCD) 15 non cardiac deaths

57 Αςκενείσ με ICD και ΚΕΑΚ 35% ςε ςφγκριςθ με αυτοφσ με ιπια δυςλειτουργία εμφάνιςαν μεγαλφτερθ επίπτωςθ ολικισ κνθτότθτασ (18% ζναντι 11%, log rank p=0.028) και καρδιακισ αιτιολογίασ κνθτότθτασ (15.4% ζναντι 5.5%, log rank p=0.005). p=0.028 p=0.005

58 Δεν υπιρξε διαφορά ςτθν επίπτωςθ πρόςφορθσ κινθτοποίθςθσ των ICD μεταξφ αςκενών με ΚΕΑΚ 35% και αυτών με ΚΕΑΚ>35% (56.9% ζναντι 65.8%, log rank p=0.93).

59 Προγνωςτικοί παράγοντεσ καρδιακισ κνθτότθτασ Hazard ratio CIs p Age (yr) Male gender ICM (yes/no) EF 35% (yes/no) NYHA class (yes/no) <0.001 Secondary prevention (yes/no) ICM=Ischemic cardiomyopathy, LVEF=Left ventricular ejection fraction, NYHA=New York Heart Association

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