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Role of Implantable Cardioverter Defibrillators (ICDs) in Preventing Sudden Cardiac Death, Slides of Medicine

An in-depth look into the history and evolution of implantable cardioverter defibrillators (icds), their role in preventing sudden cardiac death, and the major trials that led to the current guidelines for icd placement. Topics covered include secondary and primary prevention, ischemic and non-ischemic conditions, and the latest guidelines.

Typology: Slides

2011/2012

Uploaded on 12/13/2012

sethuraman_h34rt
sethuraman_h34rt 🇮🇳

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ICD’s: Current Roles and
Evidence
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Download Role of Implantable Cardioverter Defibrillators (ICDs) in Preventing Sudden Cardiac Death and more Slides Medicine in PDF only on Docsity!

ICD’s: Current Roles and

Evidence

Learning Objectives

  • Brief history of the ICD
  • Review of the prevalence of Sudden Cardiac Death.
  • Gaining familiarity with major trials that went into the current guidelines of ICD placement. - Secondary Prevention - Primary prevention in Heart Failure - Ischemic - Non Ischemic
  • Familiarity with the latest guidelines for ICD placement.
  • Briefly discuss CRT
  • We will not talk about ethical or economic issues.

The first ICD

  • Because of Dr. Mirowski:
  • In 1980, the first patient received an ICD at Johns Hopkins Hospital.
  • 1985: FDA approves sale and use of ICD’s

Evolution of ICD’s

  • First ICD’s required a thoracotomy and used epicardial leads.
  • The device was so large, that it needed to placed in the abdomen.
  • Invention of transvenous defibrillator in 1969 allowed for a great reduction in ICD size, and made Mirowski’s idea practicle.

ICD

Road to ICDs

The Problem: Sudden Cardiac Death

  • In the United States, accounts for 325, 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.

Secondary Prevention

  • ICD’s first treatment group to be studied were those had already suffered a VF or VT event.
  • Important trial
    • AVID
  • Preceding AVID (smaller trials)
    • CASH - Cardiac Arrest Survival in Hamburg (349 subjects)
    • CIDS – Canadian Implantable Defibrillator Study (659 subjects)
    • The above two showed trends, but not signifcance towards less mortality with ICD’s (underpowered)

AVID trial

  • 1013 study subjects received either an ICD or medical thearpy (sotalol or amiodarone)
  • There was crossover both ways of 20% (either ICD’s or antiarrythmics added).
  • Study terminated early due greatly improved outcome in ICD group.
    • Survival

Antiarrythmics ICD Year 1 82.3 % 89.3 % Year 2 74.7 % 81.6 % Year 3 64.1% 75.4 %

AVID trial

Primary Prevention

  • As so many patients do not survive SCD neurologically intact or at all, there was a focus to investigate which groups of patients would benefit from ICD’s as primary prevention.
  • Focus of investigation
    • High risk (Brugada syndrome, long qt syndrome, Arrythmogenic Right Ventricular dysplasia)
    • Cardiomyopathy (Ischemic or Nonischemic)

ICD’s as primary prevention:

Ischemic Cardiomyopathy

MADIT I

  • 196 patients who had
    • Prior MI AND
    • NYHA class I, II, or III AND
    • NSVT AND
    • LV dysfunction (LVEF 35%) AND
    • Inducible VT despite procainamide
  • Randomly assigned to ICD, antiarrythmic drug.

MADIT I

  • 196 patients enrolled
  • 15 deaths in ICD group (N = 101) vs 39 in conventional therapy (N=95).
  • ICD reduced overall mortality by 54% and arrhythmic mortality by 75% compared to antiarrythmic therapy
  • Mean followup was 27 months