1. Healthcare

DAI en pacientes con
función ventricular
preservada: ¿cómo
distinguir a la población en
riesgo?
Dr. Juan Ramón
Fabregat
Hospital Angeles Lomas
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Consultar con nuevo miembro de
SOMEEC
2
From: Indications for Implantable Cardioverter-Defibrillators Based on Evidence and Judgment
J Am Coll Cardiol. 2009;54(9):747-763. doi:10.1016/j.jacc.2009.03.078
Figure Legend:
Date of download:
10/18/2013
ICD Indications in Genetic Disorders Associated With SCD Risk
Copyright © The American College of Cardiology.
All rights reserved.
3
Fuera de las canalopatías confirmadas con fenotipo
alterado:
4
The Class I recommendations for ICD
Level of Evidence – A
With LVEF ≤ 35% due to prior MI who are at least 40 days post-MI and are in NYHA Functional Class II
or III
With LV dysfunction due to prior MI who are at least 40 days post-MI, have an LVEF ≤ 30%, and are in
NYHA Functional Class 1
Who are survivors of sudden cardiac arrest due to ventricular fibrillation (VF) after evaluation to define
the cause of the event and to exclude any completely reversible causes
Level of Evidence – B
With nonischemic DCM who have an LVEF ≤ 35% and who are in NYHA Functional Class II or III
With nonsustained ventricular tachycardia (VT) due to prior MI, LVEF < 40%, and inducible ventricular
fibrillation or sustained ventricular tachycardia at electrophysiological study
With structural heart disease and spontaneous sustained VT, whether
hemodynamically stable or unstable
With syncope of undetermined origin with clinically relevant,
hemodynamically significant sustained VT or VF induced at
electrophysiological study
* Assuming patients are on chronic, optimal medical therapy and have a reasonable expectation of
survival with good functional status for > 1 year. Recommendations for ICD Defibrillators
5
CMS determines that the evidence is adequate to conclude that an implantable defibrillator is
reasonable and necessary for patients with
1) A documented episode of cardiac arrest due to ventricular fibrillation (VF), not
due to a transient or reversible cause;
2) Documented sustained ventricular tachyarrhythmia, either spontaneous or
induced by an electrophysiology (EP) study, not associated with myocardial
infarction (MI) and not due to a transient or reversible cause;
3) Documented familial or inherited conditions with a high risk of life-threatening
ventricular tachyarrhythmias, such as long QT syndrome or hypertrophic
cardiomyopathy;
4) Coronary artery disease with a documented prior myocardial infarction, a measured left
ventricular ejection fraction ≤ 0.35, and inducible, sustained ventricular tachycardia (VT) or
VF at EP study. (The myocardial infarction must have occurred more than 4 weeks prior to
implantable defibrillator insertion. The EP test must be performed more than 4 weeks after
the qualifying myocardial infarction.)
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Class II Recommendations for ICD Defibrillators
Level of Evidence – B
To reduce sudden cardiac death in patients with Long QT Syndrome who are experiencing syncope
and/or ventricular tachycardia while receiving beta blockers
Level of Evidence – C
With unexplained syncope, significant LV dysfunction, and nonischemic DCM
With sustained ventricular tachycardia and normal or near-normal ventricular function
With catecholaminergic polymorphic VT who have syncope and/or documented sustained VT while
receiving beta blockers
For the prevention of sudden cardiac death in patients with ARVD/C who have one or more risk factors
for sudden cardiac death
With HCM who have one or more major risk factors for sudden cardiac death
With Brugada syndrome who have had syncope or documented VT that has not resulted in cardiac arrest
With cardiac sarcoidosis, giant cell myocarditis, or Chagas disease
For nonhospitalized patients awaiting transplantation
* Assuming patients are on chronic, optimal medical therapy and have a reasonable expectation of
survival with good functional status for > 1 year.
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5) CMS determines that the evidence is adequate to conclude that an implantable defibrillator is
reasonable and necessary for patients with a documented prior myocardial infarction and a measured left
ventricular ejection fraction ≤ 0.30 and a QRS duration of > 120 milliseconds. Patients must not have:
New York Heart Association classification IV;
Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm; have
Had a coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA)
within past 3 months;
Had an enzyme-positive MI within past month;
Clinical symptoms or findings that would make them a candidate for coronary revascularization; or
Irreversible brain damage from preexisting cerebral disease;
Any disease, other than cardiac disease (e.g. cancer, uremia, liver failure), associated with a likelihood of
survival less than one year; and patients must be able to give informed consent.
Myocardial infarctions must be documented by elevated cardiac enzymes or Q-waves on an
electrocardiogram. Ejection fractions must be measured by angiography, radionuclide scanning or
echocardiography.
CMS determines that the evidence is not adequate to conclude that an implantable defibrillator is
reasonable and necessary for all patients with a prior myocardial infarction, a left ventricular ejection
fraction ≤ 0.30, and a QRS ≤ 120 ms.
All other indications are also noncovered.
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El problema radica en la
selección de riesgos
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El problema Radica en que la mayor parte de
los
es en pacientes con FE baja
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Selected Randomized, Clinical Trials of Implantable Cardioverter–Defibrillator (ICD)Therapy.
DiMarco JP. N Engl J Med 2003;349:1836-1847.
12
From: Indications for Implantable Cardioverter-Defibrillators Based on Evidence and Judgment
J Am Coll Cardiol. 2009;54(9):747-763. doi:10.1016/j.jacc.2009.03.078
Figure Legend:
Date of download:
10/18/2013
Secondary Prevention Trials
Copyright © The American College of Cardiology.
All rights reserved.
13
From: Indications for Implantable Cardioverter-Defibrillators Based on Evidence and Judgment
J Am Coll Cardiol. 2009;54(9):747-763. doi:10.1016/j.jacc.2009.03.078
Figure Legend:
Date of download:
10/18/2013
Primary Prevention ICD Trials
Copyright © The American College of Cardiology.
All rights reserved.
14
From: Indications for Implantable Cardioverter-Defibrillators Based on Evidence and Judgment
J Am Coll Cardiol. 2009;54(9):747-763. doi:10.1016/j.jacc.2009.03.078
Figure Legend:
Date of download:
10/18/2013
Primary Prevention ICD Trials
Copyright © The American College of Cardiology.
All rights reserved.
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Risk of Death or Heart Failure
Moss AJ et al. N Engl J Med 2009;361:1329-1338
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Complications of Implantable Cardioverter–Defibrillator Therapy.
DiMarco JP. N Engl J Med 2003;349:1836-1847.
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Baseline Demographic and Clinical Characteristics of the Patients
Moss AJ et al. N Engl J Med 2009;361:1329-1338
22
Changes in Mean Echocardiographic Left Ventricular Volumes and Ejection Fraction between
Baseline and 1-Year Follow-up
Moss AJ et al. N Engl J Med 2009;361:1329-1338
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Se solicita residente: