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Out-of-Hospital cardiac arrest survivors
EF < 30% heart failure
Any prior coronary event
High coronary risk sub-group
Overall incidence in adult
population
Convalescent phase
VT/VF after MI Sudden
Non-Sudden
Sudden Non-
Sudden
50 25 5 0 5 25 50
Percent/year 0 250.000 250.000
Events/year
CARDIAC DEATHS – INCIDENCE AND TOTAL EVENTS
Modified from Myerburg
ANAMNESI PATOLOGICA REMOTA
Precedente ischemia coronarica o IMA o ICTUS, claudicatio intermittens, ipercolesterolemia, ipertrigliceridemia, ipertensione arteriosa; valvulopatia aortica; malattie della coagulazione. Disordini endocrini, Cushing, feocromocitoma, ipo o ipertiroidismo, diabete e gotta; Fenomeno di Raynaud.
From Netter’s Cardiology, Icon Learning Systems (mod)
ANAMNESI FISIOLOGICA
Età, sesso, stress , obesità, sedentarietà, alimentazione ricca di grassi animali. Abitudini: fumo di sigaretta, abuso di cocaina, uso di contraccettivi orali.
From Netter’s Cardiology, Icon Learning Systems (mod)
• LVEF is far to be an ideal risk-stratification test on
which to base prophylactic ICD therapy
• Multiple factors interact with EF to influence mortality
of patients with similar degrees of left ventricular
dysfunction. Thus, we need combinations of tests
based on individual characteristics if we are to use
ICD therapy most efficiently for primary prevention of
sudden death
AE Buxton Circulation 2005; 111: 2537
Ejection Fraction for risk
stratification
The evidence is accumulating that the occurrence of
an abrupt ventricular arrhythmia is a multifactorial
process …..
We are most likely dealing with a probabilistic event in
which each of the currently measured risk factors
identifies only a small fraction of the multifactorial risk
process…
At present is probably better to predict coronary
patients for both sudden and non sudden cardiac
death and simply assume that SCD accounts for
approximately 50% of all cardiac deaths
AJ Moss JACC 2003, 42: 659
Is it still valuable to look for “specific”
sudden death predictors?
Functional contractile
surrogates
Measures of myocardial conduction disorders
- Signal averaged ECG
- Electrophysiologic Study
Measures of dispersion of repolarization
- QT dispersion
- T-wave alternans
Measures of autonomic imbalance
- Resting Heart Rate
- Heart Rate Variability
- Baroreflex Sensitivity
Measures of electrical instability
- VPCs
- NSVT
Electrophysiologic
surrogates
NYHA CLASS
Left Ventricular Ejection Fraction
Left Ventricular Volume
Peak Oxygen Consumption
Brain Natriuretic Peptide
Conventional Risk Stratifiers for SD
Dispensed ACE Inhibitors or ARB Prescriptions Dispensed -Adrenoreceptor Antagonists
Low-Risk
Average-Risk
High-Risk
Risk-Treatment Mismatch in the
Heart Failure
Lee DS et al JAMA. 2005;294:1240-1247
24 31 37 44
54 63
84
105
132
154
180
208
250
280
2,5 4 6 8 10 14 18 27 31 38 44
56 60
22
0
50
100
150
200
250 Annual ICD implants
per million inhabitants
Europe
USA
Updated from S. Nisam
The Gap in ICDs
Acute Exacerbations May Contribute to the Progression
of the Disease
Time
Ventr
icula
r fu
nctio
n
Acute event
With each event,
hemodynamic alterations
and myocardial damage
contribute to progressive
ventricular dysfunction
From Gheorghiade . Am J Cardiol 2005 (modified)
Acute Exacerbations may Contribute to
the Progression of the Disease
Time
Ventr
icula
r fu
nction
Acute event
With each event,
hemodynamic alterations
and myocardial damage
contribute to progressive
ventricular dysfunction
From Gheorghiade . Am J Cardiol 2005 (modified)
• In the first years after MI the benefit
of ICD is dominating and with
progression of HF-disease the benefit
of CRT-D becomes more dominant.
•After > 15 years, HF progression
shows an increasing event rate for
ICD and CRT-D population which can
be less and less impacted by device
therapy.
< 3 years 3-8 years 8-15 years >15 years
MADIT TRIALS – Long Term Follow up data HF duration and device benefit
Barsheshet A et al,Eur Heart J. 2011 Jul;32(13):1614-21.
Magnitude of sympathoexcitation predicts mortality in heart failure.
Cohn et al., NEJM 1984;311:819.
Pro
bab
ilit
y o
f su
rviv
al
Elapsed time in months 0 10 20 30 40 50 60
0
0.2
0.4
0.6
0.8
1.0
Plasma
norepinephrine
200 pg/ml
400 pg/ml
700 pg/ml 1000 pg/ml 1200 pg/ml
Distribution of QTc values among patients and
controls
Schwartz PJ, Wolf S. Circulation 1978;57:1074
Endocardial
Repolarization
Mapping
Swann et al. JCE 2003
21 in-hospital CA in 216 pts admitted
for evaluation for Txt
% Mortality
Severe Bradycardia
III AVB, AV dissociation
VT/VF
M Luu et al Circulation 1989
VT/VF
Bradyarrhythmia
% Mortality
P Faggiano et al, Am J Cardiol 2001
48 in-hospital CA
Sudden is always Arrhythmic?
N° at Risk BRS >3, LVEF >35 879 851 761 598 373
BRS <3, LVEF >35 124 116 104 81 47
BRS >3, LVEF <35 120 110 94 71 52
BRS <3, LVEF <35 59 53 46 35 19
Years
0,8
0,82
0,84
0,86
0,88
0,9
0,92
0,94
0,96
0,98
1
1,02
0 0,5 1 1,5 2
Pro
po
rtio
n S
urv
ivin
g
Log Rank = 47.97
(p<0.0001) BRS <3, LVEF <35 ( 59)
BRS >3, LVEF <35 (120)
Autonomic Tone and Reflexes After
Myocardial Infarction
1 2 3 4 5 6
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0
Cu
mul
ativ
e
sur
viv
al
BRS < 3 ms/mmHg
BRS > 3 ms/mmHg
Follow-up (years)
p = 0.0007
Freedom from All-cause Mortality
103 stable HF pts in sinus rhythm, endpoint cardiac death + urgent TXT