sudden cardiac death definition –death occurs within minutes –cardiac in nature –unwitnessed...

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  • Slide 1
  • Sudden Cardiac Death Definition Death occurs within minutes Cardiac in nature Unwitnessed death Incidence 375,000 people suffer Sudden Cardiac Death per year Approximately 43 people every hour 75,000 (20%) survive Definition Death occurs within minutes Cardiac in nature Unwitnessed death Incidence 375,000 people suffer Sudden Cardiac Death per year Approximately 43 people every hour 75,000 (20%) survive
  • Slide 2
  • Sudden Cardiac Arrest
  • Slide 3
  • Magnitude of SCA in the U.S. 1 U.S. Census Bureau, Statistical Abstract of the United States: 2001. 2 American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001. 3 2002 Heart and Stroke Statistical Update, American Heart Association. 4 Zheng Z. Circulation. 2001;104:2158-2163. AIDS 1 Breast Cancer 2 Lung Cancer 2 Stroke 3 SCA 4 SCA claims more lives each year than these other diseases combined 450,000 167,366 157,400 40,600 42,156 #1 Killer in the U.S.
  • Slide 4
  • Sudden Cardiac Arrest is one of the Leading Causes of Death in the U.S. 0 50,000 100,000 150,000 200,000 250,000 300,000 AIDS Breast Cancer Lung Cancer Stroke SCA Source: Statistical Abstract of the U.S. 1998, Hoovers Business Press, 118 th Edition
  • Slide 5
  • Sudden Cardiac Death Causes 80-90% are tachyarrhythmias Only 10-20% are due to an acute myocardial infarction or to bradyarrhythmias Causes 80-90% are tachyarrhythmias Only 10-20% are due to an acute myocardial infarction or to bradyarrhythmias
  • Slide 6
  • PrimaryVF8% Underlying Arrhythmia of Sudden Cardiac Arrest Adapted from Bays de Luna A. Am Heart J. 1989;117:151-159. Torsades de Pointes 13% Bradycardia 17% VT 62% 62%
  • Slide 7
  • Coronary Heart Disease An estimated 13 million people had CHD in the U.S. in 2002. 1 Sudden death was the first manifestation of coronary heart disease in 50% of men and 63% of women. 1 CHD accounts for at least 80% of sudden cardiac deaths in Western cultures. 3 An estimated 13 million people had CHD in the U.S. in 2002. 1 Sudden death was the first manifestation of coronary heart disease in 50% of men and 63% of women. 1 CHD accounts for at least 80% of sudden cardiac deaths in Western cultures. 3 1 American Heart Association. Heart Disease and Stroke Statistics2003 Update. Dallas, Tex.: American Heart Association; 2002. 2 Adapted from Heikki et al. N Engl J Med, Vol. 345, No. 20, 2001. 3 Myerberg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6 th ed. P. 895. Etiology of Sudden Cardiac Death 2,3 * ion-channel abnormalities, valvular or congenital heart disease, other causes 80% Coronary Heart Disease 15% Cardiomyopathy 5% Other*
  • Slide 8
  • SCD CAD Risk Factors
  • Slide 9
  • Reduced left ventricular ejection fraction (LVEF) remains the single most important risk factor for overall mortality and sudden cardiac death. 1
  • Slide 10
  • References in slide notes. * MADIT-II mortality values at 20 months. SCD Rates in Post-MI Patients with LV Dysfunction Total Mortality ~20-30%; SCD accounts for ~50% of the total deaths.
  • Slide 11
  • Treatments to Reduce SCD Correcting Ischemia Revascularization Beta-blocker Preventing Plaque Rupture Statin ACE inhibitor Aspirin Stabilizing Autonomic Balance Beta-blocker ACE inhibitor Correcting Ischemia Revascularization Beta-blocker Preventing Plaque Rupture Statin ACE inhibitor Aspirin Stabilizing Autonomic Balance Beta-blocker ACE inhibitor Improving Pump Function ACE inhibitor Beta-blocker Prevention of Arrhythmias Beta-blocker Amiodarone Terminating Arrhythmias ICDs AEDs Prevent Ventricular Remodeling and Collagen Formation Aldosterone receptor blockade Zipes DP. Circulation. 1998;98:2334-2351. Pitt B. N Engl J Med. 2003;348:1309-1321.
  • Slide 12
  • MADIT II (1997-2002) Multicenter Automatic Defibrillator Implantation Trial II Objective - To evaluate the role of ICD vs. medical therapy in a group of patients with left ventricular dysfunction and MI Inclusion - Post MI patients with EF < 30%. No prior assessment of VT in the EP lab. Requirement for freq. PVCs was dropped six months in to the study (only 23 pts enrolled). Exclusion - Approved indication for an ICD; Undergone coronary revascularization within 3-months; An MI within the past 1-month Objective - To evaluate the role of ICD vs. medical therapy in a group of patients with left ventricular dysfunction and MI Inclusion - Post MI patients with EF < 30%. No prior assessment of VT in the EP lab. Requirement for freq. PVCs was dropped six months in to the study (only 23 pts enrolled). Exclusion - Approved indication for an ICD; Undergone coronary revascularization within 3-months; An MI within the past 1-month Ann Noninvasive Electrocardiol. 1999;4:83-91
  • Slide 13
  • MADIT II Multicenter Automatic Defibrillator Implantation Trial II Patients - 1,232 randomized in a 3:2 ratio to receive an ICD (752) or conventional medical therapy (490) Results - Over a 4-yr period with an average follow-up of 20-months, the ICD group resulted in a 5.6% absolute and 31% relative risk reduction in mortality over conventional group - 14.2% vs. 19.8% respectively Study terminated early due to this favorable result Patients - 1,232 randomized in a 3:2 ratio to receive an ICD (752) or conventional medical therapy (490) Results - Over a 4-yr period with an average follow-up of 20-months, the ICD group resulted in a 5.6% absolute and 31% relative risk reduction in mortality over conventional group - 14.2% vs. 19.8% respectively Study terminated early due to this favorable result
  • Slide 14
  • MADIT II Multicenter Automatic Defibrillator Implantation Trial II Probability of Survival Moss, A. et. al. N Engl J Med 2002;877-83
  • Slide 15
  • 60% MUSTT 5 5 years 5 years 54% MADIT 4 2 years 20% CIDS 3 3 years 37% CASH 2 2 years 31% AVID 1 3 years Reductions in Mortality with ICDs Compared to Antiarrhythmic Drugs 0% 10% 20% 30% 40% 50% 60% % Mortality Reduction 1 The AVID Investigators. N Engl J Med. 1997;337:1576-1583. 2 Kuck K. ACC98 News Online. April, 1998. Press release. 3 Connolly S. ACC98 News Online. April, 1998. Press release. 4 Moss AJ. N Engl J Med. 1996;335:1933-1940. 5 Buxton AE. N Engl J Med. 1999;341:1882-1890.
  • Slide 16
  • $0 $20 $40 $60 $80 $100 $120 $140 $160 $180 $200 $LYS (X 1000) Incremental Cost-Effectiveness Results ($LYS)* Highly Cost Effective Cost Effective Borderline Cost Effective Expensive Unattractive *Versus Conventional Therapy 1 Kupersmith. Progress in Cardiovascular Disease. 1995. 2 Owens. Annals of Internal Medicine. 1997. 3 Kupperman. Circulation. 1990 Captopril$28,400 Post MI EF
  • EF Clinic Program Patient Screening Pathway (The Ohio Heart & Vascular Center) Determine EF Does patient have history of cardiac arrest, VF, or symptomatic VT? Non-Ischemic Consult EP for possible CRT-D Optimize therapies or consult HF specialist EF 35% Ischemic PATIENT 40 days post MI with EF 30% NYHA Class I CHF EF > 35% 40 days post MI OR 3 months post revascularization Consult EP for possible ICD 3 months post diagnosis 1. Consider referral to HF Specialist or HF Program. 2. Repeat diagnostics with change of symptoms. Class III or IV CHF and QRS > 120 ms Consult EP for possible ICD Consult EP for possible ICD Is patient on optimal medical therapy? YES NO Note: Pathway only begins after optimal medical therapy & coronary evaluation / intervention as appropriate Consult EP for possible ICD NYHA Class II or III CHF This is a general protocol to assist in the management of patients. This protocol is not designed to replace clinical judgment or individual patient needs.
  • Slide 19
  • 1.Cardiac Arrest Due to VT or VF Not due to transient or reversible cause 2.Spontaneous sustained VT Structural heart disease must be present 3.Syncope of undetermined origin with: Sustained VT that has clinical relevance and/or hemodynamic significance VF induced during EP study when drug therapy to sustained VT is not preferred 1.Cardiac Arrest Due to VT or VF Not due to transient or reversible cause 2.Spontaneous sustained VT Structural heart disease must be present 3.Syncope of undetermined origin with: Sustained VT that has clinical relevance and/or hemodynamic significance VF induced during EP study when drug therapy to sustained VT is not preferred Class I Indications for ICD
  • Slide 20
  • 4.Nonsustained VT with: Coronary disease Prior MI LV Dysfunction Inducible VF or sustained VT (Non-suppressible by antiarrhythmic drugs) 5.Spontaneous sustained VT Not amenable to other treatments 4.Nonsustained VT with: Coronary disease Prior MI LV Dysfunction Inducible VF or sustained VT (Non-suppressible by antiarrhythmic drugs) 5.Spontaneous sustained VT Not amenable to other treatments Class I Indications for ICD
  • Slide 21
  • 1.LVEF 100,000 implants/year
  • Slide 28
  • ICD Evolution
  • Slide 29
  • How it Works The ICD System * Animation
  • Slide 30
  • The ICD System How it Works Atrium & Ventricle Bradycardia sensing Bradycardia pacing Antitachycardia pacing Atrium & Ventricle Bradycardia sensing Bradycardia pacing Antitachycardia pacing Ventricle VT prevention Antitachycardia pacing Cardioversion Defibrillation Ventricle VT prevention Antitachycardia pacing Cardioversion Defibrillation
  • Slide 31
  • (Header) (Used for Telemetry) ICD Device Components
  • Slide 32
  • Question? What is the function of an ICD? Sense Detect Therapy Pace Sense Detect Therapy Pace
  • Slide 33
  • Question? What is Sensing? The process of identifying cardiac depolarizations from an intracardiac electrogram The process of identifying cardiac depolarizations from an intracardiac electrogram Its what the device sees
  • Slide 34
  • Sensing Sensing - what the device sees Electrical Activity - what the device is looking for Lead contains the eyeball of the device
  • Slide 35
  • The EGM Signal Farfield Morphology Comparison EGM Source = Variable SINUS RHYTHM VT
  • Slide 36
  • TP = Anti-Tachycardia Pacing Initiated (ATP) CE = Charge End CD = Charge Delivered TP = Anti-Tachycardia Pacing Initiated (ATP) CE = Charge End CD = Charge Delivered Therapy: Marker Channel ICD Function Annotations * in Medtronic devices
  • Slide 37
  • Detection Measured in: Beat-to-beat intervals (milliseconds), or Beats-per-minute (BPM) Measured in: Beat-to-beat intervals (milliseconds), or Beats-per-minute (BPM) Detection Rate Classifies rhythm by detection zone: VT = Ventricular Tachycardia VF = Ventricular Fibrillation Classifies rhythm by detection zone: VT = Ventricular Tachycardia VF = Ventricular Fibrillation Programmable in ranges of rates Example:VT = 162 bpm 188 bpm VF = 188 bpm and faster Programmable in ranges of rates Example:VT = 162 bpm 188 bpm VF = 188 bpm and faster
  • Slide 38
  • Question? Can you name some therapies delivered by an ICD?
  • Slide 39
  • ICD Therapies ICD Therapy Low Power (Pacing Therapies) Anti-tachycardia Pacing (ATP Bradyarrhythmia Pacing High Power (Shock Therapies) Cardioversion Defibrillation ICD Therapy Low Power (Pacing Therapies) Anti-tachycardia Pacing (ATP Bradyarrhythmia Pacing High Power (Shock Therapies) Cardioversion Defibrillation
  • Slide 40
  • ICD Therapies Tachyarrhythmia Therapy Anti-Tachycardia Pacing (ATP) Pacing pulses delivered at a rate faster than the rhythm detected Can successfully terminate re-entrant tachycardias Anti-Tachycardia Pacing (ATP) Pacing pulses delivered at a rate faster than the rhythm detected Can successfully terminate re-entrant tachycardias Low Power
  • Slide 41
  • Anti-Tachycardia Pacing * Animation Click image to view animation
  • Slide 42
  • Anti-Tachycardia Pacing Re-entry initiated ATP delivered at a rate faster than tachyarrhythmia. Wavefronts collide. ATP delivered at a rate faster than tachyarrhythmia. Wavefronts collide. Subsequent Pulse: Wavefronts collide closer to re-entry circuit Subsequent Pulses: Wavefronts collide even closer to re-entry circuit Arrhythmia terminated
  • Slide 43
  • Cardioversion Delivers shock on an R-wave Aborts if synchronization cannot be obtained due to arrhythmia termination Delivers shock on an R-wave Aborts if synchronization cannot be obtained due to arrhythmia termination
  • Slide 44
  • Defibrillation * Animation Click image to view animation
  • Slide 45
  • ICD Therapy VT FVT VF Benefits of Tiered Therapy
  • Slide 46
  • Bradyarrhythmia Therapy Most ICDs offer: Single Chamber Pacing AAI(R), VVI(R) and VOO Dual Chamber Pacing DDD(R), DDI(R), DOO and ODO Mode Switch Separate post-shock pacing programming Ensures capture Most ICDs offer: Single Chamber Pacing AAI(R), VVI(R) and VOO Dual Chamber Pacing DDD(R), DDI(R), DOO and ODO Mode Switch Separate post-shock pacing programming Ensures capture Pacing Modes