Dé éfibrillateurs dans les fibrillateurs dans les D Cardiopathies Cardiopathies Isché émiques et Dilat miques et Dilaté ées es Isch Simon ABOU JAOUDE Simon ABOU JAOUDE Service de Cardiologie Service de Cardiologie Hôtel- -Dieu Dieu, Beyrouth , Beyrouth Hôtel
Survival Trends in Heart Failure Survival Trends in Heart Failure 5 years 5 years survival : survival : < 50%. < 50%. Levy D. Levy D. N N Engl Engl J Med 2002; J Med 2002; 347: 1397 347: 1397- -402. 402.
Risk of SCD in Treatment Treatment Arms Arms Risk of SCD in of CHF- -Beta Blocker Trials Beta Blocker Trials of CHF 156 160 145 140 Sudden Deaths Number of Deaths 120 Total Deaths 100 79 80 60 48 40 22 20 12 0 CIBIS II MERIT-HF U.S. CARVEDILOL Sudden Sudden Death % of Death % of 31% 31% 54% 54% 54% 54% Total Death Total Death
Many studies have shown Many studies have shown that in selected that in selected cardiomyopathy patients, patients, cardiomyopathy ICD therapy can reduce ICD therapy can reduce mortality by reducing the risk reducing the risk mortality by of sudden death of sudden death
The main difficulty is to The main difficulty is to identify the the patient at risk patient at risk identify who will benefit from ICD who will benefit from ICD implantation implantation
Survivors of SCD, VF or Survivors of SCD, VF or poorly tolerated VT poorly tolerated VT Recurrence rate Recurrence rate = 25- -30 % at one year 30 % at one year = 25
SECONDARY PREVENTION SECONDARY PREVENTION AVID ( Antiarrhythmic Drug Versus Defibrillator) Resuscitated SCD, Syncopal VT Resuscitated SCD, Syncopal VT Amiodarone Amiodarone V V ICD ICD S S or Sotalol or Sotalol 507 509 NEJM NEJM pts pts 1997; 337:1576 1997; 337:1576
SECONDARY PREVENTION SECONDARY PREVENTION AVID ( Antiarrhythmic Drug Versus Defibrillator) P<0.02 Survival Survival Years Years NEJM NEJM 1997; 337:1576 1997; 337:1576
SECONDARY PREVENTION SECONDARY PREVENTION AVID ( Antiarrhythmic Drug Versus Defibrillator) NEJM NEJM 1997; 337:1576 1997; 337:1576
SECONDARY PREVENTION TRIALS SECONDARY PREVENTION TRIALS 60% 60% 50% 50% % % Mortality Mortality 40% 40% 37% 37% Reduction Reduction 31% 31% 30% 30% ICD ICD 20% 20% vs vs 20% 20% AA drugs AA drugs 10% 10% 0% 0% AVID AVID CIDS CIDS CASH CASH 3 years 3 years 3 years 3 years 2 years 2 years
Meta- -analysis of secondary analysis of secondary Meta prevention trials prevention trials Ezekowitz Ezekowitz. . Ann Intern Ann Intern Med. Sudden cardiac cardiac death death Med. Sudden 2003;138:445 2003;138:445
Meta- -analysis of secondary analysis of secondary Meta prevention trials prevention trials Ezekowitz Ezekowitz. . Ann Intern Ann Intern Med. All- -cause cause mortality mortality Med. All 2003;138:445 2003;138:445
SECONDARY PREVENTION SECONDARY PREVENTION ACC/AHA/NASPE 2002 Guidelines ACC/AHA/NASPE 2002 Guidelines ICD indications in CAD and DCM pts ICD indications in CAD and DCM pts - Cardiac arrest due to VF or VT not due Cardiac arrest due to VF or VT not due - to a transient or reversible cause. to a transient or reversible cause. - Spontaneous sustained VT. Spontaneous sustained VT. -
M 68y, DCM since 1996, EF = 20% 1999 : Syncope => Fast VT 210/min
2000 : Syncope and choc 2000 : Syncope and choc Endocavitary tracing
ICD interrogation ICD interrogation Endocavitary tracing CHOC SINUS & PACED RYTHM Ventricular Fibrillation CHARGING
PLACE OF ICDs ICDs IN IN PLACE OF PRIMARY PREVENTION PRIMARY PREVENTION
Primary Prevention Trials Primary Prevention Trials isch CM CM dilated CM isch dilated CM CABG PATCH CAT CAT CABG PATCH CABG PATCH CAT MADIT AMIOVERT AMIOVERT MADIT MADIT AMIOVERT MUSTT MUSTT MUSTT MADIT II DEFINITE DEFINITE MADIT II MADIT II DEFINITE SCD- -HeFT HeFT SCD SCD-HeFT
MADIT II MADIT II Post-MI patients EF ≤ 30% 1232 pts 1232 pts conventional V V ICD medical S S therapy N Engl N Engl J Med J Med 2002; 346:877 2002; 346:877
MADIT II MADIT II Survival Survival ICD ICD No ICD No ICD P=0.007 P=0.007 - 31% - 31% at at 20 M 20 M Years N Engl N Engl J Med J Med Years 2002; 346:877 2002; 346:877
MADIT II MADIT II Mortality Events Mortality Events N N Engl Engl J Med J Med 2002; 346:877 2002; 346:877
Meta- -analysis of primary analysis of primary Meta prevention trials in CAD pts prevention trials in CAD pts Ezekowitz Ezekowitz. . Ann Intern Ann Intern Med. Sudden cardiac cardiac death death Med. Sudden 2003;138:445 2003;138:445
Meta- -analysis of primary analysis of primary Meta prevention trials in CAD pts prevention trials in CAD pts Ezekowitz Ezekowitz. . Ann Intern Ann Intern Med. All- -cause cause mortality mortality Med. All 2003;138:445 2003;138:445
NEJM NEJM Janv 2005 2005 Janv
SCD- -HeFT HeFT SCD Will Amiodarone and/or an ICD improve survival compared to placebo in patients with: CHF (NYHA Class II and III) due to CHF ischemic or nonischemic dilated cardiomyopathy and EF ≤ ≤ 35% 35% EF NEJM NEJM Janv 2005 2005 Janv
SCD- -HeFT HeFT protocol protocol SCD Inclusion criteria Inclusion criteria ICD implant (829) Placebo (847) Amiodarone (845) Amiodarone (845) ICD implant (829) Placebo (847) 40 months average follow- - up up 40 months average follow NEJM NEJM • Optimize: Optimize: β B, ACE- -I, I, • β B, ACE Janv 2005 2005 Janv Diuretics Diuretics
SCD- -HeFT HeFT Endpoints Endpoints SCD • Primary Primary • all cause –To compare To compare all cause – mortality after 2.5 years of after 2.5 years of mortality follow- -up up (Power: 90% to detect 25% benefit) follow (Power: 90% to detect 25% benefit) • Secondary Secondary • – Mortality Mortality – – Ischemic, Non Ischemic, Non- -Ischemic Ischemic – – … … – NEJM NEJM Janv 2005 2005 Janv
SCD- -HeFT HeFT SCD Patients characteristics Patients characteristics • NYHA II 70%, NYHA III 30% NYHA II 70%, NYHA III 30% • • Ischemic 52%, non Ischemic 52%, non- -ischemic 48% ischemic 48% • • ACE Inhibitor or ARB ACE Inhibitor or ARB 87% 87% • • Beta Beta- -blocker 78% blocker 78% • NEJM NEJM Janv 2005 2005 Janv
SCD- -HeFT HeFT SCD Results Results -23 % 23 % - NEJM NEJM Janv 2005 2005 Janv
SCD- -HeFT HeFT – – Results Results SCD CAD patients CAD patients NEJM NEJM Janv 2005 2005 Janv
SCD- -HeFT HeFT – – Results Results SCD DCM patients DCM patients NEJM NEJM Janv 2005 2005 Janv
Meta- -analysis analysis of of Randomized Randomized Controlled Controlled Meta Trials: Trials: ICD for the the Prevention Prevention of of Mortality Mortality in in Nonischemic Nonischemic Cardiomyopathy Cardiomyopathy ICD for All- -Cause Cause Mortality Mortality All - 31% 31% - (p=0.002) Akshay Akshay JAMA JAMA Without COMPANION : RR 0.74; 95% CI, 0.58 COMPANION : RR 0.74; 95% CI, 0.58- -0.96; 0.96; P =0.02 Without P =0.02 Dec 2004 Dec 2004
ESC Guidelines (update 2005) ESC Guidelines (update 2005) ICD implantation is reasonable for ICD implantation is reasonable for primary prevention in patients primary prevention in patients - with LVEF < 30 with LVEF < 30– –35% 35% - - on optimal background therapy on optimal background therapy - including ACEi ACEi, beta , beta- -blocker, and blocker, and including an aldosterone aldosterone antagonist. antagonist. an (Class of recommendation I, level of evidence A) (Class of recommendation I, level of evidence A) European Heart European Heart Journal (2005) 26, 1115 Journal (2005) 26, 1115– –1140 1140
ACC/AHA 2005 Guideline Update ACC/AHA 2005 Guideline Update ICD therapy is recommended for primary ICD therapy is recommended for primary prevention in patients with: prevention in patients with: • ischemic and non ischemic heart disease ischemic and non ischemic heart disease • • who have an LVEF less than or equal to 30%, who have an LVEF less than or equal to 30%, • • with NYHA functional class II or III symptoms with NYHA functional class II or III symptoms • • while undergoing chronic optimal medical therapy, while undergoing chronic optimal medical therapy, • and have reasonable expectation of survival with a • • and have reasonable expectation of survival with a good functional status for more than 1 year. good functional status for more than 1 year. (Class I recommendation) (Class I recommendation) www.acc.org www.acc.org and and www.americanheart. www.americanheart. org org
Limitations of of ICD ICD Limitations Therapy Therapy
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