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McCabe MD, Cervantes R, Kewcharoen J, Sran J, Garg J. Quelling the Storm: A Review of the Management of Electrical Storm. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00338-5. [PMID: 37296026 DOI: 10.1053/j.jvca.2023.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/17/2023] [Indexed: 06/12/2023]
Abstract
Heightened sympathetic input to the myocardium potentiates cardiac electrical instability and may herald an electrical storm. An electrical storm is characterized by 3 or more episodes of ventricular tachycardia, ventricular fibrillation, or appropriate internal cardiac defibrillator shocks within 24 hours. Management of electrical storms is resource-intensive and inevitably requires careful coordination between multiple subspecialties. Anesthesiologists have an important role in acute, subacute, and long-term management. Identifying the phase of an electrical storm and understanding the characteristics of each morphology may help the anesthesiologist anticipate the management approach. In the acute phase, management of an electrical storm is aimed at providing advanced cardiac life support and identifying reversible causes. After initial stabilization, subacute management focuses on dampening the sympathetic surge with sedation, thoracic epidural, or stellate ganglion blockade. Definitive long-term management with surgical sympathectomy or catheter ablation also may be warranted. Our objective is to provide an overview of electrical storms and the anesthesiologist's role in management.
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Affiliation(s)
- Melissa D McCabe
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California.
| | - Richard Cervantes
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Jakrin Kewcharoen
- Cardiac Arrhythmia Service, Loma Linda University School of Medicine, Loma Linda, California
| | - Jasmine Sran
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Jalaj Garg
- Cardiac Arrhythmia Service, Loma Linda University School of Medicine, Loma Linda, California
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 300] [Impact Index Per Article: 150.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Martinek M, Manninger M, Schönbauer R, Scherr D, Schukro C, Pürerfellner H, Petzl A, Strohmer B, Derndorfer M, Bisping E, Stühlinger M, Fiedler L. Expert consensus on acute management of ventricular arrhythmias - VT network Austria. IJC HEART & VASCULATURE 2021; 34:100760. [PMID: 33869728 PMCID: PMC8047164 DOI: 10.1016/j.ijcha.2021.100760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 12/11/2022]
Abstract
The Arrhythmia Working Group of the Austrian Society of Cardiology (ÖKG) has set the goal of systematically structuring and organizing the acute care of patients with ventricular arrhythmias (VA), i.e. ventricular tachycardia (VT) or ventricular fibrillation (VF) in Austria. Within a consensus paper, national recommendations on the basic diagnostic work-up of VA (12-lead ECG, medical history, family history, laboratory analyses, echocardiography, search for reversible causes, ICD interrogation), as well as further medical treatment and therapeutic measures (indication of coronary angiography, ablation therapy) are established. Since acute ablation of VT is indicated in the current ESC guidelines as a class IB indication for scar-associated incessant VT or electrical storm (ES; ≥ 3 ICD therapies in 24 h) as well as for ischemic cardiomyopathy (iCMP) with recurrent ICD shocks, organizational measures must be taken to ensure that these guidelines can be implemented. Therefore, a VT network will be established covering all areas in Austria, consisting of primary and secondary VT centers. Organizational aspects of an acute VT network are defined and should subsequently be implemented by the participating hospitals. All electrophysiologic centers in Austria that deal with VT ablation are to be integrated into the network in the medium-term. Centers that co-operate in the network are divided into primary and secondary VT centers according to predefined criteria.
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Affiliation(s)
- M. Martinek
- Ordensklinikum Linz Elisabethinen, Interne 2 mit Kardiologie, Angiologie und Intensivmedizin, Fadingerstrasse 1, 4020 Linz, Austria
- Universitätsklinikum St. Pölten, Interne 3 – Kardiologie, Dunant-Platz 1, 3100 St. Pölten, Austria
| | - M. Manninger
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin – Klinische Abteilung für Kardiologie, Auenbruggerplatz 15, 8036 Graz, Austria
| | - R. Schönbauer
- Universitätsklinik für Innere Medizin II – Klinische Abteilung für Kardiologie, Währinger Gürtel 18-20, 1090 Wien, Austria
| | - D. Scherr
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin – Klinische Abteilung für Kardiologie, Auenbruggerplatz 15, 8036 Graz, Austria
| | - C. Schukro
- Universitätsklinik für Innere Medizin II – Klinische Abteilung für Kardiologie, Währinger Gürtel 18-20, 1090 Wien, Austria
| | - H. Pürerfellner
- Ordensklinikum Linz Elisabethinen, Interne 2 mit Kardiologie, Angiologie und Intensivmedizin, Fadingerstrasse 1, 4020 Linz, Austria
| | - A. Petzl
- Universitätsklinikum St. Pölten, Interne 3 – Kardiologie, Dunant-Platz 1, 3100 St. Pölten, Austria
| | - B. Strohmer
- Universitätsklinik für Innere Medizin II – Paracelsus Medizinische Privatuniversität, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
| | - M. Derndorfer
- Ordensklinikum Linz Elisabethinen, Interne 2 mit Kardiologie, Angiologie und Intensivmedizin, Fadingerstrasse 1, 4020 Linz, Austria
| | - E. Bisping
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin – Klinische Abteilung für Kardiologie, Auenbruggerplatz 15, 8036 Graz, Austria
| | - M. Stühlinger
- Universitätsklinik für Innere Medizin III – Kardiologie und Angiologie, Anichstrasse 35, 6020 Innsbruck, Austria
| | - L. Fiedler
- Landesklinikum Wiener Neustadt, Abteilung für Innere Medizin, Kardiologie und Nephrologie, Corvinusring 3-5, 2700 Wiener Neustadt, Austria
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Hasin T, Davarashvili I, Michowitz Y, Farkash R, Presman H, Glikson M, Rav-Acha M. Association of Guideline-Based Medical Therapy with Malignant Arrhythmias and Mortality among Heart Failure Patients Implanted with Cardioverter Defibrillator (ICD) or Cardiac Resynchronization-Defibrillator Device (CRTD). J Clin Med 2021; 10:1753. [PMID: 33920719 PMCID: PMC8073338 DOI: 10.3390/jcm10081753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/04/2021] [Accepted: 04/14/2021] [Indexed: 11/29/2022] Open
Abstract
AIM Evaluate prevalence of heart failure (HF) medications and their association with ventricular arrhythmia (VA) and survival among patients implanted with primary prevention implantable cardiac defibrillator (ICD)/cardiac resynchronization therapy + defibrillator (CRTD) devices. METHODS Association of treatment and dose (% guideline recommended target) of beta-adrenergic receptor antagonist (BB), angiotensin-antagonists (AngA), and mineralocorticoid-antagonists (MRA), after ICD/CRTD implant with VA and mortality was retrospectively analyzed. RESULTS Study included 186 HF patients; 42.5% and 57.5% implanted with ICD and CRTD, respectively. During 3.8 (2.1;6.7) years; 52 (28%) had VA and 77 (41.4%) died. Treatment (% of patients) included: BB (83%), AngA (87%), and MRA (59%). Median doses were 25(12.5;50)% of target for all medications. BB treatment >25% target dose was associated with reduced VA incidence. In the multivariable model including age, gender, diabetes, heart rate, and medication doses, increased BB dose was associated with reduced VA (hazard ratio (HR) 0.443 95% CI 0.222-0.885; p = 0.021). In the multivariable model for overall mortality including age, gender, renal disease, VA, and medical treatment, VA was associated with increased mortality (HR 2.672; 95% CI 1.429-4.999; p = 0.002) and AngA treatment was associated with reduced mortality (HR 0.515; 95% CI 0.285-0.929; p = 0.028). CONCLUSIONS In this cohort of real-life HF patients discharged after ICD/CRTD implant, prevalence of guideline-based HF medications was high, albeit with low doses. Higher BB dose was associated with reduced VA, while AngA was associated with improved survival.
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Affiliation(s)
- Tal Hasin
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Hebrew University, Jerusalem 9103102, Israel; (T.H.); (I.D.); (Y.M.); (R.F.); (M.G.)
- Faculty of Medicine, Hebrew University, Jerusalem 9103102, Israel;
| | - Ilia Davarashvili
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Hebrew University, Jerusalem 9103102, Israel; (T.H.); (I.D.); (Y.M.); (R.F.); (M.G.)
| | - Yoav Michowitz
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Hebrew University, Jerusalem 9103102, Israel; (T.H.); (I.D.); (Y.M.); (R.F.); (M.G.)
- Faculty of Medicine, Hebrew University, Jerusalem 9103102, Israel;
| | - Rivka Farkash
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Hebrew University, Jerusalem 9103102, Israel; (T.H.); (I.D.); (Y.M.); (R.F.); (M.G.)
| | - Haya Presman
- Faculty of Medicine, Hebrew University, Jerusalem 9103102, Israel;
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Hebrew University, Jerusalem 9103102, Israel; (T.H.); (I.D.); (Y.M.); (R.F.); (M.G.)
- Faculty of Medicine, Hebrew University, Jerusalem 9103102, Israel;
| | - Moshe Rav-Acha
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Hebrew University, Jerusalem 9103102, Israel; (T.H.); (I.D.); (Y.M.); (R.F.); (M.G.)
- Faculty of Medicine, Hebrew University, Jerusalem 9103102, Israel;
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Kugamoorthy P, Spears DA. Management of tachyarrhythmias in pregnancy - A review. Obstet Med 2020; 13:159-173. [PMID: 33343692 PMCID: PMC7726166 DOI: 10.1177/1753495x20913448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/16/2020] [Indexed: 11/16/2022] Open
Abstract
The most common arrhythmias detected during pregnancy include sinus tachycardia, sinus bradycardia, and sinus arrhythmia, identified in 0.1% of pregnancies. Isolated premature atrial or ventricular arrhythmias are observed in 0.03% of pregnancies. Arrhythmias may become more frequent during pregnancy or may manifest for the first time.
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Affiliation(s)
| | - Danna A Spears
- University Health Network – Toronto General Hospital, Toronto, Canada
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Yadav R, Chandra A, Yadav G, Naik N. Prospective evaluation of outcome of Indian patients who meet MADIT II (Multicenter Automatic Defibrillator Implantation Trial) criteria for implantable cardioverter defibrillator implantation: is it appropriate for Indian patients? Indian Heart J 2020; 72:172-178. [PMID: 32768016 PMCID: PMC7411118 DOI: 10.1016/j.ihj.2020.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The MADIT II investigators had concluded that prophylactic use of an ICD improved survival in patients with prior myocardial infarction reduced left ventricular ejection fraction. Whether MADIT II criteria for ICD implantation are appropriate for Indian patients also is unclear and not studied. METHODS A total of 144 patients, Mean age 56.23 ± 10.9 years who met MADIT II criteria were prospectively followed for 20.78 + 5.9 months. RESULTS During the follow-up period, 26 (18.1%) patients died. 18 were sudden cardiac deaths and 8 were non SCD deaths. Total mortality did not correlate with Age, NYHA class, NSVT on Holter, PVC >10/hours, QRS width, or use of statins. Multivariate logistic regression model identified the following variables associated with increase all-cause mortality: No use of beta blocker (odd ratio:13.068, p = 0.021), No past revascularization (odd ratio:11.613,p = 0.007) and Increase serum creatinine level (odd ratio: 4.066, p = 0.035). The mortality rate in the present series was comparable with that in the MADIT II conventional therapy group though patient in present study are younger, less diabetic, hypertensive, smokers and better treated with beta-blockers, ACE/ARB and statin. CONCLUSION Indian patients with prior MI (more than one month back) and left ventricular ejection fraction of 30% or less had a cardiac mortality similar to western population who are not treated with prophylactic ICD. Patients of Indian origin should derive a similar benefit with prophylactic implantation of ICD as per MADIT II criteria as would a western population.
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Affiliation(s)
- Rakesh Yadav
- Dept. of Cardiology AIIMS, Ansari Nagar New Delhi, 29, India.
| | | | | | - Nitish Naik
- Dept. of Cardiology AIIMS, Ansari Nagar New Delhi, 29, India
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Dyer S, Mogni B, Gottlieb M. Electrical storm: A focused review for the emergency physician. Am J Emerg Med 2020; 38:1481-1487. [PMID: 32345562 DOI: 10.1016/j.ajem.2020.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/31/2020] [Accepted: 04/06/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Electrical storm is a dangerous condition presenting to the Emergency Department that requires rapid diagnosis and management. OBJECTIVE This article provides a review of the diagnosis and management of electrical storm for the emergency clinician. DISCUSSION Electrical storm is defined as ≥3 episodes of sustained ventricular tachycardia, ventricular fibrillation, or shocks from an implantable cardioverter defibrillator within 24 h. Patients may present with a wide array of symptoms. Initial evaluation should include an electrocardiogram with a rhythm strip and continuous cardiac monitoring, a medication history, assessment of hemodynamic stability, and identification of potential triggers. Management includes an antiarrhythmic and a beta blocker. Refractory patients may benefit from double-sequential defibrillation or more invasive procedures such as intra-aortic balloon pumps, catheter ablation and extracorporeal membrane oxygenation for critically ill patients. These patients will typically require admission to an intensive care unit. CONCLUSION Electrical storm is a condition associated with significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the evaluation and management of these patients.
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Affiliation(s)
- Sean Dyer
- Department of Emergency Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, United States of America.
| | - Benjamin Mogni
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
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Bae MH, Cho Y, Hwang J, Park HS, Han S, Lee YS, Cho HJ, Jung BC, Lee CH, Hyun DW, Park JS, Ahn J, Kim KH, Shin DG. Clinical Impact of Implantable Cardioverter-Defibrillator Therapy and Mortality Prediction Model for Effective Primary Prevention in Korean Patients. J Korean Med Sci 2020; 35:e49. [PMID: 32141247 PMCID: PMC7061144 DOI: 10.3346/jkms.2020.35.e49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 01/07/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Studies on the efficacy of implantable cardioverter-defibrillator (ICD) therapy for primary prevention in Asian patients are relatively lacking compared to those for secondary prevention. Also, it is important to stratify which patients will benefit from ICD therapy for primary prevention. METHODS Of 483 consecutive patients who received new implantation of ICD in 9 centers in Korea, 305 patients with reduced left ventricular systolic function and/or documented ventricular fibrillation/tachycardia were enrolled and divided into primary (n = 167) and secondary prevention groups (n = 138). RESULTS During mean follow-up duration of 2.6 ± 1.6 years, appropriate ICD therapy occurred in 78 patients (25.6%), and appropriate ICD shock and anti-tachycardia pacing occurred in 15.1% and 15.1% of patients, respectively. Appropriate ICD shock rate was not different between the two groups (primary 12% vs. secondary 18.8%, P = 0.118). However, appropriate ICD therapy rate including shock and anti-tachycardia pacing was significantly higher (primary 18% vs. secondary 34.8%, P = 0.001) in the secondary prevention group. Type of prevention and etiology, appropriate and inappropriate ICD shock did not affect all-cause death. High levels of N-terminal pro-B-type natriuretic peptide, New York Heart Association functional class, low levels of estimated glomerular filtration ratio, and body mass index were associated with death before appropriate ICD shock in the primary prevention group. When patients were categorized in 5 risk score groups according to the sum of values defined by each cut-off level, significant differences in death rate before appropriate ICD shock were observed among risk 0 (0%), 1 (3.6%), 2 (3%), 3 (26.5%), and 4 (40%) (P < 0.001). CONCLUSION In this multicenter regional registry, the frequency of appropriate ICD therapy is not low in the primary prevention group. In addition, combination of poor prognostic factors of heart failure is useful in risk stratification of patients who are not benefiting from ICD therapy for primary prevention.
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Affiliation(s)
- Myung Hwan Bae
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yongkeun Cho
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jongmin Hwang
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Hyoung Seob Park
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Seongwook Han
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Young Soo Lee
- Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, Korea
| | - Hyun Jun Cho
- Department of Internal Medicine, Daegu Fatima General Hospital, Daegu, Korea
| | - Byung Chun Jung
- Department of Internal Medicine, Daegu Fatima General Hospital, Daegu, Korea
| | - Chan Hee Lee
- Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Dae Woo Hyun
- Department of Internal Medicine, Andong General Hospital, Andong, Korea
| | - Jong Sung Park
- Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
| | - Jinhee Ahn
- Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Ki Hun Kim
- Department of Internal Medicine, Inje University Busan Haeundae Paik Hospital, Busan, Korea
| | - Dong Gu Shin
- Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea.
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Martens P, Dupont M, Mullens W. Reduced occurrence of appropriate therapy for ventricular arrhythmias after beta-blocker uptitration following implant of a primary prevention CRT-defibrillator. Acta Cardiol 2020; 75:49-53. [PMID: 30650028 DOI: 10.1080/00015385.2018.1547469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Absence of beta-blocker use independently predicts appropriate therapy. Following cardiac resynchronisation therapy (CRT) implant, reverse remodelling and protection against bradycardia allows for beta-blocker dose uptitration. The differential dosing effects on the occurrence of a first episode of appropriate therapy in primary prevention CRT-defibrillator (CRT-D) patients remains unstudied.Methods and Results: Changes in beta-blocker dose following CRT-D in consecutive primary prevention patients implanted between 2008 and 2015 were retrospectively studied. Beta-blocker dose was expressed as percent of target dose. Uptitration of beta-blocker dose following implant was calculated as the change in percent of target dose between implant and 6-months follow-up. Results from a prospectively maintained database of all device analysis were used to determine the occurrence of appropriate therapy. A total of 162 patients (68 ± 8 years) were studied. One hundred and ten (68%) patients underwent uptitration (mean 47 ± 19% in target dose) and 52 (32%) remained on a stable beta-blocker dose. During 37 ± 22 months follow-up, the cumulative percent of appropriate therapy was 31% in patient receiving no-uptitration versus 10% in the uptitrated patients (p < 0.001). After correction for known predictors of appropriate therapy, uptitration was independently associated with an OR = 0.263 (CI = 0.103-0.675; p = 0.001) for the occurrence of appropriate therapy. Every 1%-increase in target dose for beta-blocker associated with a significant lower risk for appropriate therapy, OR = 0.982 (CI = 0.965-0.999; p = 0.042).Conclusion: Following implantation of a primary prevention CRT-D, uptitration of beta-blockers associated with a reduced occurrence of a first episode of appropriate therapy for ventricular arrhythmias. An inverse dose-response effect was seen between beta-blocker dose and appropriate therapy.
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Affiliation(s)
- Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
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Mattsson G, Magnusson P. Long-term follow-up of implantable cardioverter defibrillator patients with regard to appropriate therapy, complications, and mortality. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:245-253. [PMID: 31891421 PMCID: PMC7027920 DOI: 10.1111/pace.13869] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/20/2019] [Accepted: 12/29/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND An implantable cardioverter defibrillator (ICD) is recommended for patients with symptomatic heart failure with ejection fraction ≤35% despite optimal medical therapy. More recently, the benefits of ICDs have been questioned in nonischemic cardiomyopathy (CM). AIM To examine the incidence of appropriate therapy, complications, mortality, and cause of death among ICD patients in an unselected validated cohort. In primary prevention, appropriate therapy in ischemic versus nonischemic CM will be evaluated. METHODS A retrospective observational study of patients in Region Gävleborg, Sweden, who underwent ICD implantation or replacement between 2007 and 2017. RESULTS In total, 438 patients (mean age at implant: 65.9 ± 11.2 years, 82.0% males, mean follow-up: 5.2 ± 4.0 years) were included. There were 108 (24.7%) deaths (49.1% due to heart failure) and 94.9% survived the first year. Cumulative incidence of appropriate therapy at 5-year was 31.6%. Cumulative incidence of inappropriate shock at 5-year was 9.1%. A total of 98 complications requiring surgical intervention occurred (annual rate: 4.3%). In total, 236 patients with primary prevention due to ischemic (61.9%) or nonischemic (38.1%) CM were included. During a mean follow-up of 3.9 ± 2.5 years, for appropriate therapy, there was no significant difference (P = .985) between ischemic (cumulative incidence at 1, 3, and 5 years: 6.4%, 17.1%, and 19.6%) and nonischemic CM (cumulative incidence at 1, 3, and 5 years: 5.6%, 13.6%, and 24.4%). CONCLUSION Ischemic and nonischemic CM confer similar risk of ventricular arrhythmia. This supports current guidelines regarding primary-prevention ICD. Short-term survival is excellent but complications remain a problem.
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Affiliation(s)
- Gustav Mattsson
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, SE- 801 87, Sweden
| | - Peter Magnusson
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, SE- 801 87, Sweden.,Cardiology Research Unit, Department of Medicine, Karolinska Institutet, Stockholm, SE-171 76, Sweden
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Resistant Ventricular Arrhythmia and the Role of Overdrive Pacing in the Suppression of the Electrical Storm. Case Rep Cardiol 2019; 2019:6592927. [PMID: 31249712 PMCID: PMC6556359 DOI: 10.1155/2019/6592927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 02/18/2019] [Indexed: 11/18/2022] Open
Abstract
Ventricular arrhythmia storm is a state of cardiac instability characterized by multiple ventricular arrhythmias or multiple ICD therapies within a 24-hour duration. Management of this life-threatening state depends on the reversal of the cause besides either electrical or medical management of the arrhythmia. We report a case of a 54-year-old male who underwent a percutaneous coronary intervention following massive acute myocardial infarction. Afterwards, he developed frequent life-threatening ventricular arrhythmias that required multiple shocks and antiarrhythmic medications. Despite all these interventions, it was very difficult to control the electrical instability, but after overdrive ventricular pacing, the storm subsided and within a few days the case was stabilized. Overdrive pacing is an easy temporary modality to control the resistant arrhythmia following myocardial infarction.
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AlTurki A, Proietti R, Russo V, Dhanjal T, Banerjee P, Essebag V. Anti-arrhythmic drug therapy in implantable cardioverter-defibrillator recipients. Pharmacol Res 2019; 143:133-142. [PMID: 30914300 DOI: 10.1016/j.phrs.2019.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 03/20/2019] [Accepted: 03/22/2019] [Indexed: 01/14/2023]
Abstract
Implantable cardioverter-defibrillators (ICDs) have revolutionized the primary and secondary prevention of patients with ventricular arrhythmias. However, the adverse effects of appropriate or inappropriate shocks may require the adjunctive use of anti-arrhythmic drugs (AADs). Beta blockers are the cornerstone of pharmacological primary and secondary prevention of ventricular arrhythmias. In addition to their established efficacy at reducing the incidence of ventricular arrhythmias, beta-blockers are safe with few side effects. Amiodarone is superior to beta blockers and sotalol for the prevention of ventricular arrhythmia recurrence. However, long-term amiodarone use is associated with significant side effects that limit its utility. Sotalol and mexiletine are the main alternatives to amiodarone with a better side effect profile though they are less efficacious at preventing ventricular arrhythmia recurrence. Dofetilide, azimilide and ranolazine are emerging as therapeutic options for secondary prevention; more studies are needed to assess efficacy and safety in comparison to currently used agents. Beta blockers and amiodarone are the mainstay of therapy in patients experiencing electrical storm; their use reduces the frequency of ventricular arrhythmias and ICD intervention as well as affording time until catheter ablation can be considered.
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Affiliation(s)
- Ahmed AlTurki
- Division of Cardiology, McGill University Health Center, Quebec, Canada.
| | - Riccardo Proietti
- Department of Cardiac, Thoracic, and Vascular Sciences, Padua, Italy
| | - Vincenzo Russo
- Chair of Cardiology, University of Campania, Ospedale Monaldi, Naples, Italy
| | - Tarvinder Dhanjal
- Cardiology Department, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Prithwish Banerjee
- Cardiology Department, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Center, Quebec, Canada; Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada
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Watanabe T, Inoue K, Kashiwase K, Mine T, Hirooka K, Shutta R, Mizuno H, Okuyama Y, Sakata Y, Nanto S. Differences in amiodarone efficacy in relation to ejection fraction and basal rhythm in patients with implantable cardioverter defibrillators. J Electrocardiol 2018; 51:1111-1115. [PMID: 30497740 DOI: 10.1016/j.jelectrocard.2018.10.083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/23/2018] [Accepted: 10/06/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) and ventricular arrhythmias (VAs) are associated with increased morbidity and mortality. However, data are lacking concerning the association of AF and VAs. This study aimed to clarify the association between AF and VAs and to investigate the effect of amiodarone on the incidence of VAs in patients with implantable cardioverter defibrillators (ICDs). METHODS AND RESULTS We enrolled 612 patients who had ICDs or who underwent cardiac resynchronization therapy with a defibrillator (CRT-D) and classified them into two groups (sinus rhythm [SR] group, n = 427; AF group, n = 185) according to their basal rhythm at enrollment. Patients with paroxysmal AF were grouped into the AF group. The incidence of VAs, i.e., ventricular tachycardia (VT) and ventricular fibrillation (VF), was significantly lower in the AF group than in the SR group (0.54 vs 0.95 episodes/person/year, P = 0.032). Furthermore, amiodarone use was significantly higher in the AF group than in the SR group (P = 0.003). Non-use of amiodarone was associated with a significant increase in the occurrence of VT/VF in the two groups. This beneficial suppressive effect of amiodarone on the incidence of VT/VF was present in the AF group regardless of left ventricular ejection fraction (LVEF). However, this effect of amiodarone was present only in patients with LVEF ≥ 40% in the SR group. CONCLUSIONS Amiodarone was negatively associated with VT/VF occurrence and was frequently used in ICD/CRT-D patients with AF. VT/VF was controlled by amiodarone in all cases in the AF group but only in patients with an LVEF ≥ 40% in the SR group.
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Affiliation(s)
- Tetsuya Watanabe
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Japan.
| | - Koichi Inoue
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Kazunori Kashiwase
- Department of Internal Medicine, Cardiovascular Division, Hyogo College of Medicine, Hyogo, Japan
| | - Takanao Mine
- Department of Internal Medicine, Cardiovascular Division, Hyogo College of Medicine, Hyogo, Japan
| | - Keiji Hirooka
- Cardiovascular Division, Osaka Saiseikai Senri Hospital, Osaka, Japan
| | - Ryu Shutta
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Hiroya Mizuno
- Department of Cardiovascular Medicine, Osaka University School of Medicine, Suita, Japan
| | - Yuji Okuyama
- Cardiovascular Division, National Hospital Organization Osaka Minami Medical Center, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University School of Medicine, Suita, Japan
| | - Shinsuke Nanto
- Department of Cardiology, Nishinomiya Municipal Central Hospital, Nishinomiya, Japan
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Markman TM, McBride DA, Liang JJ. Catheter Ablation for Ventricular Tachycardia in Patients with Structural Heart Disease. US CARDIOLOGY REVIEW 2018. [DOI: 10.15420/usc.2017:28:3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Ventricular tachycardia is a potentially fatal arrhythmia that occurs most frequently in patients with structural heart disease. Acute and long- term management can be complex, requiring an integrated approach with multiple therapeutic modalities including antiarrhythmic drugs, implantable cardioverter defibrillators, and catheter ablation. Each of these options has a role in management of ventricular tachycardia and are generally used in combination. It is essential to be aware that each approach has potential deleterious consequences that must be balanced while establishing a treatment strategy. Catheter ablation for ventricular tachycardia is performed with increasing frequency with rapidly evolving techniques. In this review, we discuss the acute and long-term management of ventricular tachycardia with a focus on techniques and evidence for catheter ablation.
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16
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Weir MA, Herzog CA. Beta blockers in patients with end-stage renal disease-Evidence-based recommendations. Semin Dial 2018; 31:219-225. [PMID: 29482260 DOI: 10.1111/sdi.12691] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
For patients who require hemodialysis, beta blockers offer a simultaneous opportunity and challenge in the treatment of cardiovascular disease. Beta blockers are well supported by data from nondialysis populations and directly mitigate the sympathetic overactivity that links chronic kidney disease with cardiovascular sequelae. However, the evidence supporting their use in patients receiving hemodialysis is sparse and the heterogeneity of the beta blocker class makes it difficult to prescribe these medications with confidence. Despite these limitations, both trial and observational data exist that can help guide the use of these medications. In this review, we outline the reasons to consider beta blockers for patients receiving hemodialysis, discuss the barriers to their use, and provide specific evidence-based recommendations for beta blocker use in patients with heart failure, hypertension, ischemic heart disease and arrhythmia.
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Affiliation(s)
- Matthew A Weir
- Division of Nephrology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA.,Division of Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
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Muser D, Santangeli P, Liang JJ. Management of ventricular tachycardia storm in patients with structural heart disease. World J Cardiol 2017; 9:521-530. [PMID: 28706587 PMCID: PMC5491469 DOI: 10.4330/wjc.v9.i6.521] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/24/2017] [Accepted: 05/15/2017] [Indexed: 02/06/2023] Open
Abstract
Electrical storm (ES) is a medical emergency characterized by repetitive episodes of sustained ventricular arrhythmias (VAs) in a limited amount of time (at least 3 within a 24-h period) leading to repeated appropriate implantable cardioverter defibrillator therapies. The occurrence of ES represents a major turning point in the natural history of patients with structural heart disease being associated with poor short- and long-term survival particularly in those with compromised left ventricular ejection fraction (LVEF) that can develop hemodynamic decompensation and multi-organ failure. Management of ES is challenging with limited available evidence coming from small retrospective series and a substantial lack of randomized-controlled trials. In general, a multidisciplinary approach including medical therapies such as anti-arrhythmic drugs, sedation, as well as interventional approaches like catheter ablation, may be required. Accurate patient risk stratification at admission for ES is pivotal and should take into account hemodynamic tolerability of VAs as well as comorbidities like low LVEF, advanced NYHA class and chronic pulmonary disease. In high risk patients, prophylactic mechanical circulatory support with left ventricular assistance devices or extracorporeal membrane oxygenation should be considered as bridge to ablation and recovery. In the present manuscript we review the available strategies for management of ES and the evidence supporting them.
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18
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Devices for management of sudden cardiac death: Successes, challenges and perspectives. Int J Cardiol 2017; 237:34-37. [DOI: 10.1016/j.ijcard.2017.03.053] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/13/2017] [Indexed: 12/28/2022]
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Asami M, Aoki J, Tanimoto S, Horiuchi Y, Watanabe M, Furui K, Yasuhara K, Sato T, Tanabe K, Hara K. Effects of Long-Acting Loop Diuretics in Heart Failure With Reduced Ejection Fraction Patients With Cardiac Resynchronization Therapy. Int Heart J 2017; 58:211-219. [PMID: 28321027 DOI: 10.1536/ihj.16-290] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
There have been no reports evaluating the impact of long-acting loop diuretics (LLD) on the outcome of heart failure (HF) and arrhythmia treatment in HF with reduced ejection fraction (HFrEF) patients implanted with a cardiac resynchronization therapy (CRT) device.This was a prospective, single-blind, randomized crossover study. We allocated 21 consecutive CRT implanted patients into 2 groups. The furosemide group received furosemide as a first treatment and azosemide as a second treatment. The azosemide group received this treatment in the reverse order. The first treatment was given to each group for 6 months and the second treatment continued for an additional 6 months. We combined the data of each medication regimen in each group and analyzed it at baseline, 6 months, and 1 year. The primary endpoints were the variation of fluid index and thoracic impedance measured by CRT at 6 months.The baseline characteristics were similar for both groups. The difference in the primary endpoints was not statistically significant between the 2 medication arms (fluid index: -29.6 ± 64.4 versus 16.2 ± 48.2; P = 0.22, thoracic impedance: -0.49 ± 17.8 versus 2.45 ± 12.5; P = 0.56). Likewise, the clinical outcome of HF and the CRT derived parameters in both arms were comparable.HFrEF patients taking LLD after CRT implantation might be comparable to those taking short-acting loop diuretics in the treatment of HF and HF-associated arrhythmias.
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An Y, Ando K, Soga Y, Nomura A, Nagashima M, Hayashi K, Makihara Y, Fukunaga M, Hiroshima KI, Nobuyoshi M, Goya M. Mortality and predictors of appropriate implantable cardioverter defibrillator therapy in Japanese patients with Multicenter Automatic Defibrillator Implantation Trial II criteria. J Arrhythm 2016; 33:17-22. [PMID: 28217224 PMCID: PMC5300836 DOI: 10.1016/j.joa.2016.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Revised: 03/16/2016] [Accepted: 04/26/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Data regarding long-term mortality and factors influencing appropriate therapies in Japanese patients with implantable cardioverter defibrillators (ICD), who satisfy the Multicenter Automatic Defibrillator Implantation Trial II (MADIT II) criteria for primary prevention, remain scarce. METHODS A total of 118 consecutive patients who underwent ICD implantation without any prior ventricular arrhythmic event, from January 2000 to December 2012, were enrolled based on the MADIT II criteria: left ventricular ejection fraction (LVEF) of ≤30% with ischemic heart disease and at least 4 weeks after a myocardial infarction. We investigated the mortality and factors influencing appropriate ICD therapies in this population. RESULTS The mean age was 69±10 years, and the mean LVEF was 25.1±4.5%. During the median follow up of 1406 days, the mortality rate was 20%, and the incidence of appropriate ICD therapy was 37% at 3 years. Multivariate analysis by using Cox regression model showed that left ventricular diastolic diameter ≥60 mm (hazard ratio [HR], 2.31; 95% confidence interval [CI], 1.07-5.38; P=0.033) and the presence of non-sustained ventricular tachycardia (NSVT) before implantation (HR, 2.26; 95% CI, 1.17-4.39; P=0.015) were independent predictors of appropriate ICD therapy. CONCLUSIONS The mortality and incidence of appropriate ICD therapy were 20% and 37%, respectively, at 3 years in Japanese patients who met the MADIT II criteria during ICD implantation for primary prevention of sudden cardiac death. The presence of NSVT and dilated left ventricle independently predicted the incidence of appropriate ICD therapy after implantation.
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Affiliation(s)
- Yoshimori An
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Akihiro Nomura
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Michio Nagashima
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kentaro Hayashi
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Yu Makihara
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Masato Fukunaga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | | | | | - Masahiko Goya
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
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21
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Do we need further clinical-effectiveness estimates to support the use of primary prevention implantable cardioverter-defibrillators in New York Heart Association class III patients? Int J Cardiol 2016; 203:184-6. [DOI: 10.1016/j.ijcard.2015.10.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 09/08/2015] [Accepted: 10/12/2015] [Indexed: 11/20/2022]
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22
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Sagone A. Electrical Storm: Incidence, Prognosis and Therapy. J Atr Fibrillation 2015; 8:1150. [PMID: 27957218 DOI: 10.4022/jafib.1150] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/19/2015] [Accepted: 12/24/2015] [Indexed: 01/22/2023]
Abstract
The term "electrical storm" indicates a life-threatening clinical condition characterized by the recurrence of hemodynamically unstable ventricular tachycardia and/or ventricular fibrillation, in particular in patients with ICD implanted for primary or secondary prevention. Although there isn't a shared definition of electrical storm, nowadays the most accepted definition refers to three or more separate arrhythmia episodes leading to ICD therapies including antitachycardia pacing or shock occurring over a single 24 hours' time period. Clinical presentation can be dramatic and triggering mechanism are not clear at all yet, but electrical storm is associated with high mortality rates and low patients quality of life, both in the acute phase and in the long term. The first line therapy is based on antiarrhythmic drugs to suppress electrical storm, but in refractory patients, interventions such as catheter ablation or in some cases surgical cardiac sympathetic denervation might be helpful. Anyhow, earlier interventional management can lead to better outcomes than persisting with antiarrhythmic pharmacologic therapy and, when available, an early interventional approach should be preferred.
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Affiliation(s)
- Antonio Sagone
- Cardiology Department, Luigi Sacco Hospital, Milan, Italy
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23
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Pedersen CT, Kay GN, Kalman J, Borggrefe M, Della-Bella P, Dickfeld T, Dorian P, Huikuri H, Kim YH, Knight B, Marchlinski F, Ross D, Sacher F, Sapp J, Shivkumar K, Soejima K, Tada H, Alexander ME, Triedman JK, Yamada T, Kirchhof P, Lip GY, Kuck KH, Mont L, Haines D, Indik J, Dimarco J, Exner D, Iesaka Y, Savelieva I. EHRA/HRS/APHRS expert consensus on ventricular arrhythmias. J Arrhythm 2014. [DOI: 10.1016/j.joa.2014.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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25
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Pedersen CT, Kay GN, Kalman J, Borggrefe M, Della-Bella P, Dickfeld T, Dorian P, Huikuri H, Kim YH, Knight B, Marchlinski F, Ross D, Sacher F, Sapp J, Shivkumar K, Soejima K, Tada H, Alexander ME, Triedman JK, Yamada T, Kirchhof P, Lip GYH, Kuck KH, Mont L, Haines D, Indik J, Dimarco J, Exner D, Iesaka Y, Savelieva I. EHRA/HRS/APHRS expert consensus on ventricular arrhythmias. Europace 2014; 16:1257-83. [PMID: 25172618 DOI: 10.1093/europace/euu194] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Miyazaki S, Taniguchi H, Kusa S, Komatsu Y, Ichihara N, Takagi T, Iwasawa J, Kuroi A, Nakamura H, Hachiya H, Hirao K, Iesaka Y. Catheter ablation of atrial tachyarrhythmias causing inappropriate implantable cardioverter-defibrillator shocks. Europace 2014; 17:289-94. [PMID: 25061229 DOI: 10.1093/europace/euu185] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Inappropriate shocks have been an important issue post-implantable cardioverter-defibrillator (ICD) implantation. Moreover, inappropriate ICD shocks are associated with increased mortality. The objective of this study was to evaluate the feasibility of catheter ablation therapy for atrial tachyarrhythmias (ATa) responsible for inappropriate ICD shocks. METHODS AND RESULTS Among 108 consecutive patients who underwent ICD implantations, 22, 5, and 3 experienced inappropriate ICD shocks due to ATa, sinus tachycardia, and T-wave oversensing, respectively. Among the 22 patients with ATa, 18 patients (55 ± 10 years, 15 men, structural heart disease in 9) underwent catheter ablation of ATa causing inappropriate shocks. The median duration between the ICD implantation and first inappropriate shock was 10.0 (3.0-24.5) months. The ATa were atrial fibrillation (AF), atrial flutter (AFL), and atrioventricular nodal reentrant tachycardia in 14, 2, and 2 patients, respectively. One patient underwent an atrioventricular nodal ablation for persistent AF associated with a venous anomaly. Among 13 patients who underwent pulmonary vein antrum isolation, 10 (76.9%) were free from AF for a median of 21.0 (13-37.3) months after an average of 1.3 ± 0.5 procedures. In four patients with AFL or a supraventricular tachycardia, none had any arrhythmia recurrence for a median of 6.0 (3.3-93.5) months after a cavotricuspid isthmus or slow pathway ablation, respectively. There were no procedural complications. During the median follow-up of 19.0 (9.5-37.3) months after the last procedure, no patients experienced any inappropriate shocks. CONCLUSION Catheter ablation is a feasible therapeutic option for treating ATa responsible for inappropriate shock(s) in patients with ICD.
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Affiliation(s)
- Shinsuke Miyazaki
- Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, 11-7 Manabeshin-machi, Tsuchiura, Ibaraki 300-0053, Japan
| | - Hiroshi Taniguchi
- Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, 11-7 Manabeshin-machi, Tsuchiura, Ibaraki 300-0053, Japan
| | - Shigeki Kusa
- Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, 11-7 Manabeshin-machi, Tsuchiura, Ibaraki 300-0053, Japan
| | - Yuki Komatsu
- Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, 11-7 Manabeshin-machi, Tsuchiura, Ibaraki 300-0053, Japan
| | - Noboru Ichihara
- Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, 11-7 Manabeshin-machi, Tsuchiura, Ibaraki 300-0053, Japan
| | - Takamitsu Takagi
- Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, 11-7 Manabeshin-machi, Tsuchiura, Ibaraki 300-0053, Japan
| | - Jin Iwasawa
- Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, 11-7 Manabeshin-machi, Tsuchiura, Ibaraki 300-0053, Japan
| | - Akio Kuroi
- Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, 11-7 Manabeshin-machi, Tsuchiura, Ibaraki 300-0053, Japan
| | - Hiroaki Nakamura
- Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, 11-7 Manabeshin-machi, Tsuchiura, Ibaraki 300-0053, Japan
| | - Hitoshi Hachiya
- Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, 11-7 Manabeshin-machi, Tsuchiura, Ibaraki 300-0053, Japan
| | - Kenzo Hirao
- Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
| | - Yoshito Iesaka
- Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, 11-7 Manabeshin-machi, Tsuchiura, Ibaraki 300-0053, Japan
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Bunch TJ, Anderson JL. Adjuvant antiarrhythmic therapy in patients with implantable cardioverter defibrillators. Am J Cardiovasc Drugs 2014; 14:89-100. [PMID: 24288157 DOI: 10.1007/s40256-013-0056-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The risk of sudden cardiac death from ventricular fibrillation or ventricular tachycardia in patients with cardiomyopathy related to structural heart disease has been favorably impacted by the wide adaptation of implantable cardioverter defibrillators (ICDs) for both primary and secondary prevention. Unfortunately, after ICD implantation both appropriate and inappropriate ICD therapies are common. ICD shocks in particular can have significant effects on quality of life and disease-related morbidity and mortality. While not indicated for primary prevention of ICD therapies, beta-blockers and antiarrhythmic drugs are a cornerstone for secondary prevention of them. This review will summarize our current understanding of adjuvant antiarrhythmic drug therapy in ICD patients. The review will also discuss the roles of nonantiarrhythmic drug approaches that are used in isolation and in combination with antiarrhythmic drugs to reduce subsequent risk of ICD shocks.
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Affiliation(s)
- T Jared Bunch
- Intermountain Heart Institute, Intermountain Medical Center, Eccles Outpatient Care Center, 5169 Cottonwood St, Suite 510, Murray, UT, 84107, USA,
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Lymperopoulos A, Negussie S, Walklett K. β1- and α2C-adrenergic receptor polymorphisms and the antiarrhythmic effect of bucindolol in heart failure with reduced ejection fraction. Pharmacogenomics 2013; 14:1545-9. [PMID: 24088125 DOI: 10.2217/pgs.13.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Anastasios Lymperopoulos
- Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, HPD (Terry) Building/Room 1338, Fort Lauderdale, FL 33328-2018, USA
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Ruwald MH, Abu-Zeitone A, Jons C, Ruwald AC, McNitt S, Kutyifa V, Zareba W, Moss AJ. Impact of Carvedilol and Metoprolol on Inappropriate Implantable Cardioverter-Defibrillator Therapy. J Am Coll Cardiol 2013; 62:1343-50. [DOI: 10.1016/j.jacc.2013.03.087] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 03/06/2013] [Accepted: 03/26/2013] [Indexed: 10/26/2022]
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Aleong RG, Sauer WH, Robertson AD, Liggett SB, Bristow MR. Adrenergic receptor polymorphisms and prevention of ventricular arrhythmias with bucindolol in patients with chronic heart failure. Circ Arrhythm Electrophysiol 2012; 6:137-43. [PMID: 23275278 DOI: 10.1161/circep.111.969618] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND β-blockers prevent cardiac arrhythmias in patients with chronic heart failure and reduced left ventricular ejection fraction, including ventricular tachycardia/ventricular fibrillation (VT/VF). We hypothesized that prevention of ventricular arrhythmias by the β-blocker/sympatholytic agent bucindolol is influenced by genetic variation in adrenergic receptors. METHODS AND RESULTS From a substudy of the β-Blocker Evaluation of Survival Trial (n=1040), we identified those with the high functioning 389Arg versus the lower function 389Gly β(1) adrenergic receptor variant, and the loss of function α(2c)322-325 adrenergic receptor deletion versus the 322 to 325 wild-type (Wt)/deletion variant. VT/VF was recorded on case report forms as an adverse event. There were 493 Arg 389 β(1) receptor homozygotes (β(1)389 Arg/Arg) versus 547 Gly389 carriers and 207 α(2c)322-325 deletion carriers versus 833 homozygous Wts (α(2c)322-325 Wt/Wt). In all genotypes bucindolol was associated with a lower incidence of VT/VF (subhazard ratio, 0.42 [0.27-0.64]; P=0.00006). Bucindolol reduced VT/VF in β(1)389 Arg homozygotes (subhazard ratio, 0.26 [0.14-0.50]; P=0.00005) but not in β(1)389 Gly carriers (subhazard ratio, 0.60 [0.34-1.07]; P=0.09). For genotype combinations, the α(2c)322-325 polymorphism altered the VT/VF bucindolol response in β1389 Gly carriers, with α(2c) deletion genotypes associated with complete efficacy loss. A test of interaction was statistically significant (P=0.028) for the treatment group and a β(1)389/α(2c)322-325 three genotype construct, effectively identifying patients who exhibited enhanced response, no substantial response modification and loss of response. CONCLUSIONS Bucindolol prevents VT/VF in subjects with heart failure and reduced left ventricular ejection fractions, and this effect is modulated by β(1)389 Arg/Gly and α(2c)322-325 Wt/deletion adrenergic receptor polymorphisms.
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Affiliation(s)
- Ryan G Aleong
- University of Colorado, Division of Cardiology, Aurora, CO, USA.
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The dilemma of implantable cardioverter-defibrillator therapy in the geriatric population. J Geriatr Cardiol 2012; 8:195-200. [PMID: 22783305 PMCID: PMC3390073 DOI: 10.3724/sp.j.1263.2011.00195] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 09/07/2011] [Accepted: 09/14/2011] [Indexed: 11/25/2022] Open
Abstract
Current guidelines for implantable cardioverter-defibrillator (ICD) therapy in heart failure patients were established by multiple device trials; however, very few geriatric patients (patients ≥ 65 years old) were included in these studies. This article explores the controversies of ICD implantation in the geriatric population, management of delivered ICD therapy in this age group, and the end of life care in patients with ICD.
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Mainigi SK, Almuti K, Figueredo VM, Guttenplan NA, Aouthmany A, Smukler J, Sheeron B, Meldrum B, Saenz AD, Tran G, Greenspan AM. Usefulness of radiofrequency ablation of supraventricular tachycardia to decrease inappropriate shocks from implantable cardioverter-defibrillators. Am J Cardiol 2012; 109:231-7. [PMID: 22000775 DOI: 10.1016/j.amjcard.2011.08.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 08/18/2011] [Accepted: 08/18/2011] [Indexed: 11/30/2022]
Abstract
Inappropriate implantable cardioverter-defibrillator (ICD) therapies can lead to significant adverse events and increased mortality. These therapies are often the result of supraventricular tachycardias (SVTs). The objective of this study was to evaluate the incidence of SVT leading to inappropriate shocks in a large cohort of patients with ICDs and assess the efficacy of radiofrequency ablation (RFA) in decreasing these therapies. Patients with ICDs and recurrent SVTs were identified. A cohort of patients with ICD therapies subsequently underwent electrophysiologic study and RFA. Eighty-four patients (13%) were found to have SVT leading to 122 inappropriate ICD shocks and 130 episodes of antitachycardia pacing therapies. Median time to SVT onset after ICD implantation was 269 days. Electrophysiologic studies were performed in 30 patients. Successful RFA was performed for atrial tachycardia, atrial flutter, or atrioventricular nodal reentrant tachycardia in 22 patients. Ninety-five percent of patients who underwent successful SVT ablation had no further inappropriate ICD therapies compared to 63% of patients in whom ablation was not performed during a mean follow-up of 20.7 ± 11.9 months. In conclusion, SVT is responsible for a significant number of inappropriate ICD therapies. RFA is an effective strategy to substantially decrease subsequent inappropriate ICD therapies.
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Affiliation(s)
- Sumeet K Mainigi
- Section of Electrophysiology, Heart and Vascular Institute, Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA.
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Bradfield J, Tung R, Boyle NG, Shivkumar K. Managing patients with ICD shocks and programming tachycardia therapies during acute heart failure syndromes. Heart Fail Rev 2011; 16:449-56. [PMID: 21451976 PMCID: PMC3139863 DOI: 10.1007/s10741-011-9241-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
We review the pharmacologic, interventional and device programming treatment options for patients with implantable cardioverter-defibrillators who present with acute heart failure and implantable cardioverter-defibrillator shocks.
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Affiliation(s)
- Jason Bradfield
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, A2-237 CHS, 650 Charles E. Young Drive South, Los Angeles, CA 90095-1679, USA.
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Deftereos S, Giannopoulos G, Kossyvakis C, Kaoukis A, Raisakis K, Panagopoulou V, Ntzouvara O, Perpinia A, Rentoukas I, Pyrgakis V, Manolis AS, Stefanadis C. Relation of ventricular tachycardia/fibrillation to beta-blocker dose maximization guided by pacing mode analysis in nonpacemaker-dependent patients with implantable cardioverter-defibrillator. Am J Cardiol 2011; 107:1812-7. [PMID: 21481829 DOI: 10.1016/j.amjcard.2011.02.321] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2010] [Revised: 02/07/2011] [Accepted: 02/07/2011] [Indexed: 10/18/2022]
Abstract
We hypothesized that uptitration of β blockade and adjustment of pacing parameters to achieve a prevalence of single chamber atrial inhibited rate-responsive (AAIR) pacing in patients with dual-chamber implantable cardioverter--defibrillators (ICDs) would result in maximization of β-blocker dosage and thus decrease appropriate ICD therapies. We included patients with ischemic or dilated cardiomyopathy and implanted ICDs without contraindications to β blockers and atrioventricular conduction disturbances. Two 6-month periods were compared: clinically guided phase (pacing function set at back-up dual-chamber rate-responsive pacing mode at a lower rate of about 40 beats/min) and pacing-guided phase, during which β-blocker dosage was titrated with a target of achieving >90% AAIR pacing (lower rate 60 beats/min). Sixty-one patients (64.2 ± 8.3 years old) were included. During the pacing-guided phase the target of ≥90% AAIR pacing was achieved in 80.3% of patients. Mean metoprolol dose during the clinically guided phase was 96.7 ± 29.4 versus 127.0 ± 39.6 mg/day in the pacing-guided phase (p <0.001). Appropriate ICD therapies were recorded in 35 patients (57.4%) during the clinically guided phase versus 20 (32.8%) during the pacing-guided phase (p <0.001; 1.15 and 0.48 appropriate ICD therapies per patient, respectively, p <0.001). In multivariate analysis, AAIR pacing and β-blocker dose were inversely related to appropriate ICD therapies. In conclusion, a pacing-guided approach for maximizing β-blocker doses guided by maximizing AAIR pacing in patients with ICDs may be beneficial compared to the conventional strategy. This pacing-guided approach led to higher daily β-blocker doses, which were correlated to fewer appropriate ICD therapies.
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Venkataraman G, Strickberger SA. The role of ventricular tachycardia ablation in the reduction of implantable defibrillator shocks. Heart Fail Clin 2011; 7:207-13, viii. [PMID: 21439499 DOI: 10.1016/j.hfc.2010.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Frequent shocks from an implantable defibrillator (ICD) can have adverse cardiac affects and lead to increased pain, anxiety, and a decreased quality of life. Pharmacologic attempts and ICD reprogramming strategies aimed at reducing ICD shocks have modest results, with frequent discontinuation of medicines because of side effects. Ventricular tachycardia (VT) ablation is recommended in the treatment of patients with frequent ICD shocks caused by VT. VT ablation may also be considered in patients with an initial ICD shock and as prophylactic treatment in patients with a history of sustained VT who are undergoing ICD implant.
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Affiliation(s)
- Ganesh Venkataraman
- Washington Electrophysiology, and Cardiovascular Research Institute, Washington Hospital Center, 106 Irving Street, NW, South #204, Washington, DC 20010-2975, USA.
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Abstract
The implantable cardioverter-defibrillator (ICD) is the most effective treatment for patients with life-threatening ventricular tachycardia or ventricular fibrillation not due to reversible causes. The American College of Cardiology/American Heart Association class I and IIa indications for an ICD are discussed. Patients with ICDs who need pacing should be treated with biventricular pacing, not with dual-chamber rate-responsive pacing, at a rate of 70/min. Patients with ICDs should be treated with β-blockers, statins and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.
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Affiliation(s)
- Wilbert S Aronow
- Cardiology Division, New York Medical College, Macy Pavilion, Room 138, Valhalla, NY 10595, USA
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38
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Implantable Cardioverter-Defibrillators. Am J Ther 2010; 17:e208-20. [PMID: 19918166 DOI: 10.1097/mjt.0b013e3181bdc65d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jimenez-Candil J, Hernandez J, Martin A, Ruiz-Olgado M, Herrero J, Ledesma C, Morinigo J, Martin-Luengo C. Influence of beta-blocker therapy on antitachycardia pacing effectiveness for monomorphic ventricular tachycardias occurring in implantable cardioverter-defibrillator patients: a dose-dependent effect. Europace 2010; 12:1231-8. [DOI: 10.1093/europace/euq164] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Jacobson JT, Weiner JB. Management of ventricular tachycardia in patients with structural heart disease. Cardiovasc Ther 2010; 28:255-63. [PMID: 20433682 DOI: 10.1111/j.1755-5922.2010.00147.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Patients with structural heart disease and ventricular tachycardia (VT) can be difficult to manage clinically. Many treatment options are available, but no single approach can be applied to every patient. This review aims to discuss the current options available for the management of this population. VT can be associated with cardiomyopathy of any etiology, both ischemic and nonischemic. Antiarrhythmic drugs have not been shown to decrease mortality in this patient population, but they can help reduce episodes. While the advent of the implantable cardioverter-defibrillator has revolutionized the treatment of VT, patients with recurrent shocks for VT have high morbidity and mortality. The development of catheter ablation over the past few decades has greatly aided the ability to control VT in these patients. The approach to patients with VT and structural heart disease is multifaceted. Often, a combination of therapeutic techniques is required to obtain the best result.
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Affiliation(s)
- Jason T Jacobson
- Section of Cardiac Electrophysiology, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Hauptman PJ, Swindle JP, Masoudi FA, Burroughs TE. Underutilization of β-Blockers in Patients Undergoing Implantable Cardioverter-Defibrillator and Cardiac Resynchronization Procedures. Circ Cardiovasc Qual Outcomes 2010; 3:204-11. [DOI: 10.1161/circoutcomes.109.880450] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Paul J. Hauptman
- From the Department of Medicine, Division of Cardiology (P.J.H.) and Center for Outcomes Research (P.J.H., J.P.S., T.E.B.), Saint Louis University School of Medicine, St Louis Mo; and University of Colorado Denver (F.A.M.) and Denver Health Medical Center (F.A.M.), Denver, Colo
| | - Jason P. Swindle
- From the Department of Medicine, Division of Cardiology (P.J.H.) and Center for Outcomes Research (P.J.H., J.P.S., T.E.B.), Saint Louis University School of Medicine, St Louis Mo; and University of Colorado Denver (F.A.M.) and Denver Health Medical Center (F.A.M.), Denver, Colo
| | - Frederick A. Masoudi
- From the Department of Medicine, Division of Cardiology (P.J.H.) and Center for Outcomes Research (P.J.H., J.P.S., T.E.B.), Saint Louis University School of Medicine, St Louis Mo; and University of Colorado Denver (F.A.M.) and Denver Health Medical Center (F.A.M.), Denver, Colo
| | - Thomas E. Burroughs
- From the Department of Medicine, Division of Cardiology (P.J.H.) and Center for Outcomes Research (P.J.H., J.P.S., T.E.B.), Saint Louis University School of Medicine, St Louis Mo; and University of Colorado Denver (F.A.M.) and Denver Health Medical Center (F.A.M.), Denver, Colo
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VERMA ATUL, SARAK BRADLEY, KAPLAN ALEXANDERJ, OOSTHUIZEN RICHARD, BEARDSALL MARIANNE, WULFFHART ZAEV, HIGENBOTTAM JANET, KHAYKIN YAARIV. Predictors of Appropriate Implantable Cardioverter Defibrillator (ICD) Therapy in Primary Prevention Patients with Ischemic and Nonischemic Cardiomyopathy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 33:320-9. [DOI: 10.1111/j.1540-8159.2009.02566.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Patel C, Yan GX, Kocovic D, Kowey PR. Should catheter ablation be the preferred therapy for reducing ICD shocks?: Ventricular tachycardia ablation versus drugs for preventing ICD shocks: role of adjuvant antiarrhythmic drug therapy. Circ Arrhythm Electrophysiol 2010; 2:705-11; discussion 712. [PMID: 20009081 DOI: 10.1161/circep.109.893628] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Chinmay Patel
- Main Line Health Heart Center and Lankenau Hospital, Wynnewood, PA 19096, USA
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Adlbrecht C, Hülsmann M, Gwechenberger M, Strunk G, Khazen C, Wiesbauer F, Elhenicky M, Neuhold S, Binder T, Maurer G, Lang IM, Pacher R. Outcome after device implantation in chronic heart failure is dependent on concomitant medical treatment. Eur J Clin Invest 2009; 39:1073-81. [PMID: 19843157 DOI: 10.1111/j.1365-2362.2009.02217.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Device implantation in chronic heart failure (CHF) for cardiac resynchronization therapy (CRT) with or without implantable cardioverter/defibrillator (ICD) is an established treatment option for symptomatic patients under medical baseline therapy. Although recommended, the need for optimization of medical therapy was never proven. As in 'the real world', medical therapy is not always up-titrated to the desirable dosages; this provides the opportunity to evaluate the impact of optimizing medical therapy in patients who had received a device therapy with proven effectiveness. MATERIALS AND METHODS This observational cohort study retrospectively assessed the 'real life'-effect of CRT compared with that of CRT/ICD therapy and the impact of concomitant pharmacotherapy on outcome. Outcome of patients with guideline recommended renin-angiotensin system inhibitor and ss-blocker dosages was compared with that of patients who failed to reach the desired dosages. Mean follow-up for the 205 CHF (95 CRT and 110 CRT/ICD) patients was 16.8 + or - 12.4 months. RESULTS In the total study cohort, 83 (41%) reached the combined primary endpoint of all-cause death or cardiac hospitalization [CRT group: 25 (26%), CRT/ICD group: 58 (52.7%), P < 0.001]. Multiple cox regression analysis revealed non-optimized medical therapy at follow-up [HR = 2.080 (1.166-3.710), P = 0.013] and CRT/ICD vs. CRT [HR = 2.504 (1.550-4.045), P < 0.001] as significant predictors of the primary endpoint. CONCLUSION Our data stress the importance of professional monitoring and titration of pharmacotherapy not only in medically treated CHF patients but also in patients under device therapy by a heart failure unit or a specialized cardiologist.
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Affiliation(s)
- Christopher Adlbrecht
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
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45
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Mishkin JD, Saxonhouse SJ, Woo GW, Burkart TA, Miles WM, Conti JB, Schofield RS, Sears SF, Aranda JM. Appropriate Evaluation and Treatment of Heart Failure Patients After Implantable Cardioverter-Defibrillator Discharge. J Am Coll Cardiol 2009; 54:1993-2000. [DOI: 10.1016/j.jacc.2009.07.039] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Revised: 06/25/2009] [Accepted: 07/12/2009] [Indexed: 11/25/2022]
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46
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Borleffs CJW, Scherptong RW, Man SC, van Welsenes GH, Bax JJ, van Erven L, Swenne CA, Schalij MJ. Predicting Ventricular Arrhythmias in Patients With Ischemic Heart Disease. Circ Arrhythm Electrophysiol 2009; 2:548-54. [DOI: 10.1161/circep.109.859108] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- C. Jan Willem Borleffs
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Sum-Che Man
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Guido H. van Welsenes
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J. Bax
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lieselot van Erven
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cees A. Swenne
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin J. Schalij
- From the Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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47
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LaPointe NMA, Stafford JA, Pappas PA, Al-Khatib SM, Anstrom KJ. Use of beta-blockers in patients with an implantable cardioverter defibrillator. Ann Pharmacother 2009; 43:1189-96. [PMID: 19567655 DOI: 10.1345/aph.1m140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Implantable cardioverter defibrillators (ICDs) are indicated for both primary and secondary prevention of sudden cardiac arrest. beta-Blockers are also indicated in most patients who have an indication for an ICD; however, their use in this population is not well described. Some clinicians may be unaware of the recommendation for beta-blockers in this population. OBJECTIVE To explore beta-blocker use among ICD recipients. METHODS Adults who received their first ICD at Duke Hospital between July 1999 and July 2004 for primary or secondary prevention of sudden cardiac arrest were identified. Using hospital data, beta-blocker use was determined at time of discharge, and characteristics of users were compared with those of nonusers. Continued use of beta-blockers after ICD implant was explored in the subset of patients included in the Duke Databank for Cardiovascular Disease (DDCD). RESULTS The study cohort comprised 804 patients, 652 (81%) with ICD for secondary prevention of sudden cardiac arrest and 152 (19%) for primary prevention. The median age was 65 years and 75% of the patients were men. A total of 544 (68%) received a beta-blocker at time of ICD implant. There were no substantial changes in the proportion of patients with beta-blocker use from 1999 through 2004, overall or within the primary or secondary prevention groups. However, beta-blocker use was higher in the secondary prevention group than in the primary prevention group (69% vs 60%; p = 0.02). A higher proportion of beta-blocker users versus nonusers had ischemic heart disease (82% vs 68%; p < 0.0001), heart failure (84% vs 71%; p < 0.0001), previous myocardial infraction (51% vs 44%; p = 0.05), and ventricular arrhythmias (82% vs 76%; p = 0.04). Of the 425 patients included in the DDCD, only 241 (57%) were receiving beta-blockers at time of implant and during clinical follow-up. CONCLUSIONS Lower than optimal use of beta-blockers suggests the need for new methods of including evidence-based medications in clinical practice, especially for complex patients for whom numerous clinical practice guidelines may apply.
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Affiliation(s)
- Nancy M Allen LaPointe
- School of Medicine, Duke University, Duke Clinical Research Institute, Durham, NC 27705, USA.
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48
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Abstract
Underlying causes of ventricular tachycardia (VT) or complex ventricular arrhythmias (VA) should be treated if possible. Antiarrhythmic drugs should not be administered to treat asymptomatic individuals with complex VA and no heart disease. Beta-blockers are the only antiarrhythmic drugs that have been documented to reduce mortality in patients with VT or complex VA. Radiofrequency catheter ablation of VT has been beneficial in treating selected patients with arrhythmogenic foci of monomorphic VT. The automatic implantable cardioverter-defibrillator (AICD) is the most effective treatment for patients with life-threatening VT or ventricular fibrillation. Patients with AICDs should be treated with biventricular pacing, not with dual-chamber rate-responsive pacing at a rate of 70/min. Patients with AICDs should also be treated with beta-blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin blockers.
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49
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PIETRASIK GRZEGORZ, GOLDENBERG ILAN, McNITT SCOTT, POLONSKY BRONISLAVA, MOSS ARTHURJ, ZAREBA WOJCIECH. Efficacy of Medical Therapy for the Reduction of Heart Failure Events in Patients with Implanted Cardioverter Defibrillators. J Cardiovasc Electrophysiol 2009; 20:395-400. [DOI: 10.1111/j.1540-8167.2008.01333.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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50
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Blumer J, Wolber T, Hellermann J, Holzmeister J, Binggeli C, Duru F, Brunckhorst C. Predictors of Appropriate Implantable Cardioverter-Defibrillator Therapy During Long-Term Follow-up of Patients With Coronary Artery Disease. Int Heart J 2009; 50:313-21. [DOI: 10.1536/ihj.50.313] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Johannes Blumer
- Arrhythmia Service, Cardiovascular Division, University Hospital Zurich
| | - Thomas Wolber
- Arrhythmia Service, Cardiovascular Division, University Hospital Zurich
| | | | | | | | - Firat Duru
- Arrhythmia Service, Cardiovascular Division, University Hospital Zurich
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