goals of management - monterey, ca · 674 high-risk patients with recent mi 6-40 days lvef ≤35%...
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Electrophysiology and the Electrophysiology and the Management of CHFManagement of CHFManagement of CHFManagement of CHF
Byron K. Lee MDAssociate ProfessorDirector of EP [email protected]
Division of CardiologyCardiac Electrophysiology
1414thth Monterey Bay Heart SymposiumMonterey Bay Heart Symposium
May 3May 3--4, 20134, 2013
Goals of Management
• Do no harm
• Prolong life
• Improve quality of life
Do No Harm:76 yo man with fatigue, DOE, and intermittent lightheadedness
• PMH
– s/p PCI 5 years ago
– AFib
• Meds
– Toprol XL (only 25 daily because of bradycardia)
– Lipitor
– Lisinopril
– Amiodarone
• HR 48 (55 at last visit)
• BP 120/50
• ECG shows SB at 50
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Ambulatory ECG Monitor
44
76 yo man with fatigue, DOE, and intermittent lightheadedness
• After PPM implanted
– Significant improvement of symptoms
• Fatigue, DOE, and LH have resolved
• 3 years after PPM
N ti d li i f ti l t t– Notices decline in functional status
• 5 years after PPM
– Fatigue, DOE are back to previous levels
ECG
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DAVID Trial
JAMA 2002JAMA 2002
DAVID TrialInclusion CriteriaInclusion Criteria
Referred for ICDReferred for ICD
EF <40% (90% NYHA Class I and Class II patients)EF <40% (90% NYHA Class I and Class II patients)
No indication for pacingNo indication for pacing
No persistent atrial arrhythmiasNo persistent atrial arrhythmias
DAVID Trial ResultsComposite:Composite:
VVI 16.1%VVI 16.1%
DDDR 26.7%DDDR 26.7%
HF HF HospHosp::
VVI 13.3%VVI 13.3%
DDDR 22.6%DDDR 22.6%
Mortality:Mortality:
VVI 6.5%VVI 6.5%
DDDR 10.1%DDDR 10.1%
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RV Pacing Creates Dyssynchrony
RV pacingRV pacing
LBBBLBBB
Sinus Sinus nodenode •• Delayed lateral wall Delayed lateral wall
contractioncontraction
Di i d i lDi i d i l
MechanismsMechanisms
Effects of Effects of DyssynchronyDyssynchrony from Pacing or from Pacing or LBBBLBBB
AVAV
nodenode
•• Disorganized ventricular Disorganized ventricular contractioncontraction
•• Decreased pumping Decreased pumping efficiencyefficiency
Conduction Conduction blockblock
Abnormal wall motionAbnormal wall motion
HealthyHealthy DyssynchronyDyssynchrony
MechanismsMechanisms
Ventricular Ventricular DysynchronyDysynchrony
Courtesy of C. Stellbrink, MD.Courtesy of C. Stellbrink, MD.
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Do No Harm:
• RV pacing is harmful
• Mechanism of harm is the creation of dyssynchrony
R d i t id RV i• Reprogram device to avoid RV pacing– Prolong AV delay
– Special Algorithms (ie MVP)
• Consider Upgade to a BiV device
Prolong Life:67 year old male presents with three hours of sub-sternal chest pain
• Chest pain disappeared for 6 hours prior to admission
• No prior cardiac history
• Arrives to the hospital after with
• Risk factors:
– 2 packs of cigarettes per day
– Hypertension
EKG Tracing
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LAD Total Occlusion
Post PCI
Left Ventricular Cineangiogram
Ejection Fraction (EF) = 26%
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The patient does well post PCI. He is started on ACE Inhibitor, Beta Blocker, Coumadin, and Diuretic.
On monitor, NSVT is seen.
• A. ICD before discharge
• B. No ICD before discharge
DINAMIT674 high-risk patients with recent MI 6-40 days
LVEF ≤35%
Evidence of impaired cardiac autonomic modulation
(poor HR variability or mean HR above 80)
Randomized, open-label, multicenter
674 high-risk patients with recent MI 6-40 days
LVEF ≤35%
Evidence of impaired cardiac autonomic modulation
(poor HR variability or mean HR above 80)
Randomized, open-label, multicenter
NEJM December 9, 2004NEJM December 9, 2004
ICD TherapyProphylactic implantable
cardioverter defibrillator (ICD)
n=332
ICD TherapyProphylactic implantable
cardioverter defibrillator (ICD)
n=332
Endpoints (2.5 years):All-cause mortality adjudicated by blinded committee
Endpoints (2.5 years):All-cause mortality adjudicated by blinded committee
No ICD Therabyn=342
No ICD Therabyn=342
DINAMIT Trial
Hohnloser, Hohnloser, et alet al. DINAMIT Trial . DINAMIT Trial NEJMNEJM 20042004
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DINAMIT Trial
Hohnloser, Hohnloser, et alet al. DINAMIT Trial . DINAMIT Trial NEJMNEJM 20042004
DINAMIT Trial
Hohnloser, Hohnloser, et alet al. DINAMIT Trial . DINAMIT Trial NEJMNEJM 20042004
Vest prevention of Early Vest prevention of Early S dd D th T i lS dd D th T i l
UCUCSFSF
Cardiac ElectrophysiologyCardiac Electrophysiology
UCSFUCSFEpidemiology & Epidemiology &
BiostatisticsBiostatistics
Sudden Death TrialSudden Death Trial(VEST Trial)(VEST Trial)
Sponsor: Sponsor: ZollZollCoordinating Center: UCSFCoordinating Center: UCSF
PI: Jeffery PI: Jeffery OlginOlginCoCo--PI: Byron LeePI: Byron Lee
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Wearable Defibrillator Vest
Patient is now three months post-MI. EF still only 25%. On ACE Inhibitor, Beta Blocker, Coumadin, and Diuretic.
A ICD• A. ICD
• B. No ICD
MADIT II: Protocol
NONINVASIVE EVALUATION OF LV FUNCTION
ELIGIBLE PATIENTS
RICD
n = 742CONTROL
n = 490
20 MONTH F/Uoptimal medical Rx
R
Moss AJ. N Engl J Med. 2002;346:877-83.
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MADIT II: Mortality by Group
Trial stopped early
at 20 months
Mortality Reduction
• Absolute = 5.6%
• Relative = 31.0%
14.2%
19.8%
15.0%
20.0%
25.0%
n = 742 490ICD Conventional
0.0%
5.0%
10.0%
Moss AJ. N Engl J Med. 2002;346:877-83.
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JT is a 76 yo man who is status-post MI. Current EF is 29%. He is told by his internist, his cardiologist, and an electrophysiologist that he needs an ICD to prevent SCD. He doesn’t want the ICD and comes to you for a fourth opinion.
• A Tell him that he needs an ICD
• B Tell him that he does not need an ICD
MADIT II: Time since MI
Wilbur et al. Circulation 2004Wilbur et al. Circulation 2004
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Prolong Life:
• For patients
– Ischemic or non-ischemic
– EF ≤35%
medically optimized– medically optimized
– not NYHA Class IV CHF
– No recent MI
• ICDs save lives
– Even if MI was remote
Myocardial Insult
Myocardial Dysfunction
Reduced System
Heart Failure’s Complex cascade
MechanismsMechanisms
Improve Quality of Life
Renin-Angiotensin-Aldosterone System Activation
Sympathetic System Activation
Reduced System Perfusion
Altered Gene Expression Apoptosis
Remodeling
Dysynchrony
• First degree heart block
• Widened QRS
• Mechanical inefficiency and decreased cardiac output
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LBBB Creates Dyssynchrony
RV pacingRV pacing
LBBBLBBB
Prevalence:Ventricular Dyssynchrony
40%
50%
60%
0%
10%
20%
30%
Aaronson Lamp Shamim
• Aaronson KD et al. Circulation 1997; 95:2660-2667.• Lamp B et al. PACE 1998; 21:973 Abstract 736.• Shamim W et al. Eur Heart J. 1998; 19: Abstract 926.
• Sub-optimal contribution
f i l l
Sinusnode
Issue I–prolonged AV conduction delay
MechanismsMechanisms
Issues Associated with Heart Failure
of atrial systole
• Limited filling period
• Mitral regurgitation AVnode
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Sinus node
• Delayed lateral wall contraction
• Disorganized ventricular
Issue II–delayed ventricular activation
MechanismsMechanisms
Issues Associated with Heart Failure
AVnode
contraction• Decreased pumping
efficiency
Conduction block
Cardiac Resynchronization Therapy ICD(CRT-D)
CRT Device
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LV Lead Placement
Before CRT
After CRT
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Benefits of CRT in Advanced Heart Failure
• Across studies, in HF, CRT improves
–Exercise capacity
–Quality of life
CRT t d h t f il• CRT appears to reduce heart failure hospitalizations
• Mortality benefit (COMPANION, CARE-HF)
• RBBB
• Ischemic cardiomyopathy
• NYHA IV
• Advanced age
Poor Responders to CRT
• Discordant LV lead and myocardial scar
• Female sex
• Lack of prior MI
• QRS complex duration > 150 ms
• LBBB
Super Responders to CRT
• BMI < 30 kg/m2
• Smaller LA volume index
• QRS narrowing > 40 ms with CRT
• HF Symptoms < 12 months
• LVEDV < 180 ml, LVEDD < 58 mm, LVESD <48
mmEllenbogen KA et al. JACC. 2012;59:2374-77
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Improve Quality of Life:HFSA CRT Guideline Update
• CRT recommended for:
– QRS ≥ 150 ms not due to RBBB with LVEF ≤ 35% and NYHA II-III
• CRT considered for:CRT considered for:
– NYHA IV (ambulatory) with QRS ≥ 150 ms and LVEF ≤ 35% despite optimal medical therapy
– NYHA II- IV (ambulatory) with QRS ≥ 120 ms but < 150 ms and LVEF ≤ 35% despite optimal medical therapy
– NYHA II- III with QRS ≥ 120 ms, atrial fibrillation and LVEF ≤ 35% despite optimal medical therapy
Stevenson WG et al. J Card Fail. 2012;18:94-106.
• Do No Harm:
– RV pacing causes heart failure
– Use pacing algorithms and BiV pacing to avoid harm
• Save Lives:
– ICDs prolong life
– Target Population:
EF ≤35%
CONCLUSIONS
• EF ≤35%
• Improve Quality of Life:
– CRT
• Improves symptoms
• Decreases all cause mortality and CV hospitalizations
– Target Population:
• NYHA Class III and IV
• EF 35%
• QRS 120ms (intrinsic or paced)
ICDs Do Save Lives