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Teixeira RA, Fagundes AA, Baggio Junior JM, Oliveira JCD, Medeiros PDTJ, Valdigem BP, Teno LAC, Silva RT, Melo CSD, Elias Neto J, Moraes Júnior AV, Pedrosa AAA, Porto FM, Brito Júnior HLD, Souza TGSE, Mateos JCP, Moraes LGBD, Forno ARJD, D'Avila ALB, Cavaco DADM, Kuniyoshi RR, Pimentel M, Camanho LEM, Saad EB, Zimerman LI, Oliveira EB, Scanavacca MI, Martinelli Filho M, Lima CEBD, Peixoto GDL, Darrieux FCDC, Duarte JDOP, Galvão Filho SDS, Costa ERB, Mateo EIP, Melo SLD, Rodrigues TDR, Rocha EA, Hachul DT, Lorga Filho AM, Nishioka SAD, Gadelha EB, Costa R, Andrade VSD, Torres GG, Oliveira Neto NRD, Lucchese FA, Murad H, Wanderley Neto J, Brofman PRS, Almeida RMS, Leal JCF. Brazilian Guidelines for Cardiac Implantable Electronic Devices - 2023. Arq Bras Cardiol 2023; 120:e20220892. [PMID: 36700596 PMCID: PMC10389103 DOI: 10.36660/abc.20220892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | - Rodrigo Tavares Silva
- Universidade de Franca (UNIFRAN), Franca, SP - Brasil
- Centro Universitário Municipal de Franca (Uni-FACEF), Franca, SP - Brasil
| | | | - Jorge Elias Neto
- Universidade Federal do Espírito Santo (UFES), Vitória, ES - Brasil
| | - Antonio Vitor Moraes Júnior
- Santa Casa de Ribeirão Preto, Ribeirão Preto, SP - Brasil
- Unimed de Ribeirão Preto, Ribeirão Preto, SP - Brasil
| | - Anisio Alexandre Andrade Pedrosa
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Luis Gustavo Belo de Moraes
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | - Mauricio Pimentel
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | | | - Eduardo Benchimol Saad
- Hospital Pró-Cardíaco, Rio de Janeiro, RJ - Brasil
- Hospital Samaritano, Rio de Janeiro, RJ - Brasil
| | | | | | - Mauricio Ibrahim Scanavacca
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | - Martino Martinelli Filho
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | - Carlos Eduardo Batista de Lima
- Hospital Universitário da Universidade Federal do Piauí (UFPI), Teresina, PI - Brasil
- Empresa Brasileira de Serviços Hospitalares (EBSERH), Brasília, DF - Brasil
| | | | - Francisco Carlos da Costa Darrieux
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Sissy Lara De Melo
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Eduardo Arrais Rocha
- Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFC), Fortaleza, CE - Brasil
| | - Denise Tessariol Hachul
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Silvana Angelina D'Orio Nishioka
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Roberto Costa
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Gustavo Gomes Torres
- Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte (UFRN), Natal, RN - Brasil
| | | | | | - Henrique Murad
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Rui M S Almeida
- Centro Universitário Fundação Assis Gurgacz, Cascavel, PR - Brasil
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Cohen RB, Dai M, Aizer A, Barbhaiya C, Peterson C, Bernstein S, Park DS, Spinelli M, Chinitz LA, Jankelson L. QT interval dynamics and triggers for QT prolongation immediately following cardiac arrest. Resuscitation 2021; 162:171-179. [PMID: 33652119 DOI: 10.1016/j.resuscitation.2021.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 02/01/2021] [Accepted: 02/18/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The prolongation in QT interval typically observed following cardiac arrest is considered to be multifactorial and induced by external triggers such as hypothermia therapy and exposure to antiarrhythmic medications. OBJECTIVE To evaluate the corrected QT interval (QTc) dynamics in the first 10 days following cardiac arrest with respect to the etiology of arrest, hypothermia and QT prolonging medications. METHODS We enrolled 104 adult survivors of cardiac arrest, where daily ECG was available for at least 3 days. We followed their QT and QRS intervals for the first 10 days of hospitalization. We used both Bazett and Fridericia formulas to correct for heart rate. For patients with QRS < 120 we analyzed the QTc interval (n = 90) and for patients with QRS > 120 ms we analyzed the JTc (n = 104) vs. including only the narrow QRS samples (n = 89). We stratified patients by 3 groups: (1) presence of ischemic heart disease (IHD) (2) treatment with hypothermia protocol, and (3) treatment with QTc prolonging medications. Additionally, genetic information obtained during hospitalization was analyzed. RESULTS QTc and JTc intervals were significantly prolonged in the first 6 days. Maximal QTc/JTc prolongation was observed in day 2 (QTcB = 497 ± 55). There were no differences in daily QTc/JTc and QRS intervals in the first 2 days post arrest between patients with or without hypothermia induction but such difference was found with QT prolonging medications. All subgroups demonstrated significantly prolonged QTc/JTc interval regardless of the presence of IHD, hypothermia protocol or QTc prolonging medication exposure. Our results were consistent for both Bazetts' and Frediricia correction and for any QRS duration. Prolongation of the JTcB beyond 382 ms after day 3 predicted sustained QTc/JTc prolongation beyond day 6 with an ROC of 0.78. CONCLUSIONS QTc/JTc interval is significantly and independently prolonged post SCA, regardless of known QT prolonging triggers. Normalization of the QTc post cardiac arrest should be expected only after day 6 of hospitalization. Assessment of the QTc for adjudication of the etiology of arrest or for monitoring the effect of QT prolonging medications may be unreliable.
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Affiliation(s)
- Roi Bar Cohen
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY, USA
| | - Matthew Dai
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY, USA
| | - Anthony Aizer
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY, USA
| | - Chirag Barbhaiya
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY, USA
| | - Connor Peterson
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY, USA
| | - Scott Bernstein
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY, USA
| | - David S Park
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY, USA
| | - Michael Spinelli
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY, USA
| | - Larry A Chinitz
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY, USA
| | - Lior Jankelson
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY, USA.
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Chatterjee NA, Rea TD. Secondary prevention of sudden cardiac death. Heart Rhythm O2 2020; 1:297-310. [PMID: 34113884 PMCID: PMC8183887 DOI: 10.1016/j.hroo.2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The prevention and treatment of sudden cardiac death (SCD) remains a significant public health challenge. For patients with a history of sudden death attributable to ventricular arrhythmia, implantable cardioverter-defibrillator (ICD) therapy is a mainstay of treatment, although these patients remain at high risk for recurrent ventricular arrhythmia and defibrillator therapies. In this review, we summarize landmark clinical trials evaluating the efficacy of ICD therapy in secondary prevention patients, review clinical outcomes including mode of death in survivors of SCD, and highlight the role for systematic diagnostic evaluation. We additionally discuss the invasive electrophysiological management of these patients, including ICD selection and programming as well as the role and timing of antiarrhythmic drug therapy and catheter ablation. Finally, we frame future challenges and needs to advance the care for secondary prevention patients.
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Affiliation(s)
- Neal A Chatterjee
- Electrophysiology Section, Cardiology Division, University of Washington, Seattle, Washington
| | - Thomas D Rea
- Division of General Internal Medicine, University of Washington, Seattle, Washington
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Rusnak J, Behnes M, Schupp T, Reiser L, Bollow A, Taton G, Reichelt T, Ellguth D, Engelke N, Hoppner J, Weidner K, El-Battrawy I, Mashayekhi K, Weiß C, Borggrefe M, Akin I. COPD increases cardiac mortality in patients presenting with ventricular tachyarrhythmias and aborted cardiac arrest. Respir Med 2018; 145:153-160. [DOI: 10.1016/j.rmed.2018.10.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 10/17/2018] [Accepted: 10/19/2018] [Indexed: 01/24/2023]
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Munir MB, Alqahtani F, Aljohani S, Bhirud A, Modi S, Alkhouli M. Trends and predictors of implantable cardioverter defibrillator implantation after sudden cardiac arrest: Insight from the national inpatient sample. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:229-237. [PMID: 29318626 DOI: 10.1111/pace.13274] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 12/12/2017] [Accepted: 12/22/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | - Fahad Alqahtani
- West Virginia University Heart & Vascular Institute; Morgantown WV USA
| | - Sami Aljohani
- West Virginia University Heart & Vascular Institute; Morgantown WV USA
| | - Ashwin Bhirud
- West Virginia University Heart & Vascular Institute; Morgantown WV USA
| | - Sujal Modi
- West Virginia University Heart & Vascular Institute; Morgantown WV USA
| | - Mohamad Alkhouli
- West Virginia University Heart & Vascular Institute; Morgantown WV USA
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Extramiana F, Stordeur B, Furioli V, Gandjbakhch E, Lellouche N, Algalarrondo V, Varlet E, Messali A, Marijon E, Leenhardt A. Spectrum and Outcome of Patients Who Have Undergone Implantation of an Implantable Cardioverter Defibrillator After Aborted-Sudden Cardiac Arrest. Am J Cardiol 2018; 121:149-155. [PMID: 29153773 DOI: 10.1016/j.amjcard.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 09/26/2017] [Accepted: 10/04/2017] [Indexed: 11/15/2022]
Abstract
Most of implantable cardioverter defibrillator (ICD) secondary prevention studies have been published 2 decades ago. We aimed to describe a contemporary cohort of patients who have undergone implantation of an ICD after an aborted-sudden cardiac arrest (SCA). We retrospectively evaluated consecutive patients referred to our centers between 2005 and 2013. Predictors of overall mortality or heart transplant were analyzed using Cox proportional hazards models. A total of 250 patients (76.4% male, 48.7 ± 16.7 years) were included (mean follow-up = 49.6 ± 35 months). The presence of a structural heart disease (SHD) was considered as the primary cause of the aborted-SCA in 160 patients (64%). In 90 patients (36%), no SHD was observed, with patients much younger (40.9 ± 16.2 years vs 53.0 ± 15.5 years in the SHD group, p < 0.0001). The 5-year estimated rates of death or heart transplant were 14.3% and 5.2% in the group with and without SHD, respectively (hazard ratio = 4.65, 95% confidence interval 1.40 to 15.6, p = 0.014). The 5-year estimated rates of appropriate ICD therapy in the ventricular fibrillation zone were 16.7% and 25.1% in patients without and with SHD (p = 0.24), respectively. Only left ventricular ejection fraction remained independently associated with mortality or heart transplant (hazard ratio = 0.94, 95% confidence interval 0.90 to 0.97, p = 0.0004). Overall, 69 patients (27.6%) experienced at least 1 ICD-related complication. In conclusion, compared with secondary prevention pivotal studies, the current patients who have undergone implantation of an ICD after aborted-SCA are younger, with a high proportion of structurally normal hearts. Compared with patients without SHD, who depicted a relatively favorable outcome, patients with SHD present a fourfold higher risk of death during follow-up. Reduced left ventricular ejection fraction remains the major influencing factor.
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Affiliation(s)
- Fabrice Extramiana
- Université Paris Diderot, Sorbonne Paris Cité, Paris F-75018, France; AP-HP, Service de Cardiologie, Hôpital Bichat, Paris F-75018, France; CNMR Maladies Cardiaques Héréditaires Rares, Hôpital Bichat, Paris F-75018, France.
| | - Benjamin Stordeur
- AP-HP, Service de Cardiologie, Hôpital Bichat, Paris F-75018, France
| | - Vincent Furioli
- AP-HP, Hôpital européen Georges Pompidou, Paris F-75015, France
| | - Estelle Gandjbakhch
- AP-HP, Service de Cardiologie, Hôpital Pitié Salpêtrière, Paris F-75013, France
| | - Nicolas Lellouche
- AP-HP, Service de Cardiologie, Hôpital Henri Mondor, Créteil F-94000, France
| | | | - Emilie Varlet
- Université Paris Diderot, Sorbonne Paris Cité, Paris F-75018, France; AP-HP, Service de Cardiologie, Hôpital Bichat, Paris F-75018, France; CNMR Maladies Cardiaques Héréditaires Rares, Hôpital Bichat, Paris F-75018, France
| | - Anne Messali
- AP-HP, Service de Cardiologie, Hôpital Bichat, Paris F-75018, France; CNMR Maladies Cardiaques Héréditaires Rares, Hôpital Bichat, Paris F-75018, France
| | - Eloi Marijon
- AP-HP, Hôpital européen Georges Pompidou, Paris F-75015, France; Université Paris Descartes, Paris, France; INSERM U970, Paris Cardiovascular Research Center, Paris, France
| | - Antoine Leenhardt
- Université Paris Diderot, Sorbonne Paris Cité, Paris F-75018, France; AP-HP, Service de Cardiologie, Hôpital Bichat, Paris F-75018, France; CNMR Maladies Cardiaques Héréditaires Rares, Hôpital Bichat, Paris F-75018, France
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Singh S, Murawski MM. Implantable Cardioverter Defibrillator Therapy and the Need for Concomitant Antiarrhythmic Drugs. J Cardiovasc Pharmacol Ther 2016; 12:175-80. [PMID: 17875944 DOI: 10.1177/1074248407305608] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Implantable cardioverter defibrillators (ICDs) are increasingly used for the prevention of sudden cardiac death in patients with life-threatening ventricular arrhythmias (VAs); however, there is a potential for severe and debilitating anxiety caused by symptoms associated with ICD therapy and anticipation of shocks. Anxiety is a psycho-logic stressor, including physiologic components that may lead to adrenergic excitation triggering new arrhythmias and ICD therapies. This often requires concomitant antiarrhythmic medication to reduce the frequency of shocks and symptomatic arrhythmias treated by anti-tachycardia pacing. Although published studies have documented the efficacy of currently available antiarrhythmics, they have limitations in patients with heart failure, may affect the defibrillation threshold, and/or have been associated with major side-effects. In conclusion, for the patient with an ICD experiencing symptomatic ventricular tachycardia (VTs) episodes or ICD shocks, there is a need for pharmacologic therapy to reduce the incidence of such events without affecting the performance of the ICD or causing major side-effects.
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Affiliation(s)
- Steven Singh
- Veterans Affairs Medical Center, Washington, DC 20422, USA.
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8
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Chan PS, McNally B, Nallamothu BK, Tang F, Hammill BG, Spertus JA, Curtis LH. Long-Term Outcomes Among Elderly Survivors of Out-of-Hospital Cardiac Arrest. J Am Heart Assoc 2016; 5:e002924. [PMID: 27068632 PMCID: PMC4943267 DOI: 10.1161/jaha.115.002924] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Most studies on out-of-hospital cardiac arrest have focused on immediate survival. However, little is known about long-term outcomes and resource use among survivors. METHODS AND RESULTS Within the national CARES registry, we identified 16 206 adults 65 years or older with an out-of-hospital cardiac arrest between 2005 and 2010. Among 1127 patients who were discharged alive, we evaluated whether 1-year mortality, cumulative readmission incidence, and follow-up inpatient costs differed according to patients' race, sex, initial cardiac arrest rhythm, bystander delivery of cardiopulmonary resuscitation, discharge neurological status, and functional status (hospital discharge disposition). Overall 1-year mortality after hospital discharge was 31.8%. Among survivors, there were no long-term mortality differences by sex, race, or initial cardiac arrest rhythm, but worse functional status and severe neurological disability at discharge were associated with higher mortality. Moreover, compared with first responders, cardiopulmonary resuscitation delivered by bystanders was associated with 23% lower mortality (hazard ratio 0.77 [confidence interval 0.58-1.02]). Besides mortality, 638 (56.6%) patients were readmitted within the first year, and the cumulative readmission incidence was 197 per 100 patient-years. Mean 1-year inpatient costs were $23 765±41 002. Younger age, black race, severe neurological disability at discharge, and hospital disposition to a skilled nursing or rehabilitation facility were each associated with higher 1-year inpatient costs (P for all <0.05). CONCLUSION Among elderly survivors of out-of-hospital cardiac arrest, nearly 1 in 3 patients die within the first year. Long-term mortality and inpatient costs differed substantially by certain demographic factors, whether cardiopulmonary resuscitation was initiated by a bystander, discharge neurological status, and hospital disposition.
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Affiliation(s)
- Paul S Chan
- Saint Luke's Mid America Heart Institute, Kansas City, MO University of Missouri-Kansas City, Kansas City, MO
| | - Bryan McNally
- Department of Emergency Medicine, Emory University, Atlanta, GA Rollins School of Public Health, Atlanta, GA
| | - Brahmajee K Nallamothu
- VA Health Services Research and Development Center of Excellence, VA Ann Arbor Healthcare System, Department of Internal Medicine and Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Bradley G Hammill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO University of Missouri-Kansas City, Kansas City, MO
| | - Lesley H Curtis
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC Department of Medicine, Duke University School of Medicine, Durham, NC
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9
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Li YQ, Sun SJ, Liu N, Hu CL, Wei HY, Li H, Liao XX, Li X. Comparing percutaneous coronary intervention and thrombolysis in patients with return of spontaneous circulation after cardiac arrest. Clinics (Sao Paulo) 2013; 68:523-9. [PMID: 23778347 PMCID: PMC3634969 DOI: 10.6061/clinics/2013(04)14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Accepted: 12/26/2012] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To evaluate the effects of percutaneous coronary intervention and thrombolysis after restoration of spontaneous circulation in cardiac arrest patients with ST-elevation myocardial infarction using meta-analysis. METHODS We performed a meta-analysis of clinical studies indexed in the PUBMED, MEDLINE and EMBASE databases and published between January 1995 and October 2012. In addition, we compared the hospital discharge and neurological recovery rates between the patients who received percutaneous coronary intervention and those who received thrombolysis. RESULTS Twenty-four studies evaluating the effects of percutaneous coronary intervention or thrombolysis after restoration of spontaneous circulation in cardiac arrest patients with ST-elevation myocardial infarction were included. Seventeen of the 24 studies were used in this meta-analysis. All studies were used to compare percutaneous coronary intervention and thrombolysis. The meta-analysis showed that the rate of hospital discharge improved with both percutaneous coronary intervention (p<0.001) and thrombolysis (p<0.001). We also found that cardiac arrest patients with ST-elevation myocardial infarction who received thrombolysis after restoration of spontaneous circulation did not have decreased hospital discharge (p = 0.543) or neurological recovery rates (p = 0.165) compared with those who received percutaneous coronary intervention. CONCLUSION In cardiac arrest patients with ST-elevation myocardial infarction who achieved restoration of spontaneous circulation, both percutaneous coronary intervention and thrombolysis improved the hospital discharge rate. Furthermore, there were no significant differences in the hospital discharge and neurological recovery rates between the percutaneous coronary intervention-treated group and the thrombolysis-treated group.
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Affiliation(s)
- Ying-Qing Li
- The First Affiliated Hospital of Sun Yat-sen University, Emergency Department, Guangzhou, People's Republic of China
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10
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Le Heuzey JY, Marijon E, Lavergne T, Otmani A. Management of ventricular and atrial arrhythmias in humans: towards a patient-specific approach. Europace 2012; 14 Suppl 5:v125-v128. [DOI: 10.1093/europace/eus283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Möllmann H, Szardien S, Liebetrau C, Elsässer A, Rixe J, Rolf A, Nef H, Weber M, Hamm C. Clinical outcome of patients treated with an early invasive strategy after out-of-hospital cardiac arrest. J Int Med Res 2012; 39:2169-77. [PMID: 22289532 DOI: 10.1177/147323001103900613] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Little is known about the impact of early invasive treatment in patients following out-of-hospital cardiac arrest (OHCA). The present study investigated the clinical characteristics and long-term prognosis of 1254 patients with suspected acute coronary syndrome, including 65 with OHCA who underwent successful cardiopulmonary resuscitation (CPR) and 1189 patients who did not require CRP. All patients underwent immediate coronary angiography even if clear signs of myocardial infarction (MI) were absent. The incidence of ST-elevation and non-ST-elevation MI did not differ between the two groups. Cardiac biomarkers were significantly higher in CPR patients despite a shorter period from symptom onset to admission. The 6-month mortality rate was 29% in the CPR group and 4% in the non-CPR group, with > 90% of fatalities occurring ≤ 3 weeks after admission. In summary, early invasive treatment leads to a considerably reduced mortality and improved prognosis in patients after OHCA.
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Affiliation(s)
- H Möllmann
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
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12
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Pleskot M, Hazukova R, Stritecka H, Cermakova E. Five-year survival of patients after out-of-hospital cardiac arrest depending on age. Arch Gerontol Geriatr 2011; 53:e88-92. [DOI: 10.1016/j.archger.2010.06.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 06/23/2010] [Accepted: 06/25/2010] [Indexed: 11/28/2022]
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Can I, Tholakanahalli VN. Current status of implantable cardioverter-defibrillator therapy in heart failure. Curr Heart Fail Rep 2009; 6:199-209. [PMID: 19723462 DOI: 10.1007/s11897-009-0028-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Sudden cardiac arrest is one of the leading causes of death in patients with heart failure (HF). The implantable cardioverter-defibrillator (ICD) is the only evidence-based treatment strategy for patients who have survived a life-threatening ventricular arrhythmic event. Randomized clinical trials have shown that specific subsets of HF patients with ischemic and nonischemic dilated cardiomyopathy benefit from ICD therapy for primary prevention of sudden cardiac arrest. Cardiac resynchronization therapy has become the device-based therapy of choice for improving symptoms and survival in severe HF patients with evidence of ventricular dyssynchrony. This review summarizes the current status of ICD therapy in treating HF patients based on randomized clinical trials and current practice guidelines.
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Affiliation(s)
- Ilknur Can
- Division of Cardiology, University of Minnesota, Veterans Affairs Medical Center, Minneapolis, MN 55417, USA
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Jakobsson J, Nyquist O, Rehnqvist N, Nordlander R, Aström H, Vallin H, Liljefors I. Prognosis and clinical follow-up of patients resuscitated from out-of hospital cardiac arrest. ACTA MEDICA SCANDINAVICA 2009; 222:123-32. [PMID: 3673665 DOI: 10.1111/j.0954-6820.1987.tb10648.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A new organization has been formed in which ambulance personnel have been trained to recognize ventricular tachycardia and ventricular fibrillation (VF) and to defibrillate. Cardiac arrest (CA) occurred in 307 patients and 140 were defibrillated. Twenty-eight patients were resuscitated and admitted for further hospital care. A previous history of ischaemic heart disease was found in 24 patients. Twenty-two of the patients admitted were found to have VF, two asystole and four other rhythms. All 11 survivors regained circulation at the site of the CA. At the time of admission all but one of the patients were unconscious and one long-time survivor remained unconscious until the 5th day following admission. Seventeen patients died while still in hospital. In 16 cases a diagnosis of acute myocardial infarction was established, a further six had VF without evidence of acute myocardial infarction and six had other diagnoses. Ten out of the 11 survivors were still alive six months after discharge. Only one case of recurrent VF was seen during a median follow-up period of 16 months. Prolonged coma, especially in combination with convulsions, was associated with a poor prognosis, while early return of circulation was significantly more common among survivors. Ongoing medication with beta-blockers, a high QRS rate on admission and VF without proof of any acute myocardial infarction were also found to be more common in survivors.
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Affiliation(s)
- J Jakobsson
- Department of Anaesthesia and Intensive Care, Danderyd Hospital, Stockholm, Sweden
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15
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Merchant RM, Abella BS, Khan M, Huang KN, Beiser DG, Neumar RW, Carr BG, Becker LB, Vanden Hoek TL. Cardiac catheterization is underutilized after in-hospital cardiac arrest. Resuscitation 2008; 79:398-403. [PMID: 18951683 DOI: 10.1016/j.resuscitation.2008.07.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Revised: 07/22/2008] [Accepted: 07/24/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Indications for immediate cardiac catheterization in cardiac arrest survivors without ST elevation myocardial infarction (STEMI) are uncertain as electrocardiographic and clinical criteria may be challenging to interpret in this population. We sought to evaluate rates of early catheterization after in-hospital ventricular fibrillation (VF) arrest and the association with survival. METHODS Using a billing database we retrospectively identified cases with an ICD-9 code of cardiac arrest (427.5) or VF (427.41). Discharge summaries were reviewed to identify in-hospital VF arrests. Rates of catheterization on the day of arrest were determined by identifying billing charges. Unadjusted analyses were performed using Chi-square, and adjusted analyses were performed using logistic regression. RESULTS One hundred and ten in-hospital VF arrest survivors were included in the analysis. Cardiac catheterization was performed immediately or within 1 day of arrest in 27% (30/110) of patients and of these patients, 57% (17/30) successfully received percutaneous coronary intervention. Of those who received cardiac catheterization the indication for the procedure was STEMI or new left bundle branch block (LBBB) in 43% (13/30). Therefore, in the absence of standard ECG data suggesting acute myocardial infarction, 57% (17/30) received angiography. Patients receiving cardiac catheterization were more likely to survive than those who did not receive catheterization (80% vs. 54%, p<.05). CONCLUSION In patients receiving cardiac catheterization, more than half received this procedure for indications other than STEMI or new LBBB. Cardiac catheterization was associated with improved survival. Future recommendations need to be established to guide clinicians on which arrest survivors might benefit from immediate catheterization.
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Affiliation(s)
- Raina M Merchant
- The Robert Wood Johnson Clinical Scholars Program, University of Pennsylvania, School of Medicine, Philadelphia, PA 19104, United States.
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16
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Cesario DA, Turner JW, Dec GW. Biventricular pacing and defibrillator use in chronic heart failure. Cardiol Clin 2008; 25:595-603; vii. [PMID: 18063163 DOI: 10.1016/j.ccl.2007.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Since the 1970s when the implantable cardioverter defibrillator (ICD) was developed, multiple clinical trials have documented survival benefits in certain high-risk subsets of heart failure patients. Over the past decade, cardiac resynchronization therapy (CRT) emerged as an important therapy in carefully selected patients with ongoing symptoms despite optimized pharmacological therapy. ICDs should be considered first-line therapy for survivors of life-threatening ventricular arrhythmic events. Subsets of patients with both ischemic and nonischemic dilated cardiomyopathy appear to have a survival benefit from primary ICD therapy. CRT has resulted in substantial symptomatic improvement and survival benefits in a subgroup of chronic heart failure patients. CRT should be considered in heart failure patients undergoing ICD implantation who have evidence of ventricular dyssynchrony.
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Affiliation(s)
- David A Cesario
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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17
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Kiès P, Boersma E, Bax JJ, van der Burg AEB, Bootsma M, van Erven L, van der Wall EE, Schalij MJ. Determinants of Recurrent Ventricular Arrhythmia or Death in 300 Consecutive Patients with Ischemic Heart Disease Who Experienced Aborted Sudden Death: Data from the Leiden Out-of-Hospital Cardiac Arrest Study. J Cardiovasc Electrophysiol 2005; 16:1049-56. [PMID: 16191114 DOI: 10.1111/j.1540-8167.2005.50006.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Evaluation of the relation between clinical characteristics and incidence of recurrent ventricular arrhythmias (VAs) or death during long-term follow-up in a cohort of 300 consecutive ischemic heart disease (IHD) patients who had survived an episode of sudden cardiac arrest (SCA). BACKGROUND Survivors of life-threatening VA are at high risk for recurrent events. METHODS A total of 300 consecutive survivors of SCA with IHD were included in a standardized screening and evaluation protocol. Multivariable Cox regression analysis was performed to determine the relation between clinical variables at baseline and the incidence of recurrent VA, all-cause mortality and the composite of both (composite endpoint). RESULTS The presenting arrhythmia was VT in 156 (52%) patients and VF in 144 (48%) patients. Revascularization was performed in 78 (26%) patients and an ICD was implanted in 216 (72%) patients. During follow-up (mean 30 +/- 21 months) 37 (12%) patients died and 88 (29%) patients experienced a recurrence. Advanced age (adjusted hazard ratio (HR) 2.0; 1.2-3.3), history of heart failure (HR 1.8; 1.2-2.6), and amiodarone use (HR 3.1; 2.1-4.6) were independent predictors for the composite endpoint. VT as presenting arrhythmia was an independent predictor for all-cause mortality only (HR 2.4; 1.2-4.8). A decreased risk of recurrences was determined by beta-blocker use (HR 0.5; 0.4-0.8) and coronary revascularization (HR 0.3; 0.2-0.6). CONCLUSION In a cohort of 300 consecutive survivors of SCA the incidence of recurrent VA and death is dependent on patient age, history of heart failure, and use of amiodarone. In contrast, use of beta-blockers and aggressive coronary revascularization improve the outcome.
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MESH Headings
- Adrenergic beta-Antagonists/therapeutic use
- Adult
- Aged
- Aged, 80 and over
- Anti-Arrhythmia Agents/therapeutic use
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Electrophysiologic Techniques, Cardiac
- Female
- Follow-Up Studies
- Heart Arrest/mortality
- Heart Arrest/physiopathology
- Heart Arrest/therapy
- Heart Failure/physiopathology
- Humans
- Incidence
- Male
- Middle Aged
- Multivariate Analysis
- Myocardial Ischemia/mortality
- Myocardial Ischemia/physiopathology
- Myocardial Ischemia/therapy
- Proportional Hazards Models
- Recurrence
- Stroke Volume/drug effects
- Survival Analysis
- Tachycardia, Ventricular/mortality
- Tachycardia, Ventricular/physiopathology
- Tachycardia, Ventricular/therapy
- Treatment Outcome
- Ventricular Fibrillation/physiopathology
- Ventricular Function, Left/drug effects
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Affiliation(s)
- Philippine Kiès
- Department of Cardiology, Leiden University Medical Centre, the Netherlands
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18
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Cannom DS, Prystowsky EN. The evolution of the implantable cardioverter defibrillator. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:419-31. [PMID: 15009880 DOI: 10.1111/j.1540-8159.2004.00457.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- David S Cannom
- Good Samaritan Hospital, Los Angeles, California 90017, USA.
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19
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van der Burg AEB, Bax JJ, Boersma E, van Erven L, Bootsma M, van der Wall EE, Schalij MJ. Standardized screening and treatment of patients with life-threatening arrhythmias: The leiden out-of-hospital cardiac arrest evaluation study. Heart Rhythm 2004; 1:51-7. [PMID: 15851117 DOI: 10.1016/j.hrthm.2004.02.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2003] [Accepted: 02/11/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the effect of a systematic screening/treatment protocol on outcome in patients after aborted sudden death. BACKGROUND Patients after aborted sudden death are at high risk for recurrent events. In this regard, systematic screening is mandatory to reveal the underlying etiology, to detect and subsequently treat reversible causes, and to establish patient-tailored antiarrhythmic treatment. METHODS A total of 417 consecutive patients after aborted sudden death due to ventricular arrhythmias underwent echocardiography and coronary angiography. In the presence of coronary artery disease and myocardial ischemia, using stress-rest myocardial perfusion imaging/exercise testing, subsequent revascularization was performed. Patients without ischemic heart disease were further evaluated with magnetic resonance imaging, contrast echocardiography, right ventricular angiography and/or flecainide/ergonovine testing. After these diagnostic steps, final antiarrhythmic therapy was based on the outcome of electrophysiologic testing. RESULTS The majority of patients had ischemic heart disease (n = 300, 72%). After screening, 78 (78 of 300, 26%) patients underwent revascularization. In 69% of patients, ventricular arrhythmias were inducible during electrophysiologic testing. Therapy consisted of implantable defibrillators in 301 (72%) patients, antiarrhythmic drugs in 239 (57%) patients, and catheter ablation in 58 (14%) patients. During 5-year follow-up, only 3 (<1%) patients died suddenly. The 5-year survival rate was 82%; of 39 deaths, 10 (26%) patients died due to non-cardiac disease and 26 (67%) due to heart failure. CONCLUSIONS Screening and treatment of patients after aborted sudden death according to a standardized protocol resulted in <1% arrhythmic deaths during 5-year follow-up. The majority of patients died of heart failure, stressing the importance of optimizing medical and surgical therapy and screening.
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20
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Affiliation(s)
- David S Cannom
- Good Samaritan Hospital, Los Angeles, California 90017, USA.
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21
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Every N, Hallstrom A, McDonald KM, Parsons L, Thom D, Weaver D, Hlatky MA. Risk of sudden versus nonsudden cardiac death in patients with coronary artery disease. Am Heart J 2002; 144:390-6. [PMID: 12228774 DOI: 10.1067/mhj.2002.125495] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients at high risk of sudden cardiac death, yet at low risk of nonsudden death, might be ideal candidates for antiarrhythmic drugs or devices. Most previous studies of prognostic markers for sudden cardiac death have ignored the competitive risk of nonsudden cardiac death. The goal of the present study was to evaluate the ability of clinical factors to distinguish the risks of sudden and nonsudden cardiac death. METHODS We identified all deaths during a 3.3-year follow-up of 30,680 patients discharged alive after admission to the cardiac care unit of a Seattle hospital. Detailed chart reviews were conducted on 1093 subsequent out-of-hospital sudden deaths, 973 nonsudden cardiac deaths, and 442 randomly selected control patients. RESULTS Patients who died in follow-up (suddenly or nonsuddenly) were significantly different for many clinical factors from control patients. In contrast, patients with sudden cardiac death were insignificantly different for most clinical characteristics from patients with nonsudden cardiac death. The mode of death was 20% to 30% less likely to be sudden in women, patients who had angioplasty or bypass surgery, and patients prescribed beta-blockers. The mode of death was 20% to 30% more likely to be sudden in patients with heart failure, frequent ventricular ectopy, or a discharge diagnosis of acute myocardial infarction. A multivariable model had only modest predictive capacity for mode of death (c-index of 0.62). CONCLUSION Standard clinical evaluation is much better at predicting overall risk of death than at predicting the mode of death as sudden or nonsudden.
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Affiliation(s)
- Nathan Every
- Department of Biostatistics, Northwest Health Services Research and Development Center of Excellence, VA Puget Sound Healthcare System, University of Washington, Seattle, Wash, USA
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22
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Cook JR, Rizo-Patron C, Curtis AB, Gillis AM, Bigger JT, Kutalek SP, Coromilas J, Hofer BI, Powell J, Hallstrom AP. Effect of surgical revascularization in patients with coronary artery disease and ventricular tachycardia or fibrillation in the Antiarrhythmics Versus Implantable Defibrillators (AVID) Registry. Am Heart J 2002; 143:821-6. [PMID: 12040343 DOI: 10.1067/mhj.2002.121732] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients who undergo resuscitation from near-fatal ventricular arrhythmias often have significant coronary artery disease, and revascularization has been shown to reduce myocardial ischemia and cardiac arrest episodes in this patient population. The magnitude of benefit attributed to revascularization has varied by study, and the use of adjunct implantable cardioverter defibrillator (ICD) therapy has not been well-characterized. METHODS AND RESULTS The Antiarrhythmics Versus Implantable Defibrillators (AVID) registry included 3117 patients with life-threatening ventricular arrhythmias, of whom 2321 (77%) had documented coronary artery disease and 281 (17%) underwent a coronary artery bypass grafting revascularization procedure after the index event. Patients who underwent a revascularization procedure were younger, had a lower incidence rate of prior myocardial infarction and ventricular arrhythmia, had a higher left ventricular ejection fraction, had less congestive heart failure, and were more likely to have had ventricular fibrillation as the presenting arrhythmia. Patients who underwent revascularization had a better survival rate than did those who did not undergo such a procedure after the index event, and adjustment for differing baseline patient covariates did not alter the relative survival rate benefit. Further, ICD implantation offered a similar survival rate advantage to those patients in the AVID registry with coronary artery disease independent of revascularization. CONCLUSION Coronary revascularization in the AVID registry patients with coronary artery disease effected a survival rate benefit that was not attributable to differences in baseline patient characteristics. The benefit of ICD on patient survival rate was not attenuated by a revascularization procedure.
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Affiliation(s)
- James R Cook
- Division of Cardiology, Department of Medicine, Baystate Medical Center, Springfield, MA 01199, USA.
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23
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Engdahl J, Holmberg M, Karlson BW, Luepker R, Herlitz J. The epidemiology of out-of-hospital 'sudden' cardiac arrest. Resuscitation 2002; 52:235-45. [PMID: 11886728 DOI: 10.1016/s0300-9572(01)00464-6] [Citation(s) in RCA: 146] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
It is difficult to assemble data from an out-of-hospital cardiac arrest since there is often lack of objective information. The true incidence of sudden cardiac death out-of-hospital is not known since far from all of these patients are attended by emergency medical services. The incidence of out-of-hospital cardiac arrest increases with age and is more common among men. Among patients who die, the probability of having a fatal event outside hospital decreases with age; i. e. younger patients tend to more often die unexpectedly and outside hospital. Among the different initial arrhythmias, ventricular fibrillation is the most common among patients with cardiac aetiology. The true distribution of initial arrhythmias is not known since several minutes most often elapse between collapse and rhythm assessment. Most patients with out-of-hospital cardiac arrest have a cardiac aetiology. Out-of-hospital cardiac arrests most frequently occur in the patient's home, but the prognosis is shown to be better when they occur in a public place. Witnessed arrest, ventricular fibrillation as initial arrhythmia and cardiopulmonary resuscitation are important predictors for immediate survival. In the long-term perspective, cardiac arrest in connection with acute myocardial infarction, high left ventricular ejection fraction, moderate age, absence of other heart failure signs and no history of myocardial infarction promotes better prognosis. Still there is much to learn about time trends, the influence of patient characteristics, comorbidity and hospital treatment among patients with prehospital cardiac arrest.
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Affiliation(s)
- J Engdahl
- Division of Cardiology, Sahlgrenska University Hospital, Medicinmottagning II, S-413 435, Gothenburg, Sweden
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24
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Engdahl J, Bång A, Karlson BW, Lindqvist J, Sjölin M, Herlitz J. Long-term mortality among patients discharged alive after out-of-hospital cardiac arrest does not differ markedly compared with that of myocardial infarct patients without out-of-hospital cardiac arrest. Eur J Emerg Med 2001; 8:253-61. [PMID: 11785590 DOI: 10.1097/00063110-200112000-00002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of our research was to study the long-term prognosis among patients discharged alive after an out-of-hospital cardiac arrest (OHCA) in comparison with patients discharged alive after acute myocardial infarction (AMI) without OHCA, and also to study the long-term influence of AMI in connection with OHCA. Our research was conducted in the municipality of Göteborg. We retrospectively studied patients discharged from hospital 1990-91 after an OHCA of cardiac aetiology and patients discharged after an AMI without prehospital cardiac arrest. During 1980-98, we studied all patients discharged alive after OHCA of cardiac aetiology, divided into groups of precipitating AMI and no AMI. The study includes 48 patients discharged alive after an OHCA 1990-91, 30 (62%) of whom had a simultaneous AMI and 1425 patients with an AMI without OHCA. Compared with AMI survivors, survivors of an OHCA of cardiac origin were younger but had more frequently a history of congestive heart failure. Their mortality rate during the subsequent 5 years was 46%, compared with 40% among survivors of an AMI (NS). The 5-year mortality rate among patients with an OHCA precipitated by an AMI was 40%. When correcting for differences at baseline, the adjusted risk ratio for death among patients with an OHCA of cardiac origin was 1.2 (95% CI 0.8-1.8) compared with patients with an uncomplicated AMI. During 1980-98, 215 patients were judged as having an OHCA precipitated by an AMI and 115 patients had an OHCA of cardiac aetiology but no simultaneous AMI. Five-year mortality was 54% and 50% respectively (NS). It is concluded that survivors of an OHCA of cardiac origin differed from survivors of an uncomplicated AMI in that they were younger and more frequently had a history of cardiovascular disease. Their 5-year mortality after discharge was similar to that of survivors of an AMI without a prehospital cardiac arrest, even after adjusting for differences at baseline.
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Affiliation(s)
- J Engdahl
- Division of Cardiology, Sahlgrenska University Hospital, Göteborg, Sweden
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25
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Abstract
Cardiopulmonary resuscitation research is a vital area of research that has made significant contributions to medical care over the last several decades. Abundant information currently exists in the medical literature, as a result of research in the areas of cardiac arrest and outcomes, physiology of cardiac arrest, pharmacologic treatments, mechanical interventions, and societal and ethical issues. Despite numerous clinical trials demonstrating physiologic benefit of various interventions, few interventions have had as much impact on outcomes of cardiac arrest as have improvements in out-of-hospital response times and rapid availability of medical treatment. Although abundant information exists regarding physiologic aspects of resuscitation, relatively little information exists about ethical, psychological, and social aspects of resuscitation. In addition to attempts to improve outcomes of cardiac arrest, researchers should also strive to improve the experiences of patients and families involved. These realities provide future strategies and directions for the best use of resuscitation research resources; although physiologic and pharmacologic research will always have significant roles in the improvement of medical care, the rapid delivery of out-of-hospital care and ethical issues will be indispensable areas of research focus in the future.
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Affiliation(s)
- C A Marco
- Acute Care Services, St. Vincent Mercy Medical Center, Toledo, OH 43608-2691, USA.
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26
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Hickey K, Curtis AB, Lancaster S, Larsen G, Warwick D, McAnulty J, Mitchell LB. Baseline factors predicting early resumption of driving after life-threatening arrhythmias in the Antiarrhythmics Versus Implantable Defibrillators (AVID) Trial. Am Heart J 2001; 142:99-104. [PMID: 11431664 DOI: 10.1067/mhj.2001.115787] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND In the Antiarrhythmics Versus Implantable Defibrillators (AVID) Trial, patients with ventricular fibrillation or hemodynamically unstable ventricular tachycardia were randomly assigned to receive either an implantable cardioverter-defibrillator (ICD) or antiarrhythmic drug therapy. As part of the trial, patients were asked to participate in a prospective driving survey. The purpose of the survey was to determine what baseline factors and patient characteristics specifically predicted resumption of driving earlier than advised by current guidelines. METHODS Patients were surveyed anonymously as to their driving habits in the initial period after random assignment and every 6 months thereafter. AVID study coordinators were independently asked to assess their patients' driving status as well. The relation between baseline factors and time to resumption of driving was explored by means of Kaplan-Meier estimates for univariate analyses and the stepwise Cox proportional hazards regression model for multivariate analyses. RESULTS There were 802 patients who were eligible for assessment of driving status. The majority of patients (58%) resumed driving an automobile within 6 months of their index arrhythmia regardless of whether they received drug therapy or an ICD. By multivariate analysis, patients who were younger than 65 years of age, male, and college educated were more likely to drive early, as were patients whose index arrhythmia was ventricular tachycardia. CONCLUSIONS Younger, college-educated men and those whose index arrhythmia is ventricular tachycardia are most likely to resume driving <6 months after the initiation of therapy for a potentially life-threatening ventricular arrhythmia. Patients with an ICD did not appear to resume driving later than those who were discharged on antiarrhythmic drugs alone.
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Affiliation(s)
- K Hickey
- Columbia University, New York, NY, USA
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27
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Delacretaz E, Schlaepfer J, Metzger J, Fromer M, Kappenberger L. Evidence rather than costs must guide use of the implantable cardioverter defibrillator. Am J Cardiol 2000; 86:52K-57K. [PMID: 11084101 DOI: 10.1016/s0002-9149(00)01292-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Randomized controlled trials have shown superior survival rates with implantable cardioverter defibrillators (ICDs) compared with antiarrhythmic drugs in survivors of cardiac arrest and life-threatening ventricular tachyarrhythmias, as well as in high-risk patients with ischemic heart disease and inducible ventricular tachycardia (VT). Current defibrillators are small and implanted with techniques similar to standard pacemakers. They provide high-energy shocks for ventricular fibrillation (VF) and rapid VT, antitachycardia pacing for monomorphic VT, and antibradycardia pacing. Limited evidence suggests that ICD therapy is cost-effective when compared with other widely accepted treatments. The use of ICDs is likely to continue to expand in the future. Ongoing clinical trials will define further prophylactic indications of the ICD and clarify its cost-effectiveness ratio in different clinical settings.
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Affiliation(s)
- E Delacretaz
- Division of Cardiology, University Hospital, Lausanne, Switzerland
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28
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Goldberger JJ, Neelagaru S. Therapeutic developments in sudden cardiac death. Expert Opin Investig Drugs 2000; 9:2543-54. [PMID: 11060819 DOI: 10.1517/13543784.9.11.2543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Sudden cardiac death is characterised by the unexpected death of a patient who has been clinically stable. It is frequently due to the development of ventricular tachyarrhythmias. With appropriate treatment, patients can be appropriately resuscitated. Clinically, it is essential to develop treatment strategies to prevent such an episode, as most patients do not survive out-of-hospital cardiac arrest. beta-Blockers are an effective pharmacological therapy in patients following myocardial infarction and in those with congestive heart failure. They may also be effective in other types of heart disease. Anti-arrhythmic agents are not useful as prophylactic drug therapy for reducing mortality in patients at risk for sudden cardiac death. Amiodarone is a notable exception, which may have some benefit, particularly in some subgroups. The implantable cardioverter-defibrillator has emerged as the most effective therapy for preventing sudden cardiac death in high-risk patients. Further work is required to enhance the characterisation of high-risk patients. Genetic analyses in patients with cardiovascular disorders may also identify new approaches to the prevention of sudden cardiac death.
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Affiliation(s)
- J J Goldberger
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois, USA.
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29
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Abstract
This article provides a review of the risks faced by patients with sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) in the absence of a reversible or transient cause so that the goals of therapy can be clearly defined. The therapeutic approaches that have been proposed to achieve these goals are outlined and evidence comparing these various approaches to therapy is then summarized in order to propose an algorithm for the optimal use of antiarrhythmic drug therapies as primary therapy for selected VT/VF patients. Options for the ancillary uses of antiarrhythmic drug therapies in ICD patients are considered.
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Affiliation(s)
- L B Mitchell
- Division of Cardiology, University of Calgary, Alberta, Canada
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30
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31
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Epstein AE, Powell J, Yao Q, Ocampo C, Lancaster S, Rosenberg Y, Cannom DS, Herre JM, Greene HL. In-hospital versus out-of-hospital presentation of life-threatening ventricular arrhythmias predicts survival: results from the AVID Registry. Antiarrhythmics Versus Implantable Defibrillators. J Am Coll Cardiol 1999; 34:1111-6. [PMID: 10520799 DOI: 10.1016/s0735-1097(99)00305-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES This study describes the outcomes of patients from the Antiarrhythmics Versus Implantable Defibrillators (AVID) Study Registry to determine how the location of ventricular arrhythmia presentation influences survival. BACKGROUND Most studies of cardiac arrest report outcome following out-of-hospital resuscitation. In contrast, there are minimal data on long-term outcome following in-hospital cardiac arrest. METHODS The AVID Study was a multicenter, randomized comparison of drug and defibrillator strategies to treat life-threatening ventricular arrhythmias. A Registry was maintained of all patients with sustained ventricular arrhythmias at each study site. The present study includes patients who had AVID-eligible arrhythmias, both randomized and not randomized. Patients with in-hospital and out-of-hospital presentations are compared. Data on long-term mortality were obtained through the National Death Index. RESULTS The unadjusted mortality rates at one- and two-year follow-ups were 23% and 31.1% for patients with in-hospital presentations, and 10.5% and 16.8% for those with out-of-hospital presentations (p < 0.001), respectively. The adjusted mortality rates at one- and two-year follow-ups were 14.8% and 20.9% for patients with in-hospital presentations, and 8.4% and 14.1% for those with out-of-hospital presentations (p < 0.001), respectively. The adjusted long-term relative risk for in-hospital versus out-of-hospital presentation was 1.6 (95% confidence interval [CI] 1.3-1.9). CONCLUSIONS Compared with patients with out-of-hospital presentations of life-threatening ventricular arrhythmias not due to a reversible cause, patients with in-hospital presentations have a worse long-term prognosis. Because location of ventricular arrhythmia presentation is an independent predictor of long-term outcome, it should be considered as an element of risk stratification and when planning clinical trials.
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Affiliation(s)
- A E Epstein
- Department of Medicine, the University of Alabama at Birmingham, USA
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32
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Abstract
There is a wide variety of ethical issues and dilemmas involving resuscitation, the act of restoring life to a patient in cardiorespiratory arrest. Decisions must be made rapidly and often must be based on suboptimal levels of information available at the time. Certain issues should be considered when one is making decisions in the resuscitation arena, including positive-aspects of resuscitation, not only the possibility of restoring life to the patient but also providing a sense of closure and resolution of guilt for the survivors. During and following resuscitative efforts, the psychologic and emotional well-being of the survivors should also be given close attention.
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Affiliation(s)
- C A Marco
- St. Vincent Mercy Medical Center, Toledo, Ohio, USA.
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33
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Cappato R. Secondary prevention of sudden death: the Dutch Study, the Antiarrhythmics Versus Implantable Defibrillator Trial, the Cardiac Arrest Study Hamburg, and the Canadian Implantable Defibrillator Study. Am J Cardiol 1999; 83:68D-73D. [PMID: 10089843 DOI: 10.1016/s0002-9149(98)01006-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Although indisputably effective in the prevention of sudden death, use of implantable cardioverter defibrillator (ICD) therapy may not necessarily affect all-cause mortality, as most patients at risk also present with severely depressed left ventricular dysfunction. Correction of the sudden death risk in these patients creates a new clinical condition in need of a careful assessment. Should all-cause mortality be affected by the expected reduction in sudden death rate associated with ICD therapy, issues of critical importance, such as the time extent of life prolongation and the associated quality of life, still remain to established. To investigate the potential benefit of ICD therapy compared with antiarrhythmic drug treatment, 4 prospective studies--the Dutch trial, the Antiarrhythmics Versus Implantable Defibrillators (AVID) study, the Cardiac Arrest Study Hamburg (CASH), and the Canadian Implantable Defibrillator Study (CIDS)--have been conducted in which patients with documented sustained ventricular arrhythmia were randomized to 1 of these 2 treatment strategies. The enrollment criteria differed in these 4 studies: (1) in the Dutch trial, they included cardiac arrest secondary to a ventricular arrhythmia, old (> 4 weeks) myocardial infarction, and inducible ventricular arrhythmia; (2) in AVID and CIDS, ventricular fibrillation or poorly tolerated ventricular tachycardia; and (3) in CASH, cardiac arrest secondary to a ventricular arrhythmia regardless of the underlying disease. With regard to the antiarrhythmic drugs, the Dutch trial tested class I and III agents, whereas AVID and CIDS compared ICD therapy with class III agents (mostly amiodarone). In CASH, 3 drug subgroups were investigated: propafenone, amiodarone, and metoprolol. All trials used all-cause mortality as the primary endpoint. Data from these trials provide support for ICD as a therapy superior to antiarrhythmic drugs in prolonging survival in patients meeting the entry criteria. This review briefly summarizes the methods, results, limitations, and clinical implications of these 4 studies.
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Affiliation(s)
- R Cappato
- Second Department of Internal Medicine, St. Georg Hospital, Hamburg, Germany
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34
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Abstract
Catecholamines and ischemia play an important role in the induction of ventricular tachyarrhythmias. Beta blockers antagonize the effect of catecholamines and have anti-ischemic properties. Several controlled studies performed in the early 1980s in patients after myocardial infarction have shown that beta-blocker therapy clearly decreases sudden and nonsudden cardiac death. Despite the lack of recent randomized trials, data from uncontrolled studies suggest that the beneficial effect of beta blockers is still present in the thrombolytic era. Thus, it is incomprehensible that today in the United States and in most parts of Europe, < 40% of post-myocardial infarction patients are treated with beta blockers. Even in patients with documented sustained ventricular tachycardias (VTs) or ventricular fibrillation (VF), clinical studies indicate that beta blockers improve survival. Thus, even in the thrombolytic era, beta blockers should be used as a basic therapy in patients who are at risk of sudden cardiac death.
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Affiliation(s)
- D Andresen
- Department of Cardiology, Urban Hospital, Berlin, Germany
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Abstract
Heart transplantation is an accepted therapeutic option for patients with end-stage heart disease. However, because the availability of heart donors fails to keep pace with the growing demand, increasing numbers of potential recipients are placed on the waiting list, resulting in longer waiting times. About 20% of patients die while awaiting heart transplantation. The majority die from progressive pump failure (46%), whereas about 30% of all deaths occur suddenly. Monitored terminal cardiac electrical activity in patients dying while awaiting transplantation reveals that bradyarrhythmias and/or electromechanical dissociation are involved in 68% of cases and ventricular tachyarrhythmias in 32% of cases. Patients with a history of aborted cardiac arrest are at highest risk for recurrent malignant arrhythmias. The implantable cardioverter defibrillator (ICD) is the most effective therapy for preventing sudden cardiac death from ventricular tachyarrhythmias. Pooled data from a total of 75 sudden death survivors listed for cardiac transplantation demonstrate that ICD therapy can be applied with low mortality, low morbidity, and high efficacy, with up to 94% of the patients receiving appropriate shocks during the waiting period. However, there is considerable concern that this early survival benefit conferred by the ICD may be nullified by the competing risk of death due to terminal pump failure, as the waiting list and waiting time to transplantation lengthens. In advanced heart failure, risk stratification for sudden tachyarrhythmic death is only of limited value. Therefore, although sudden tachyarrhythmic death appears to constitute only a minor fraction of total cardiac death in patients awaiting heart transplantation, prophylactic ICD implantation as on electronic bridge to transplant may be considered. To define conclusively the role of prophylactic ICD therapy in this setting, prospective randomized studies are needed.
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Affiliation(s)
- H Schmidinger
- Department of Cardiology, University of Vienna, Austria
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Kriegsman WE, Mace SE. The impact of paramedics on out-of-hospital cardiac arrests in a rural community. PREHOSP EMERG CARE 1998; 2:274-9. [PMID: 9799013 DOI: 10.1080/10903129808958879] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine whether paramedics influence the outcome of cardiac arrest patients in a rural area. METHODS Retrospective analysis of cardiorespiratory arrest patients in rural southeast Alaska from 1987 to 1996. RESULTS Paramedics treated 37 patients and advanced life support emergency medical technicians (EMT-IIIs) treated 34 patients. Demographics/CPR variables of the two groups were similar. Return of spontaneous circulation (ROSC) was 46% (17/37) for the paramedic-treated patients and 18% (6/34) for the EMT-III-treated patients (p = 0.01). Intensive care unit (ICU) admission was 38% (14/37) for the paramedic-treated patients and 15% (5/34) for the EMT-III-treated patients (p < 0.03). Discharge from the hospital neurologically intact was 20% (7/35) for the paramedic-treated patients and 9% (3/34) for the EMT-III-treated patients (p = NS). Two patients in the paramedic-treated group had ROSC and survived in the local hospital ICU for several days before being transferred to a tertiary care hospital in another state and were lost to follow-up for the discharge-from-hospital-neurologically-intact category but were included in the ROSC and ICU admission analysis. CONCLUSION In this rural setting, a paramedic on the scene significantly improved the ROSC (paramedics = 46% vs 18% for EMT-III, p = 0.01) and survival to ICU admission (38% vs 15%, p = 0.03). The presence of a paramedic on the scene increased survival to hospital discharge neurologically intact (20% vs 9%), although this was not statistically significant.
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37
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MITCHELL LBRENT. Pharmacological Therapy for Ventricular Arrhythmias in the Era of the Implantable Cardioverter Defibrillator: Indispensable or Inadvisable? J Interv Cardiol 1998. [DOI: 10.1111/j.1540-8183.1998.tb00124.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Kaul TK, Fields BL, Riggins LS, Wyatt DA, Jones CR. Ventricular arrhythmia following successful myocardial revascularization: incidence, predictors and prevention. Eur J Cardiothorac Surg 1998; 13:629-36. [PMID: 9686792 DOI: 10.1016/s1010-7940(98)00085-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES We estimated the risk of sudden cardiac death (SCD), from a spontaneous episode of ventricular arrhythmia (VT/VF), after a successful surgical myocardial revascularization (coronary artery bypass grafting; CABG) procedure. Predictors of these events were identified, and long term benefits of the prophylactic regimes, that were used to control these events, were evaluated. METHODS We selected 8642 consecutive patients, who had undergone an isolated and first time CABG procedure, between 1/3/1980 and 1/3/1995. A standard hazard function model (1) was used for statistical analysis. Efficacy of the prophylactic regimes, was examined in a group of 350 high risk patients, with a preoperative left ventricular ejection fraction 30% or less, who were recently operated since 1/1/1988. Electrophysiologic (EP) guided prophylaxis was used in 92 (26%) patients, who had survived a documented episode of SCD, and remaining 258 patients were maintained on antiarrhythmic medication on an empirical basis. A sequential EP evaluation was performed, when indicated. RESULTS During an early phase of hazard, which mainly lasted for up to 3 months after CABG, incremental risk factors were preoperative LVEF 30% or less (P = 0.0007) and preoperative episodes of VT/VF (P = 0.04). This phase was followed by a constant phase with a low risk of the events, which merged into a slowly rising late phase after 6 years. EP guided prophylaxis, reduced the risk of SCD in high risk patients (P = 0.03). A sequential EP evaluation, helped to detect the problems of drug resistance and a cross over from non-sustained to sustained runs of VT/VF. CONCLUSIONS Despite a successful CABG surgery, risk of VT/VF persists. A routine EP evaluation before and after a CABG procedure is recommended in all patients with a poor left ventricular function.
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Affiliation(s)
- T K Kaul
- Department of Cardiac Surgery, Baptist Medical Center, Birmingham, AL, USA
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39
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Abstract
Sudden cardiac death due to ventricular arrhythmias is a significant cause of mortality in patients with structural heart disease. Over the past several decades, the introduction of new pharmacologic and nonpharmacologic therapy has expanded the treatment options available. This article will focus on the use of antiarrhythmic medication for the treatment of ventricular arrhythmias and will review the following: (1) treatment goals for various clinical populations, (2) the mechanisms of antiarrhythmic and proarrhythmic actions of antiarrhythmic medications, and (3) empiric versus guided pharmacologic therapy.
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Affiliation(s)
- M D Landers
- Department of Medicine, University of Colorado Health Sciences Center, Denver 80262, USA
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40
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Abstract
While it is assumed that the normal heart does not predispose to serious arrhythmias, several conditions are now being recognized as being associated with short-lasting ventricular arrhythmias. It also becomes clear that idiopathic VT (or repetitive monomorphic VT) sometimes exists on the background of a compromised heart. Whether this dysfunction is due to the arrhythmia or vice versa is not evident. Finally, VF occurs in patients who, at a first glance, have no apparent heart disease, and it is then called idiopathic VF. These complex electrical abnormalities probably reflect disorders, which often are genetically determined. Recognition of these syndromes, often characterized by abnormal repolarization or a disturbed autonomic function is possible if appropriate techniques are used.
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Affiliation(s)
- L Jordaens
- Department of Cardiology, University Hospital Ghent, Belgium
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41
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Underwood RD, Sra J, Akhtar M. Evaluation and treatment strategies in patients at high risk of sudden death post myocardial infarction. Clin Cardiol 1997; 20:753-8. [PMID: 9294665 PMCID: PMC6655294 DOI: 10.1002/clc.4960200908] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/1995] [Accepted: 05/05/1997] [Indexed: 02/05/2023] Open
Abstract
Over 50 percent of deaths in patients who survive an acute myocardial infarction are due to fatal ventricular tachyarrhythmias. Patients who survive an episode of sustained ventricular arrhythmia are at highest risk of recurrent cardiac arrest. Electrophysiologic studies have been found to be useful in guiding therapy and reducing mortality in these patients and in patients with syncope due to arrhythmic etiology. Evaluation and treatment of nonsustained ventricular tachycardia post infarction remains somewhat controversial. A recently published trial (MADIT), however, showed improved survival with an implanted defibrillator in patients with coronary disease and asymptomatic nonsustained ventricular tachycardia. Asymptomatic patients post infarction at high risk include those who have significant left ventricular dysfunction, late potentials, high-grade ventricular ectopy, and abnormal heart rate variability. These tests individually, however, have a low positive predictive accuracy. This, combined with the fact that antiarrhythmic drugs are frequently not effective and can be proarrhythmic, leaves the best treatment for these patients uncertain. It is known, however, that beta-adrenoreceptor blocking agents do reduce mortality after an acute myocardial infarction. Early studies have shown mixed results relating to sudden death and total mortality with amiodarone. To date, no other antiarrhythmic drug has shown benefit, while several have been shown to be harmful. Recent studies have also shown some beneficial effects of angiotensin-converting enzyme inhibitors, carvedilol, a third-generation beta-blocking agent with vasodilator properties, and the angiotensin II receptor antagonist losartan. However, their precise role in reducing sudden death needs to be defined further.
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Affiliation(s)
- R D Underwood
- Electrophysiology Laboratory, Milwaukee Heart Institute of Sinai Samaritan Medical Center, Wisconsin, USA
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42
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Gomes JA, Mehta D, Ip J, Winters SL, Camunas J, Ergin A, Newhouse TT, Pe E. Predictors of long-term survival in patients with malignant ventricular arrhythmias. Am J Cardiol 1997; 79:1054-60. [PMID: 9114763 DOI: 10.1016/s0002-9149(97)00046-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The study consisted of 369 patients (age 62 +/- 13 years) who presented to our institution from April 1984 to April 1994 for malignant ventricular arrhythmias presenting as sustained ventricular tachycardia (VT) in 57% of patients, ventricular fibrillation in 25% of patients, and syncope due to VT in 17% of patients. Coronary artery disease was present in 74% of patients, cardiomyopathy in 19% of patients, and no evident heart disease in 7% of patients. Two hundred twenty-one patients were given drug, therapy, 47 patients underwent arrhythmia surgery, and 75 patients had an implantable cardioverter-defibrillator (ICD). During a mean follow-up of 30 months (range 1 to 101), 66 patients (18%) died from a cardiac death of which 26 (39%) were sudden. Cox regression analysis was conducted utilizing a total of 19 variables (clinical and therapeutic) in the entire population and separately in patients with coronary artery disease and cardiomyopathy. The most significant variables (multivariate analysis) of survival from cardiac mortality in the entire population were: congestive heart failure (CHF) class (p = 0.0003), ejection fraction (p = 0.02), and the use of drug therapy (p = 0.03); in patients with coronary artery disease, CHF class (p = 0.0001) and ejection fraction (p = 0.0006); and in patients with cardiomyopathy, CHF class (p = 0.009) and sustained VT on Holter monitoring (p = 0.007). Kaplan-Meier survival rates from cardiac death were: significantly lower (p = 0.005) in patients with CHF class III and IV compared with CHF class I and II (25% vs 58%, p = 0.005) with drug therapy; marginally significant (47% vs 88%, p = 0.06) from 20 to 40 months in patients with an ICD; and nonsignificant in patients who underwent arrhythmia surgery (63% vs 71%). Patients with an ICD had a better expected survival (82%) than patients who had arrhythmia surgery (69%) and drug therapy (65%). Thus, in patients with malignant ventricular arrhythmias, CHF class was the most significant independent predictor of survival from cardiac mortality over all disease substrates, and therapy influenced survival depending on the CHF class. Patients in CHF class III and IV who underwent arrhythmia surgery or had an ICD had a better expected survival than those taking drug therapy, and the negative impact of antiarrhythmic therapy was most prominent in patients with CHF class III and IV.
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Affiliation(s)
- J A Gomes
- Department of Medicine, Mount Sinai Medical Center, New York, New York 10029, USA
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43
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Kaul TK, Agnihotri AK, Fields BL, Riggins LS, Wyatt DA, Jones CR. Coronary artery bypass grafting in patients with an ejection fraction of twenty percent or less. J Thorac Cardiovasc Surg 1996; 111:1001-12. [PMID: 8622298 DOI: 10.1016/s0022-5223(96)70377-x] [Citation(s) in RCA: 82] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Over a 7-year period, 5.8% (n = 210) of patients who underwent coronary artery bypass grafting at our institution had severely impaired global left ventricular function with an ejection fraction of 20% or less. Mean age at operation was 66 years (+/- 0.7; standard error), and 76% of patients were male. Primary indications for operation were unstable angina (73 patients, 35%), return of symptoms with previous bypass grafting (41 patients, 20%), congestive heart failure with reversible ischemia (55 patients, 26%), and recurrent ventricular arrhythmias (41 patients, 20%). Overall, actuarial survival (n = 210) was 82%, 79%, and 73% at 1, 2, and 5 years. Risk of death was highest early after the operation, and then declined rapidly to a constant level. Patients who did not receive retrograde coronary sinus cardioplegia (p = 0.05), older patients (p = 0.004), and those with preoperative ventricular arrhythmias (p = 0.003) or renal failure (p < 0.0001) had an increased risk of death early after operation. Patients with congestive symptoms and those requiring extensive or redo bypass grafting (p = 0.02) were found to be at an increased risk of death throughout the follow-up period. When the number of distal anastomoses performed increased, survival was found to decrease (p < 0.003), and to a greater extent in women than in men (p = 0.02). Of the four primary indications for operation, unstable angina yielded the highest risk-adjusted survival. Successful results after surgical revascularization in patients with severe impairment of ventricular function can be achieved by careful patient selection and management.
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Affiliation(s)
- T K Kaul
- Division of Cardiac Surgery, Princeton Baptist Medical Center, Birmingham, AL 35211, USA
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44
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Ritchie JL. ACC/AHA Guidelines for Clinical Intracardiac Electrophysiological and Catheter Ablation Procedures. J Cardiovasc Electrophysiol 1995. [DOI: 10.1111/j.1540-8167.1995.tb00443.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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45
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Zipes DP, DiMarco JP, Gillette PC, Jackman WM, Myerburg RJ, Rahimtoola SH, Ritchie JL, Cheitlin MD, Garson A, Gibbons RJ. Guidelines for clinical intracardiac electrophysiological and catheter ablation procedures. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Intracardiac Electrophysiologic and Catheter Ablation Procedures), developed in collaboration with the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol 1995; 26:555-73. [PMID: 7608464 DOI: 10.1016/0735-1097(95)80037-h] [Citation(s) in RCA: 156] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- D P Zipes
- Educational Services, American College of Cardiology, Bethesda, Maryland 20814-1699, USA
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46
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Berntsen RF, Gunnes P, Rasmussen K. Pattern of coronary artery disease in patients with ventricular tachycardia and fibrillation exposed by exercise-induced ischemia. Am Heart J 1995; 129:733-8. [PMID: 7900625 DOI: 10.1016/0002-8703(95)90323-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The majority of patients with serious exercise-induced ventricular arrhythmias have extensive coronary artery disease. These arrhythmias develop, however, only in a minority of patients with angina pectoris. The purpose of the present study was therefore to investigate whether these arrhythmia patients are characterized by any specific "arrhythmogenic" pattern of coronary artery disease. Among 1100 consecutive patients undergoing coronary artery bypass grafting, 30 (2.7%) patients had ventricular tachycardia or fibrillation during preoperative exercise testing. For each of these patients, two matched controls with angina pectoris but no ventricular arrhythmia were selected. All patients underwent angiocardiography by standard techniques. The recordings were blinded and interpreted in random order by an experienced invasive cardiologist. Significant stenosis (> or = 50%) of the main left coronary artery was found in 27% of the case patients compared to 12% of the matched controls (p = 0.069, two-tailed t test); proximal left anterior descending artery stenoses were more frequent in the arrhythmia patients. Although stenosis > or = 75% was only moderately more frequent in the case patients, the difference was highly significant for stenosis > or = 95%, which was seen in 47% of the case patients compared to 22% of the controls (p = 0.015). The difference was even more pronounced for the combination of main left coronary artery stenosis and/or high-grade stenosis (> or = 95%) of the left anterior descending artery. This pattern was seen in 60% of the case patients compared to 28% of the matched controls (p = 0.004).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R F Berntsen
- Department of Medicine, University Hospital of Tromsø, Norway
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47
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Sauvé MJ. Long-term physical functioning and psychosocial adjustment in survivors of sudden cardiac death. Heart Lung 1995; 24:133-44. [PMID: 7759274 DOI: 10.1016/s0147-9563(05)80008-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To identify and describe a range of functional health outcomes in a sample of sudden cardiac death survivors. DESIGN Cross-sectional survey. SETTING Northern California tertiary medical center. SUBJECTS Sixty-one sudden cardiac death survivors at least 6 months but not more than 4 years after cardiac arrest. Subjects were excluded if they had uncontrolled congestive heart failure, unstable angina, other debilitating cardiac or concomitant illness, or evident cognitive deficits. METHODS Chart reviews, patient interviews, and a standardized questionnaire. RESULTS Survivors reported significantly poorer physical functioning than normal subjects (p < 0.001), although none were limited in self-care. Mental Health Index Scores and subscale scores for psychologic well-being were within established norms. However, mean scores for the psychologic distress subscale were elevated (p < 0.001). Initial work return was 72%. Of the 37 (61%) survivors who were sexually active before their arrests, 78% resumed coitus. Twenty-five survivors reported mild to moderately severe impairments in memory or other cognitive skills. Poor physical functioning was associated with illness severity, change in work status, and increased anxiety. Psychologic distress was associated with change in work status and poor physical functioning, but not illness severity. CONCLUSIONS Despite significant decreases in physical functioning and reports of mild to moderately severe cognitive impairments, only a minority of sudden cardiac death survivors are severely psychologically distressed. Illness severity is a strong predictor of physical functioning, but its contribution to psychologic distress is indirect, acting largely through the aegis of poor physical functioning and loss of prearrest work status.
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Affiliation(s)
- M J Sauvé
- Department of Physiological Nursing, University of California, San Francisco 94143, USA
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48
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Williams JM, Rock DT, Pabst SJ, Grill CR, DeAntonio HJ, Mahmud R, Chitwood WR. Clinical experience with the implantable cardioverter defibrillator. Ann Thorac Surg 1994; 58:1297-303. [PMID: 7944810 DOI: 10.1016/0003-4975(94)90533-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The implantable cardioverter defibrillator has played an increasingly greater role in the management of episodes of sudden cardiac-related death related to ventricular tachycardia or ventricular fibrillation. This study reviews the cases of 142 patients who underwent insertion of an implantable cardioverter defibrillator, 104 who received a device alone (group I) and 38 who underwent insertion of the device in combination with other cardiac surgical procedures (group II). The overall operative mortality was 3.5% and this did not differ between the two groups. The complication rate was higher for group II than for group I patients, and consisted primarily of an increased incidence of atrial arrhythmias (53% versus 13%; p < 0.001). Late complications included three device infections requiring removal of the defibrillator. The late mortality did not differ between the two groups and was primarily related to congestive heart failure. Sudden cardiac-related death was an uncommon late event, with an actuarial freedom from sudden cardiac-related death of 98%, 97%, and 87% at 1, 2, and 5 years, respectively. The morbidity and mortality rate are low in association with the insertion of an implantable cardioverter defibrillator, even when this is combined with other cardiac surgical procedures. Its insertion is also associated with a low subsequent rate of sudden cardiac-related death.
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Affiliation(s)
- J M Williams
- Division of Cardiothoracic Surgery, East Carolina University School of Medicine, Greenville, North Carolina 27858
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49
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Fan W, Peter CT. Survival and incidence of appropriate shocks in implantable cardioverter defibrillator recipients who have no detectable structural heart disease. CEDARS Investigators. Am J Cardiol 1994; 74:687-90. [PMID: 7942526 DOI: 10.1016/0002-9149(94)90310-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Prognosis of patients with episodes of hypotensive ventricular tachycardia (VT) or ventricular fibrillation (VF) in the absence of structural heart disease is poorly defined. To solve this problem, this study analyzed a subgroup of 25 such patients chosen from 468 consecutive patients who had an initial implantable cardioverter defibrillator (ICD) inserted between May 1984 and May 1990 in 9 medical centers and were followed up for at least 1 year. The patient group consisted of 17 men and 8 women, aged 8 to 75 years. Cardiac arrest occurred in 20 patients, 3 patients had recurrent VT, and 2 patients had both. Left ventricular ejection fraction ranged from 50% to 70%. During electrophysiologic study, a specific response was seen in 13 patients, defined as monomorphic VT (5 patients), or VF in those who had a history of VF (8 patients). In 8 patients, only a nonspecific response was seen. No arrhythmia could be induced in 4 patients. Of the 13 patients with a specific response, antiarrhythmic drug was tested in 9; in 3 of them the arrhythmia was suppressed. Within the first year, 6 of the 25 patients (24%) received appropriate shock. In the remaining 436 patients who had organic heart disease, 155 (36%) received appropriate ICD shock (p = NS). Therefore, ICD implantation appears to be warranted in patients with a history of life-threatening arrhythmias, not only in the presence but also in the absence of demonstrable structural heart disease.
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Affiliation(s)
- W Fan
- Cedars-Sinai Medical Center, Los Angeles, California 90048
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50
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Lessmeier TJ, Lehmann MH, Steinman RT, Fromm BS, Akhtar M, Calkins H, DiMarco JP, Epstein AE, Estes NA, Fogoros RN. Implantable cardioverter-defibrillator therapy in 300 patients with coronary artery disease presenting exclusively with ventricular fibrillation. Am Heart J 1994; 128:211-8. [PMID: 8037084 DOI: 10.1016/0002-8703(94)90470-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
To determine outcomes of implantable cardioverter-defibrillator (ICD) therapy in a uniform population of survivors of sudden cardiac death, we used epicardial defibrillation lead systems to study 300 patients with coronary artery disease (CAD) presenting exclusively with ventricular fibrillation (VF) unassociated with acute myocardial infarction. Operative (30-day) mortality, 2.7% overall, was lower (0.6%) in patients with ejection fractions (EF) > or = 0.30. Over a median follow-up of 1.9 years, cumulative actuarial shock incidence was similar in patients who underwent concomitant coronary artery bypass graft (CABG) surgery (38%) and in those who did not. The 2-year cumulative actuarial incidences of any or appropriate shocks were 65% and 38%, respectively. Sudden death survival at 2 years was 92.5% and 99.3% for patients with EFs < or = 0.30 and > 0.30, respectively. The total mortality rate was similar in shocked and in unshocked patients. Multivariate analysis identified EF and female gender as significant predictors of any and appropriate shock occurrence (all p values < or = 0.05) and EF as a significant predictor of sudden, cardiac, and total mortality (all p values < 0.03). We conclude that in CAD patients presenting exclusively with VF unassociated with acute myocardial infarction and treated with thoracotomy-requiring ICD therapy: (1) operative (30-day) mortality is minimal for patients with an EF > or = 0.30; (2) device use is high and sudden death rates low regardless of concomitant CABG; (3) low EF is a significant predictor of cumulative shock occurrence and mortality (sudden, cardiac, and total); (4) female gender may be a predictor of shock occurrence; and (5) similar mortalities and low sudden-death rates in shocked and nonshocked ICD patients imply that ICD therapy improves survival in shocked patients to a level observed in comparable patients in whom ventricular tachyarrhythmia does not recur.
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Affiliation(s)
- T J Lessmeier
- Department of Internal Medicine, Wayne State University/Harper Hospital, Detroit, MI
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