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La stratificazione del rischio aritmico oltre la frazione di eiezione

Heart Failure & Co. La stratificazione del rischio aritmico oltre la frazione di eiezione. Milano 17 Aprile 2009. Prof. Luigi Padeletti. Get With The Guidelines-Heart Failure (GWTG-HF). Shah et al. J Am Coll Cardiol 2009. Potential barriers to the dissemination of ICD therapy.

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La stratificazione del rischio aritmico oltre la frazione di eiezione

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  1. Heart Failure & Co La stratificazione del rischioaritmico oltre la frazione dieiezione Milano 17 Aprile 2009 Prof. Luigi Padeletti

  2. Get With The Guidelines-Heart Failure (GWTG-HF) Shah et al. J Am Coll Cardiol 2009

  3. Potential barriers to the dissemination of ICD therapy Al-Khatib et al. Am Heart J 2008

  4. Potential barriers to the dissemination of ICD therapy Al-Khatib et al. Am Heart J 2008

  5. Potential barriers to the dissemination of ICD therapy Al-Khatib et al. Am Heart J 2008

  6. Beta-blocker and Amiodarone utilization can affect the outcome of ICD trials

  7. Cumulative Benefit of ACEI and Beta Blockers P < 0.01 P < 0.05 Exner DV et al. JACC; 1999; 33: 916-23

  8. Beta - Adrenergic Blocking Agents MERIT-HF SCD - Treated pts MERIT-HF 3.6% CIBIS II 4% US Carvedilol 1.7% MOCHA 2.3% • AVERAGE SD decrease 30% Lancet 1999; 353: 2001-7

  9. Outcome of recent major Beta-blocker trials Siddiqui et al Curr Opin Cardiol 2006

  10. Beta-Blockers to reduce sudden death in HF Adamson et al J Cardiac Fail 2006

  11. Beta-Blockers and ICD therapy Brodine et al. Am J Cardiol 2005

  12. Tung R et al. J Am Coll Cardiol 2008;52:1111–21 Amiodarone :not an innocent drug!

  13. MADIT I In the conventional-therapy group, overall mortality was slightly higher among those who were receiving amiodarone at one month than among those who were not receiving the drug (36 percent vs. 26 percent) Moss et al N Engl J Med 1996

  14. Guidelines for ICD implantation for the secondary And primary prevention of SCD Al-Khatib et al. Am Heart J 2008

  15. Meta-analysis of ICD secondary prevention trials Connolly et al Eur Heart J 2000

  16. Meta-analysis of ICD secondary prevention trials Connolly et al Eur Heart J 2000

  17. Meta-analysis of ICD secondary prevention trials The prolongation of life by the ICD over amiodarone was 2.1 months at 3 years of follow-up and 4.4 months at 6 years Connolly et al Eur Heart J 2000

  18. Guidelines for ICD implantation for the secondary And primary prevention of SCD Al-Khatib et al. Am Heart J 2008

  19. The optimal timing of defibrillator insertion after myocardial infarction remains unresolved

  20. NEJM 352;2581

  21. Dinamit-trial Hohnloser et al N Engl J Med 2004

  22. Dinamit-trial Hohnloser et al N Engl J Med 2004

  23. MADIT II Specifically, 73 patients (14.9 percent) in the conventional-therapy group and 148 in the defibrillator group (19.9 percent) were hospitalized with heart failure, representing 9.4 and 11.3 patients so hospitalized per 1000 months of active follow-up, respectively (nominal p=0.09) Moss et al N Engl J Med 2002

  24. Gorgeles et al Eur Heart J 2003;24:1204

  25. Inclusion criteria:…myocardial infarction one month or more before entry…

  26. Time Dependence of Mortality Risk and Defribrillator Benefit After Myocardial Infarction * * p 0.02 for HR Wilber et al Circulation 2004;109:1082

  27. MADIT II – Inclusion/Exclusion Criteria • Inclusion criteria • MI > 4 weeks • LVEF < 30% • > 21 years • Exclusion criteria • Previous cardiac arrest • Sustained VT • NYHA Class IV • CABG or PTCA < 3 months • CABG or PTCA planned • Life-threatening diseases • < 21 years

  28. PCI in SCD-Heft Al-Khatib et al J Cardiovasc Electrophysiol 2008

  29. CABG in SCD-Heft Al-Khatib et al J Cardiovasc Electrophysiol 2008

  30. SCD-Heft trial Amiodarone or ICD for congestive heart failure Hohnloser et al N Engl J Med 2004

  31. SCD-Heft trial Amiodarone or ICD for congestive heart failure Hohnloser et al N Engl J Med 2004

  32. SCD-Heft trial Amiodarone or ICD for congestive heart failure Hohnloser et al N Engl J Med 2004

  33. ACC/AHA/ESC Guidelines EF cutoff: 2006 < 40% 2008 < 35%

  34. Prediction of Sudden Cardiac Death After Myocardial Infarction in the Beta-Blocking Era EF (%) 37 ± 11 NYHA I 24% EF (%) 41 ± 11 NYHA I 55% Huikuri et al JACC 2003;42:652

  35. NEJM 352;2581

  36. VALIANT MADIT II NEJM 352;2581

  37. Influence of Ejection Fraction on Cardiovascular Outcomes in a Broad Spectrum of Heart Failure Patients CHARM study Solomon et al Circulation 2005;112:3738

  38. Gorgeles et al Eur Heart J 2003;24:1204

  39. Gorgeles et al Eur Heart J 2003;24:1204

  40. Clincal Trials and Clinical Indications for ICD Bunch TJ et al Circulation 2007;115:2451

  41. Sugeng L et al Circulation 2006;114:654

  42. Ejection fraction by imaging modality: An analysis of SCD-Heft Gula et alAm Heart J 2008

  43. Clincal Trials and Clinical Indications for ICD Bunch TJ et al Circulation 2007;115:2451

  44. Buxton et al Circulation 2002;106:2466

  45. Clincal Trials and Clinical Indications for ICD Bunch TJ et al Circulation 2007;115:2451

  46. Sudden cardiac death The role of risk stratification There is currently no single test capable of accurate prediction of the SCD risk in various clinical settings and patient populations. The risk itself is nonlinear and changes dynamically with the progression of disease and therapies applied. Kusmirck and Gold Am Heart J 2007;153:S252S33

  47. Amiodarone Trials Meta-Analysis on 6553 Pts “The most potent single predictor of arrhythmic/sudden death was the presence of symptomatic CHF (NYHA class III - IV) which carried a 12,2% annual risk of arrhythmic/sudden compared to 5.0% for those without symptoms.” Lancet 1997; 350:1417-24

  48. The problem is that trials were designed to demonstrate that the ICD reduces mortality in selected populations; they were not designed to test how best to use the ICD. That is the task before us. Buxton 2005

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