Transcript IMPANTABLE CARDIOVERTER DEFIBRILLATORS (ICDs)

IMPANTABLE
CARDIOVERTER
DEFIBRILLATORS (ICDs)
Janet McComb
Freeman Hospital
Newcastle upon Tyne
“Chain of Survival”
Cummins et al Circulation 1991;83:1832-1847.
“Chain of Survival”
Cummins et al Circulation 1991;83:1832-1847.
rapid access
Survival to leave hospital after out of hospital
cardiac arrest: effect of arrest being witnessed
30%
24%
25%
20%
41% not
witnessed
15%
10%
5%
4%
0%
not witnessed
witnessed
Eisenberg & Mengert, NEJM, 2001;344:1304-1313
“Chain of Survival”
Cummins et al Circulation 1991;83:1832-1847.
rapid access
rapid CPR
Survival after out of hospital arrest:
effect of early CPR
3
2.5
2
1.5
1
OR 1.41
[1.19-1.66]
0.5
OR 2.15
[1.85-2.50]
0
No CPR
dispatcher
bystander CPR
assisted CPR
Rea et al, Circulation, 2001;104:2413-2516.
Survival after out of hospital arrest:
effect of quality of CPR
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
none
other
lay persons
police
officers
medical
personnel
ambulance
staff
Holmberg et al Eur Heart J 2001;22:511-519
Survival to leave hospital after out of hospital
cardiac arrest: initial rhythm
40%
34%
35%
30%
25%
20%
15%
12%
10%
5%
6%
1%
0%
not VF
VF
not witnessed
not VF
VF
witnessed
Eisenberg & Mengert, NEJM, 2001;344:1304-1313
“Chain of Survival”
Cummins et al Circulation 1991;83:1832-1847.
rapid access
rapid CPR
rapid defibrillation
Rapid defibrillation
Larsen et al
Ann Emerg Med
1993;22:80-84
Survival to leave hospital after out of hospital
witnessed cardiac arrest due to VF: PAD
70%
60%
50%
40%
56%
59%
40%
34%
33%
1990-1999,
Seattle,
Eisenberg
& Mengert
Qantas,
O'Rourke
et al
30%
20%
10%
0%
American
Airlines,
Page et al
O'Hare,
Caffrey et
al
Casino,
Valenzuela
et al
Eisenberg & Mengert, NEJM, 2001;344:1304-1313
minutes
Impact of first responder volunteers
Time from call to arrival
8
7
6
5
4
3
2
1
0
p=0.05
Survival
6.2
4.8
12%
10%
8%
6%
10.5%
8.4%
6.2%
4.8%
3.3%
2.4%
4%
2%
0%
PPV
EMS
overall
survival
PPV
EMS
neurologically intact
Capucci et al Circulation 2002;106:1065-1070
Survival to leave hospital after out of hospital
witnessed VF: Impact of AEDs in police cars
Time from call to arrival
Hospital survivors
10
25%
7.6
minutes
8
24.0%
20%
6.2
6
15%
10.5%
4
10%
2
5%
0
0%
police AED
standard EMS
police AED
standard EMS
Myerburg et al Circulation 2002;106:1058-1064
Survival to leave hospital after out of hospital
witnessed VF: Impact of PAD & AEDs in police
cars
time from call to arrival
minutes
7
6
5
4
EMS
AED
% survival to leave hospital
8
survival: witnessed VF
50
40
30
20
10
0
EMS
AED
Piacenza
Miami-Dade
Goteborg
VF in 14 of 99 who had lost
consciousness (and had an
ECG recorded)
6 (40%) survived to leave
hospital
Page et al N Engl J
Med 2000;343:1210
nursing home 8%
public place 21%
home 71%
Eisenberg & Mengert,
NEJM, 2001;344:1304
Survival to leave hospital after cardiac arrest
King Co 1983-2000
15.1%
Seattle 1989-1998
12.4%
9.6%
Piacenza AED 1999-2001
7.6%
Miami-Dade Co 1999-2001
Scotland 1988-1994
6.7%
Maastricht 1991-1994
6.2%
Piacenza EMS 1999-2001
6.2%
Nottingham 1991-1994
6.1%
West Yorkshire 1987-1997
6.0%
Miami-Dade Co 1997-1999
6.0%
4.5%
UK 1994-1995
3.7%
Paris 1993-1997
0%
5%
10%
15%
20%
“Chain of Survival”
Cummins et al Circulation 1991;83:1832-1847.
rapid access
rapid CPR
rapid defibrillation
11 seconds
The ICD comprises
one or more leads, which will
sense the heart rhythm
pace the heart
defibrillate the heart
a generator, which contains
the electrical circuitry for this
RA lead
RV leads
LV lead
 62
cc
 Dual-chamber
 35-Joule
output
Can®
electrode
 Active
relative risk reduction in
mortalty
Mortality reduction in ICD trials
80%
73%
70%
60%
54%
51%
50%
40%
39%
38%
31%
30%
20%
20%
10%
0%
MADIT MUSTT MADIT
II
Primary prevention
Dutch
AVID
CIDS
CASH
Secondary prevention
10
20
Myerberg et al Am J Cardiol 1997;80:10F-19F
Emergencies in ICD patients
Shocks
Rhythm problems
Cardiac problems
Other emergencies
Emergencies in ICD patients:
Other emergencies
Treat as usual
Emergencies in ICD patients:
Cardiac problems
Heart failure is common, treat as
usual
Myocardial infarction occurs,
treat as usual (ECG may be
paced, making it more difficult
to interpret)
Emergencies in ICD patients:
Shocks
Shocks may be
appropriate, or
inappropriate
Emergencies in ICD patients:
Shocks
Appropriate shocks
VT or VF
Emergencies in ICD patients:
Shocks
Inappropriate shocks
AF
sinus tachycardia
lead fracture
lead displacement
sensing problems
Double counting: sensing from RV & LV
Double counting: LV lead displacement
Emergencies in ICD patients:
Shocks
Patients having one or two
shocks are advised to contact
their ICD clinic within 24
hours if they feel well
Emergencies in ICD patients:
Shocks
Patients having multiple shocks
are advised to contact their
nearest CCU or 999
Emergencies in ICD patients:
Shocks
Monitoring & recording of
rhythm is important
(appropriate vs inappropriate)
If the shocks are inappropriate
the ICD can be disabled by
placing a magnet over it
Emergencies in ICD patients:
Shocks
Inappropriate shocks
AF
sinus tachycardia
lead fracture
lead displacement
sensing problems
drugs
programming
/revision
Emergencies in ICD patients:
Rhythm problems
“the ICD isn’t working”
treat rhythm problem as usual
Emergencies in ICD patients:
Cardiac arrest
“the ICD isn’t working”
If the ICD doesn’t deliver a
shock within 20 - 30 seconds,
treat as usual
If the ICD shocks, but does not
resuscitate, treat as usual
ICDs: conclusions
Many of the patients you resuscitate
should receive an ICD
Many of the patients you thrombolyse
should be assessed for an ICD
ICDs: conclusions
Patients with ICDs should be treated
in the usual way
If the ICD does not appear to be
working treat cardiac arrest in the
usual way
If the ICD is giving “inappropriate”
shocks it can be disabled with a
magnet
ICDs: conclusions
The ICD will not hurt bystanders
or those resuscitating a patient
So, don’t be concerned, and treat
the patient as normal!
RESUSCITATION FROM
VT or VF
EP REFERRAL
RVOT TACHYCARDIA,
FASCICULAR
TACHYCARDIA,
PRE EXCITED AF,
LEFT VENTRICULAR FUNCTION?
IMPAIRED
NYHA
I-III
NORMAL
BRUGADA SYNDROME,
LONG QT
NYHA IV
CONSIDER ICD
ACE I, SPIRONOLACTONE,
 BLOCKERS, DIGOXIN
ACE I, SPIRONOLACTONE,
 BLOCKERS, DIGOXIN
ACUTE ISCHAEMIA?
CORONARY ARTERY DISEASE?
ACUTE ISCHAEMIA?
CORONARY ARTERY DISEASE?
REVASCULARISATION
+ RISK FACTOR MODIFICATION,
ASA,  BLOCKERS, STATINS, etc
REVASCULARISATION
+ RISK FACTOR MODIFICATION,
ASA,  BLOCKERS, STATINS, etc
AMIODARONE
CONSIDER ICD