Background: The value of an implantable cardioverter defibrillator(ICD) for primary prevention in dilated cardiomyopathy(DCM) is unclear, as randomized trials could not show a survival benefit compared to drug therapy...Background: The value of an implantable cardioverter defibrillator(ICD) for primary prevention in dilated cardiomyopathy(DCM) is unclear, as randomized trials could not show a survival benefit compared to drug therapy. It has not been investigated if patients with a very poor left ventricular function(LVEF) could profit from an ICD. Methods: Consecutive patients with DCM who received an ICD between December 1996 and November 2003 were included in this analysis. Patients were divided in group A(secondary prevention) and group B(primary prevention). Both groups were stratified in subgroups with left ventricular ejection fraction(LVEF) below and above 20% . Results: Fifty eight patients were included(male 50, age 56.4± 12.7 years). Follow-up was 34± 19 months. There was no difference regarding death(18% vs. 11% ), but significant differences(p value< 0.05) regarding any adverse events(55% vs. 22% ), any ICD intervention(48% vs. 17% ) and ICD interventions for life-threatening arrhythmias(27% vs. 0% )between group A and B. LVEF was not predictive for events in group A, whereas in group B only patients with a LVEF< 20% had events(p value 0.02). Over time there was an increase of the LVEF of more than 15% determined by echocardiography in 36% of patients, significantly more often in group B. Conclusions: Indication for primary prevention with an ICD in DCM should be made with caution. Larger studies are needed to determine if patients with LVEF of< 20% might benefit from an ICD.展开更多
Background: Indications for implantable cardioverter defibrillator(ICD) implantation are expanding, but many primary and secondary ICD trials have excluded patients with advanced renal insufficiency. We investigated t...Background: Indications for implantable cardioverter defibrillator(ICD) implantation are expanding, but many primary and secondary ICD trials have excluded patients with advanced renal insufficiency. We investigated the effect of renal function on the incidence and time to first appropriate ICD shock. Method: We analyzed data from all new ICD implantations at a tertiary care center from July 2001 to December 2002. Results: During a mean follow-up time of 445±285 days, 29(13%) of 230 patients(age 63±14 years, 79%men, 77%white, 75%coronary artery disease, left ventricular ejection fraction 0.28±0.14) received 41 appropriate shocks. Patients were divided into tertiles according to their serum creatinine level. The 1-year incidence of appropriate ICD shock was 3.8%, 10.8%, and 22.7%in the first, second, and third tertiles, respectively(P=.003). Using the same cut off values of serum creatinine, the 1-year incidence of appropriate ICD therapy(shock and antitachycardia pacing)was 8.8%, 20.8%, and 26.3%(P=.02). After correcting for age, sex, race, left ventricular ejection fraction, indication for ICD implantation, and use of β-blockers in a Cox regression model, serum creatinine was still an independent predictor of the time to first appropriate ICD shock(hazard ratio 6.0 for the third compared with the first tertile, P=.001). Conclusion: Renal insufficiency is a strong predictor of appropriate ICD shocks. Defibrillator therapy should therefore not be withheld based on the presence of this comorbidity. The mechanisms underlying the relationship between renal function and ventricular arrhythmias deserve further investigation.展开更多
The utility of programmed ventricular stimulation to predict future arrhythmic events in patients with cardiac sarcoidosis is unknown. Similarly, the long-term benefit of implantable cardioverter-defibrillators(ICDs) ...The utility of programmed ventricular stimulation to predict future arrhythmic events in patients with cardiac sarcoidosis is unknown. Similarly, the long-term benefit of implantable cardioverter-defibrillators(ICDs) in cardiac sarcoidosis has not been established. Thirty-two consecutive patients with cardiac sarcoidosis underwent programmed ventricular stimulation. Patients with spontaneous or inducible sustained ventricular arrhythmias(n=12) underwent ICD insertion. All study patients were followed for the combined arrhythmic event end point of appropriate ICD therapies or sudden death. Mean length of follow-up to sustained ventricular arrhythmia or sudden death was 32±30 months. Five of 6 patients(83%) with spontaneous sustained ventricular arrhythmias and 4 of 6 patients(67%) without spontaneous but with inducible sustained ventricular arrhythmias received appropriate ICD therapy. Two of 20 patients(10%) with neither spontaneous nor inducible sustained ventricular arrhythmias experienced sustained ventricular arrhythmias or sudden death. Programmed ventricular stimulation predicted subsequent arrhythmic events in the entire population(relative hazard 4.47, 95%confidence interval[CI] 1.30 to 15.39) and in patients who presented without spontaneous sustained ventricular arrhythmias(relative hazard 6.97, 95%CI 1.27 to 38.27). No patient with an ICD died of a primary arrhythmic event. In patients with spontaneous or inducible sustained ventricular arrhythmias, mean survival from first appropriate ICD therapy to death or cardiac transplant was 60±46 months, with only 2 patients dying or reaching transplant at study end. In conclusion, programmed ventricular stimulation identifies patients with cardiac sarcoidosis at high risk for future arrhythmic events. ICDs effectively terminate life-threatening arrhythmias in high-risk patients, with significant survival after first appropriate therapy.展开更多
文摘Background: The value of an implantable cardioverter defibrillator(ICD) for primary prevention in dilated cardiomyopathy(DCM) is unclear, as randomized trials could not show a survival benefit compared to drug therapy. It has not been investigated if patients with a very poor left ventricular function(LVEF) could profit from an ICD. Methods: Consecutive patients with DCM who received an ICD between December 1996 and November 2003 were included in this analysis. Patients were divided in group A(secondary prevention) and group B(primary prevention). Both groups were stratified in subgroups with left ventricular ejection fraction(LVEF) below and above 20% . Results: Fifty eight patients were included(male 50, age 56.4± 12.7 years). Follow-up was 34± 19 months. There was no difference regarding death(18% vs. 11% ), but significant differences(p value< 0.05) regarding any adverse events(55% vs. 22% ), any ICD intervention(48% vs. 17% ) and ICD interventions for life-threatening arrhythmias(27% vs. 0% )between group A and B. LVEF was not predictive for events in group A, whereas in group B only patients with a LVEF< 20% had events(p value 0.02). Over time there was an increase of the LVEF of more than 15% determined by echocardiography in 36% of patients, significantly more often in group B. Conclusions: Indication for primary prevention with an ICD in DCM should be made with caution. Larger studies are needed to determine if patients with LVEF of< 20% might benefit from an ICD.
文摘Background: Indications for implantable cardioverter defibrillator(ICD) implantation are expanding, but many primary and secondary ICD trials have excluded patients with advanced renal insufficiency. We investigated the effect of renal function on the incidence and time to first appropriate ICD shock. Method: We analyzed data from all new ICD implantations at a tertiary care center from July 2001 to December 2002. Results: During a mean follow-up time of 445±285 days, 29(13%) of 230 patients(age 63±14 years, 79%men, 77%white, 75%coronary artery disease, left ventricular ejection fraction 0.28±0.14) received 41 appropriate shocks. Patients were divided into tertiles according to their serum creatinine level. The 1-year incidence of appropriate ICD shock was 3.8%, 10.8%, and 22.7%in the first, second, and third tertiles, respectively(P=.003). Using the same cut off values of serum creatinine, the 1-year incidence of appropriate ICD therapy(shock and antitachycardia pacing)was 8.8%, 20.8%, and 26.3%(P=.02). After correcting for age, sex, race, left ventricular ejection fraction, indication for ICD implantation, and use of β-blockers in a Cox regression model, serum creatinine was still an independent predictor of the time to first appropriate ICD shock(hazard ratio 6.0 for the third compared with the first tertile, P=.001). Conclusion: Renal insufficiency is a strong predictor of appropriate ICD shocks. Defibrillator therapy should therefore not be withheld based on the presence of this comorbidity. The mechanisms underlying the relationship between renal function and ventricular arrhythmias deserve further investigation.
文摘The utility of programmed ventricular stimulation to predict future arrhythmic events in patients with cardiac sarcoidosis is unknown. Similarly, the long-term benefit of implantable cardioverter-defibrillators(ICDs) in cardiac sarcoidosis has not been established. Thirty-two consecutive patients with cardiac sarcoidosis underwent programmed ventricular stimulation. Patients with spontaneous or inducible sustained ventricular arrhythmias(n=12) underwent ICD insertion. All study patients were followed for the combined arrhythmic event end point of appropriate ICD therapies or sudden death. Mean length of follow-up to sustained ventricular arrhythmia or sudden death was 32±30 months. Five of 6 patients(83%) with spontaneous sustained ventricular arrhythmias and 4 of 6 patients(67%) without spontaneous but with inducible sustained ventricular arrhythmias received appropriate ICD therapy. Two of 20 patients(10%) with neither spontaneous nor inducible sustained ventricular arrhythmias experienced sustained ventricular arrhythmias or sudden death. Programmed ventricular stimulation predicted subsequent arrhythmic events in the entire population(relative hazard 4.47, 95%confidence interval[CI] 1.30 to 15.39) and in patients who presented without spontaneous sustained ventricular arrhythmias(relative hazard 6.97, 95%CI 1.27 to 38.27). No patient with an ICD died of a primary arrhythmic event. In patients with spontaneous or inducible sustained ventricular arrhythmias, mean survival from first appropriate ICD therapy to death or cardiac transplant was 60±46 months, with only 2 patients dying or reaching transplant at study end. In conclusion, programmed ventricular stimulation identifies patients with cardiac sarcoidosis at high risk for future arrhythmic events. ICDs effectively terminate life-threatening arrhythmias in high-risk patients, with significant survival after first appropriate therapy.
