ABSTRACT
BACKGROUND: Antitachycardia pacing (ATP) is routinely used to terminate ventricular tachyarrhythmias (VTs). However, little guidance exists on the most effective programming of ATP. OBJECTIVE: This study evaluated whether additional ATP sequences are more effective in reducing implantable cardioverter-defibrillator shocks. METHODS: In patients from the Shock-Less study, the number of overall shocks were compared between patients programmed to ≤3 ATP sequences (VT zone) and ≤1 ATP sequence (fast ventricular tachycardia [FVT] zone) (nominal group) and patients programmed to receive additional ATP sequences in VT (>3) or FVT (>1) zones. RESULTS: Of the 4112 patients (15% receiving secondary prevention; 77% men; mean age 65.9 ± 12.6 years), 1532 patients (37%) were programmed with additional ATP sequences (1025 with >3 ATP sequences in the VT zone; 699 patients with >1 ATP sequence in the FVT zone). Over a mean follow-up period of 19.6 ± 10.7 months, 4359 VT/FVT episodes occurred in 591 patients. Compared with the nominal group, in patients with additional ATP programming, there was a 39% reduction in the number of shocked VT episodes (0.46 episodes per patient-year vs 0.28 episodes per patient-year; incidence rate ratio [IRR] 0.61; P < .001) and a 44% reduction in the number of shocked FVT episodes (0.83 episodes per patient-year vs 0.47 episodes per patient-year; IRR 0.56; P < .001). The reduction in shocked VT episodes was observed in both primary (IRR 0.68; 95% confidence interval 0.51-0.90; P = .007) and secondary (IRR 0.51; 95% confidence interval 0.35-0.72; P < .001) prevention patients. CONCLUSION: Programming more than the nominal number of ATP sequences in both the VT and FVT zones is associated with a lower occurrence of implantable cardioverter-defibrillator shocks in clinical practice.
Subject(s)
Arrhythmias, Cardiac/therapy , Defibrillators, Implantable/standards , Electric Countershock/standards , Heart Rate/physiology , Secondary Prevention/methods , Aged , Equipment Design , Female , Follow-Up Studies , Humans , Male , Prospective Studies , Treatment OutcomeABSTRACT
BACKGROUND: Implantable cardioverter-defibrillator (ICD) shocks are associated with increased anxiety, health care utilization, and potentially mortality. OBJECTIVE: The purpose of the Shock-Less Study was to determine if providing feedback reports to physicians on their adherence to evidence-based shock reduction programming could improve their programming behavior and reduce shocks. METHODS: Shock-Less enrolled primary prevention (PP) and secondary prevention (SP) ICD patients between 2009 and 2012 at 118 study centers worldwide and followed patients longitudinally after their ICD implant. Center-specific therapy programming reports (TPRs) were delivered to each center 9 to 12 months after their first enrollment. The reports detailed adherence to evidence-based programming targets: number of intervals to detect ventricular fibrillation (VF NID), longest treatment interval (LTI), supraventricular tachycardia (SVT) discriminators (Wavelet, PR Logic), SVT limit, Lead Integrity Alert (LIA), and antitachycardia pacing (ATP). Clinicians programmed ICDs at their discretion. The primary outcome measure was the change in utilization of evidence-based shock reduction programming before (phase I, n = 2694 patients) and after initiation of the TPR (phase II, n = 1438 patients). RESULTS: Patients implanted after feedback reports (phase II) were up to 20% more likely to have their ICDs programmed in line with evidence-based shock reduction programming (eg, VF NID in PP patients 30/40 in 33.5% vs 18.6%, P < .0001). Patients implanted in phase II had a lower risk of all-cause shock (adjusted hazard ratio 0.72, 95% confidence interval 0.58-0.90, P = .003). CONCLUSION: Providing programming feedback reports improves adherence to evidence-based shock reduction programming and is associated with lower risk of ICD shocks.
Subject(s)
Cardiac Resynchronization Therapy Devices/adverse effects , Defibrillators, Implantable/adverse effects , Electric Countershock/statistics & numerical data , Syncope/prevention & control , Tachycardia, Supraventricular/therapy , Ventricular Fibrillation/therapy , Aged , Aged, 80 and over , Evidence-Based Medicine , Feedback , Female , Follow-Up Studies , Humans , Incidence , Male , Middle Aged , Primary Prevention/statistics & numerical data , Secondary Prevention/statistics & numerical data , Syncope/etiology , Tachycardia, Supraventricular/physiopathology , Tachycardia, Supraventricular/prevention & control , Treatment Outcome , Ventricular Fibrillation/physiopathology , Ventricular Fibrillation/prevention & controlABSTRACT
AIMS: This cross-sectional study evaluated the application of accepted international implantable cardioverter defibrillator (ICD) guidelines for primary prevention of sudden cardiac death in patients with heart failure. METHODS AND RESULTS: The PLASMA (Probabilidad de Sufrir Muerte Arritmica) study was designed to characterize management of cardiac patients in Latin America. Twelve centres included 1958 consecutively admitted patients in cardiology units in 2008 and 2009. Discharged patients were evaluated for primary prevention, ICD indication and prescription by general cardiologists. Of 1711 discharged patients, 1525 (89%) had data available for evaluating indication status. Class I indications for ICD therapy were met for 153 (10%) patients based on collected data. Only 20 (13%, 95% confidence interval: 7.7-18.4%) patients with indication were prescribed an ICD. Patients prescribed an ICD were younger than patients who were not prescribed an ICD (62 vs. 68 years, P < 0.01). The reasons given by cardiologists for not prescribing an ICD for 133 patients with an indication were: indication criteria not met (75%), life expectancy <1 year (9.7%), rejection by the patient (5.2%), no medical coverage paying for the device (3.7%), psychiatric patient (2.2%), and other reasons (4.2%). CONCLUSIONS: In Latin America, international guidelines for primary prevention ICD implantation are not well followed. The main reason is that cardiologists believe that patients do not meet indication criteria, even though study data confirm that criteria are met. This poses a significant challenge and underlines the importance of continuous and improved medical education.
Subject(s)
Cardiology/standards , Death, Sudden, Cardiac/epidemiology , Death, Sudden, Cardiac/prevention & control , Defibrillators, Implantable/standards , Heart Failure/mortality , Practice Guidelines as Topic , Adolescent , Adult , Aged , Aged, 80 and over , Child , Cost-Benefit Analysis , Cross-Sectional Studies , Defibrillators, Implantable/economics , Defibrillators, Implantable/statistics & numerical data , Female , Heart Failure/economics , Heart Failure/therapy , Humans , Incidence , Latin America/epidemiology , Male , Middle Aged , Risk Factors , Tachycardia, Ventricular/economics , Tachycardia, Ventricular/epidemiology , Tachycardia, Ventricular/therapy , Young AdultABSTRACT
AIM: The purpose of this study was to investigate the modes of initiation of malignant ventricular tachyarrhythmias in patients with Chagas' cardiomyopathy (ChC) with an implantable cardioverter-defibrillator (ICD) through the analysis of stored intracardiac electrograms. Specifically, we analyzed the incidence of ventricular arrhythmias preceded by the short-long-short-pattern (sls). METHODS: We analyzed 179 spontaneous malignant ventricular tachyarrhythmias episodes in 15 patients with Chagas' cardiomyopathy with an ICD. The mean cycle length in normal sinus rhythm before initiation of the malignant ventricular tachyarrhythmias, the ventricular tachycardia (VT) cycle length, the prematurity ratio and the number of ventricular premature contractions (VPCs) (single, pairs or multiple) that triggered malignant ventricular tachyarrhythmias were compared between the two different initiation modes. RESULTS: Mean age: 60.4 +/- 5.7 -years-old, mean EF, 33.2 +/- 8.5%, 9 men and 6 women. A sls-pattern was found in 43.5% of the malignant ventricular tachyarrhythmias. Baseline cycle length (795 +/- 16 vs 788 +/- 14 ms), VT cycle length (320 +/- 7.7 ms vs 329 +/- 5.7 ms) and prematurity ratio (0.57 +/- 11 vs 0.60 +/- 12) were similar between sls and non-sls-sequences. Multiple VPCs as a trigger of malignant ventricular tachyarrhythmias was significantly less often in sls-events than in non-sls events (14% vs 40%; P < 0.0001). CONCLUSIONS: In this select population of patients with ChC, we observed a high prevalence of sls-pattern just before initiation of malignant ventricular tachyarrhythmias. Multiple VPCs were often associated with a non-sls trigger mode.
Subject(s)
Chagas Cardiomyopathy/therapy , Defibrillators, Implantable , Tachycardia, Ventricular/therapy , Chagas Cardiomyopathy/physiopathology , Electrocardiography , Female , Humans , Male , Middle Aged , Retrospective Studies , Tachycardia, Ventricular/physiopathologyABSTRACT
AIM: The purpose of this study was to investigate the modes of initiation of malignant ventricular tachyarrhythmias in patients with Chagas' cardiomyopathy (ChC) with an implantable cardioverter-defibrillator (ICD) through the analysis of stored intracardiac electrograms. Specifically, we analyzed the incidence of ventricular arrhythmias preceded by the short-long-short-pattern (sls). METHODS: We analyzed 179 spontaneous malignant ventricular tachyarrhythmias episodes in 15 patients with Chagas' cardiomyopathy with an ICD. The mean cycle length in normal sinus rhythm before initiation of the malignant ventricular tachyarrhythmias, the ventricular tachycardia (VT) cycle length, the prematurity ratio and the number of ventricular premature contractions (VPCs) (single, pairs or multiple) that triggered malignant ventricular tachyarrhythmias were compared between the two different initiation modes. RESULTS: Mean age: 60.4 +/- 5.7 -years-old, mean EF, 33.2 +/- 8.5%, 9 men and 6 women. A sls-pattern was found in 43.5% of the malignant ventricular tachyarrhythmias. Baseline cycle length (795 +/- 16 vs 788 +/- 14 ms), VT cycle length (320 +/- 7.7 ms vs 329 +/- 5.7 ms) and prematurity ratio (0.57 +/- 11 vs 0.60 +/- 12) were similar between sls and non-sls-sequences. Multiple VPCs as a trigger of malignant ventricular tachyarrhythmias was significantly less often in sls-events than in non-sls events (14% vs 40%; P < 0.0001). CONCLUSIONS: In this select population of patients with ChC, we observed a high prevalence of sls-pattern just before initiation of malignant ventricular tachyarrhythmias. Multiple VPCs were often associated with a non-sls trigger mode.
Subject(s)
Female , Humans , Male , Middle Aged , Chagas Cardiomyopathy , Defibrillators, Implantable , Tachycardia, Ventricular , Chagas Cardiomyopathy , Electrocardiography , Retrospective Studies , Tachycardia, VentricularSubject(s)
Humans , Arrhythmias, Cardiac , Bundle-Branch Block , Death, Sudden, Cardiac , Defibrillators, Implantable , Risk Factors , SyndromeABSTRACT
Los cardiodesfibriladores son una terapéutica eficaz en el tratamiento de las arritmias ventriculares malignas. Nuestro trabajo tiene por objetivo valorar si los teléfonos celulares de tipo analógico (disponibles en nuestro país) producen interferencia electromagnética clínicamente significativa en pacientes con dispositivos implantables. Se evaluaron 25 pacientes portadores de cardiodesfibriladores y sólo un paciente presentó interferencia electromagnética sin repercusión clínica manifiesta por ausencia de registro en el marcador de canales y en el electrograma endocavitario. Se concluye que los teléfonos celulares producen interferencia electromagnética en los cardiodesfibriladores, pero sólo en ocasiones particulares podrían tener relevancia clínica. Asimismo se recomienda llevar y utilizar los teléfonos del lado contralateral al del implante
Subject(s)
Humans , Defibrillators, Implantable , Electromagnetic Fields , TelephoneABSTRACT
Los cardiodesfibriladores son una terapéutica eficaz en el tratamiento de las arritmias ventriculares malignas. Nuestro trabajo tiene por objetivo valorar si los teléfonos celulares de tipo analógico (disponibles en nuestro país) producen interferencia electromagnética clínicamente significativa en pacientes con dispositivos implantables. Se evaluaron 25 pacientes portadores de cardiodesfibriladores y sólo un paciente presentó interferencia electromagnética sin repercusión clínica manifiesta por ausencia de registro en el marcador de canales y en el electrograma endocavitario. Se concluye que los teléfonos celulares producen interferencia electromagnética en los cardiodesfibriladores, pero sólo en ocasiones particulares podrían tener relevancia clínica. Asimismo se recomienda llevar y utilizar los teléfonos del lado contralateral al del implante (AU)
Subject(s)
Humans , Defibrillators, Implantable , Electromagnetic Fields , Telephone/statistics & numerical dataABSTRACT
La Sociedad Argentina de Cardiología implementó un programa de educación a distancia. El análisis poblacional de los 459 médicos que participaron del mismo durante el primer año evidenció la necesidad de educación médica contínua. El antecedente de residencia médica, al igual que la actividad asistencial, marcaron una metodología hacia el aprendizaje, particularmente en la población más joven del país
Subject(s)
Humans , Adult , Middle Aged , Cardiology/education , Education, Medical, Continuing , Educational TechnologyABSTRACT
La Sociedad Argentina de Cardiología implementó un programa de educación a distancia. El análisis poblacional de los 459 médicos que participaron del mismo durante el primer año evidenció la necesidad de educación médica contínua. El antecedente de residencia médica, al igual que la actividad asistencial, marcaron una metodología hacia el aprendizaje, particularmente en la población más joven del país (AU)
Subject(s)
Humans , Adult , Middle Aged , Aged , Cardiology/education , Education, Medical, Continuing , Educational TechnologyABSTRACT
El objetivo del presente estudio fue valorar la utilidad del tilt test en pacientes con síncope de origen desconocido. Entre enero de 1994 y setiembre de 1995 se realizó tilt test a 93 pacientes, edad promedio 59 años, 46 por ciento de sexo masculino, con diagnóstico de síncope de origen desconocido y a 30 sujeitos control, edad promedio 53 años, 50 por ciento de sexo masculino. El estudio consistió en una primera etapa de reposo en decúbito dorsal de 15 minutos para obtener parámetros basalaes y una segunda etapa de inclinación a 80 grados durante 30 minutos. La tensión arterial (TA) y la frecuencia cardíaca fueron monitoreadas cada minuto durante el procedimento. El test se consideró positivo cuando el paciente presentaba caída de la TA sistólica > 30 mmHg. (vasodepresor), bradiasistolia (cardioinhibidor), o respuesta mixta, acompañada de síntomas. El tilt test fue positivo en 31 de 93 pacientes. (33 por ciento). Diecisiete pacientes (55 por ciento) presentaron respuesta vasodepresora, 3 pacientes (9 por ciento) cardioinhibitoria y 11 pacientes (36 por ciento) respuesta mixta. Los síntomas fueron presíncope en el 62 por ciento, síncope en el 19 por ciento y en los restantes pacientes. (19 por ciento), mareos, disnea o pérdida del equilibrio. Todos los pacientes se recuperaron en forma espontánea al retornar a la posición supina. Ningún sujeto del grupo control desarrolló respuesta anormal o síntomas durante el estudio (sensibilidad: 33 por ciento y Especificidad: 100 por ciento). Se concluye due el tilt test es un método diagnóstico seguro y efectivo para identificar el sustrato neurocardiogénico en pacientes con diagnóstico de síncope de origen desconocido.
Subject(s)
Adult , Aged , Female , Humans , Middle Aged , Adolescent , Syncope/diagnosis , Tilt-Table Test/methods , Aged, 80 and overABSTRACT
El objetivo del presente estudio fue valorar la utilidad del tilt test en pacientes con síncope de origen desconocido. Entre enero de 1994 y setiembre de 1995 se realizó tilt test a 93 pacientes, edad promedio 59 años, 46 por ciento de sexo masculino, con diagnóstico de síncope de origen desconocido y a 30 sujeitos control, edad promedio 53 años, 50 por ciento de sexo masculino. El estudio consistió en una primera etapa de reposo en decúbito dorsal de 15 minutos para obtener parámetros basalaes y una segunda etapa de inclinación a 80 grados durante 30 minutos. La tensión arterial (TA) y la frecuencia cardíaca fueron monitoreadas cada minuto durante el procedimento. El test se consideró positivo cuando el paciente presentaba caída de la TA sistólica > 30 mmHg. (vasodepresor), bradiasistolia (cardioinhibidor), o respuesta mixta, acompañada de síntomas. El tilt test fue positivo en 31 de 93 pacientes. (33 por ciento). Diecisiete pacientes (55 por ciento) presentaron respuesta vasodepresora, 3 pacientes (9 por ciento) cardioinhibitoria y 11 pacientes (36 por ciento) respuesta mixta. Los síntomas fueron presíncope en el 62 por ciento, síncope en el 19 por ciento y en los restantes pacientes. (19 por ciento), mareos, disnea o pérdida del equilibrio. Todos los pacientes se recuperaron en forma espontánea al retornar a la posición supina. Ningún sujeto del grupo control desarrolló respuesta anormal o síntomas durante el estudio (sensibilidad: 33 por ciento y Especificidad: 100 por ciento). Se concluye due el tilt test es un método diagnóstico seguro y efectivo para identificar el sustrato neurocardiogénico en pacientes con diagnóstico de síncope de origen desconocido. (AU)
