goals of management - monterey, ca · 674 high-risk patients with recent mi 6-40 days lvef ≤35%...

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Electrophysiology and the Electrophysiology and the Management of CHFManagement of CHFManagement of CHFManagement of CHF

Byron K. Lee MDAssociate ProfessorDirector of EP [email protected]

Division of CardiologyCardiac Electrophysiology

1414thth Monterey Bay Heart SymposiumMonterey Bay Heart Symposium

May 3May 3--4, 20134, 2013

Goals of Management

• Do no harm

• Prolong life

• Improve quality of life

Do No Harm:76 yo man with fatigue, DOE, and intermittent lightheadedness

• PMH

– s/p PCI 5 years ago

– AFib

• Meds

– Toprol XL (only 25 daily because of bradycardia)

– Lipitor

– Lisinopril

– Amiodarone

• HR 48 (55 at last visit)

• BP 120/50

• ECG shows SB at 50

22

Ambulatory ECG Monitor

44

76 yo man with fatigue, DOE, and intermittent lightheadedness

• After PPM implanted

– Significant improvement of symptoms

• Fatigue, DOE, and LH have resolved

• 3 years after PPM

N ti d li i f ti l t t– Notices decline in functional status

• 5 years after PPM

– Fatigue, DOE are back to previous levels

ECG

33

DAVID Trial

JAMA 2002JAMA 2002

DAVID TrialInclusion CriteriaInclusion Criteria

Referred for ICDReferred for ICD

EF <40% (90% NYHA Class I and Class II patients)EF <40% (90% NYHA Class I and Class II patients)

No indication for pacingNo indication for pacing

No persistent atrial arrhythmiasNo persistent atrial arrhythmias

DAVID Trial ResultsComposite:Composite:

VVI 16.1%VVI 16.1%

DDDR 26.7%DDDR 26.7%

HF HF HospHosp::

VVI 13.3%VVI 13.3%


Mortality:Mortality:

VVI 6.5%VVI 6.5%


44

RV Pacing Creates Dyssynchrony

RV pacingRV pacing

LBBBLBBB

Sinus Sinus nodenode •• Delayed lateral wall Delayed lateral wall

contractioncontraction

Di i d i lDi i d i l

MechanismsMechanisms

Effects of Effects of DyssynchronyDyssynchrony from Pacing or from Pacing or LBBBLBBB

AVAV

nodenode

•• Disorganized ventricular Disorganized ventricular contractioncontraction

•• Decreased pumping Decreased pumping efficiencyefficiency

Conduction Conduction blockblock

Abnormal wall motionAbnormal wall motion

HealthyHealthy DyssynchronyDyssynchrony


Ventricular Ventricular DysynchronyDysynchrony

Courtesy of C. Stellbrink, MD.Courtesy of C. Stellbrink, MD.

55

Do No Harm:

• RV pacing is harmful

• Mechanism of harm is the creation of dyssynchrony

R d i t id RV i• Reprogram device to avoid RV pacing– Prolong AV delay

– Special Algorithms (ie MVP)

• Consider Upgade to a BiV device

Prolong Life:67 year old male presents with three hours of sub-sternal chest pain

• Chest pain disappeared for 6 hours prior to admission

• No prior cardiac history

• Arrives to the hospital after with

• Risk factors:

– 2 packs of cigarettes per day

– Hypertension

EKG Tracing

66

LAD Total Occlusion

Post PCI

Left Ventricular Cineangiogram

Ejection Fraction (EF) = 26%

77

The patient does well post PCI. He is started on ACE Inhibitor, Beta Blocker, Coumadin, and Diuretic.

On monitor, NSVT is seen.

• A. ICD before discharge

• B. No ICD before discharge

DINAMIT674 high-risk patients with recent MI 6-40 days

LVEF ≤35%

Evidence of impaired cardiac autonomic modulation

(poor HR variability or mean HR above 80)

Randomized, open-label, multicenter

674 high-risk patients with recent MI 6-40 days

LVEF ≤35%

Evidence of impaired cardiac autonomic modulation

(poor HR variability or mean HR above 80)

Randomized, open-label, multicenter

NEJM December 9, 2004NEJM December 9, 2004

ICD TherapyProphylactic implantable

cardioverter defibrillator (ICD)

n=332

ICD TherapyProphylactic implantable

cardioverter defibrillator (ICD)

n=332

Endpoints (2.5 years):All-cause mortality adjudicated by blinded committee

Endpoints (2.5 years):All-cause mortality adjudicated by blinded committee

No ICD Therabyn=342

No ICD Therabyn=342

DINAMIT Trial

Hohnloser, Hohnloser, et alet al. DINAMIT Trial . DINAMIT Trial NEJMNEJM 20042004

88

DINAMIT Trial


DINAMIT Trial


Vest prevention of Early Vest prevention of Early S dd D th T i lS dd D th T i l

UCUCSFSF

Cardiac ElectrophysiologyCardiac Electrophysiology

UCSFUCSFEpidemiology & Epidemiology &

BiostatisticsBiostatistics

Sudden Death TrialSudden Death Trial(VEST Trial)(VEST Trial)

Sponsor: Sponsor: ZollZollCoordinating Center: UCSFCoordinating Center: UCSF

PI: Jeffery PI: Jeffery OlginOlginCoCo--PI: Byron LeePI: Byron Lee

99

Wearable Defibrillator Vest

Patient is now three months post-MI. EF still only 25%. On ACE Inhibitor, Beta Blocker, Coumadin, and Diuretic.

A ICD• A. ICD

• B. No ICD

MADIT II: Protocol

NONINVASIVE EVALUATION OF LV FUNCTION

ELIGIBLE PATIENTS

RICD

n = 742CONTROL

n = 490

20 MONTH F/Uoptimal medical Rx

R

Moss AJ. N Engl J Med. 2002;346:877-83.

1010

MADIT II: Mortality by Group

Trial stopped early

at 20 months

Mortality Reduction

• Absolute = 5.6%

• Relative = 31.0%

14.2%

19.8%

15.0%

20.0%

25.0%

n = 742 490ICD Conventional

0.0%

5.0%

10.0%

Moss AJ. N Engl J Med. 2002;346:877-83.

1111

JT is a 76 yo man who is status-post MI. Current EF is 29%. He is told by his internist, his cardiologist, and an electrophysiologist that he needs an ICD to prevent SCD. He doesn’t want the ICD and comes to you for a fourth opinion.

• A Tell him that he needs an ICD

• B Tell him that he does not need an ICD

MADIT II: Time since MI

Wilbur et al. Circulation 2004Wilbur et al. Circulation 2004

1212

Prolong Life:

• For patients

– Ischemic or non-ischemic

– EF ≤35%

medically optimized– medically optimized

– not NYHA Class IV CHF

– No recent MI

• ICDs save lives

– Even if MI was remote

Myocardial Insult

Myocardial Dysfunction

Reduced System

Heart Failure’s Complex cascade


Improve Quality of Life

Renin-Angiotensin-Aldosterone System Activation

Sympathetic System Activation

Reduced System Perfusion

Altered Gene Expression Apoptosis

Remodeling

Dysynchrony

• First degree heart block

• Widened QRS

• Mechanical inefficiency and decreased cardiac output

1313

LBBB Creates Dyssynchrony

RV pacingRV pacing

LBBBLBBB

Prevalence:Ventricular Dyssynchrony

40%

50%

60%

0%

10%

20%

30%

Aaronson Lamp Shamim

• Aaronson KD et al. Circulation 1997; 95:2660-2667.• Lamp B et al. PACE 1998; 21:973 Abstract 736.• Shamim W et al. Eur Heart J. 1998; 19: Abstract 926.

• Sub-optimal contribution

f i l l

Sinusnode

Issue I–prolonged AV conduction delay


Issues Associated with Heart Failure

of atrial systole

• Limited filling period

• Mitral regurgitation AVnode

1414

Sinus node

• Delayed lateral wall contraction

• Disorganized ventricular

Issue II–delayed ventricular activation


Issues Associated with Heart Failure

AVnode

contraction• Decreased pumping

efficiency

Conduction block

Cardiac Resynchronization Therapy ICD(CRT-D)

CRT Device

1515

LV Lead Placement

Before CRT

After CRT

1616

Benefits of CRT in Advanced Heart Failure

• Across studies, in HF, CRT improves

–Exercise capacity

–Quality of life

CRT t d h t f il• CRT appears to reduce heart failure hospitalizations

• Mortality benefit (COMPANION, CARE-HF)

• RBBB

• Ischemic cardiomyopathy

• NYHA IV

• Advanced age

Poor Responders to CRT

• Discordant LV lead and myocardial scar

• Female sex

• Lack of prior MI

• QRS complex duration > 150 ms

• LBBB

Super Responders to CRT

• BMI < 30 kg/m2

• Smaller LA volume index

• QRS narrowing > 40 ms with CRT

• HF Symptoms < 12 months

• LVEDV < 180 ml, LVEDD < 58 mm, LVESD <48

mmEllenbogen KA et al. JACC. 2012;59:2374-77

1717

Improve Quality of Life:HFSA CRT Guideline Update

• CRT recommended for:

– QRS ≥ 150 ms not due to RBBB with LVEF ≤ 35% and NYHA II-III

• CRT considered for:CRT considered for:

– NYHA IV (ambulatory) with QRS ≥ 150 ms and LVEF ≤ 35% despite optimal medical therapy

– NYHA II- IV (ambulatory) with QRS ≥ 120 ms but < 150 ms and LVEF ≤ 35% despite optimal medical therapy

– NYHA II- III with QRS ≥ 120 ms, atrial fibrillation and LVEF ≤ 35% despite optimal medical therapy

Stevenson WG et al. J Card Fail. 2012;18:94-106.

• Do No Harm:

– RV pacing causes heart failure

– Use pacing algorithms and BiV pacing to avoid harm

• Save Lives:

– ICDs prolong life

– Target Population:

EF ≤35%

CONCLUSIONS

• EF ≤35%

• Improve Quality of Life:

– CRT

• Improves symptoms

• Decreases all cause mortality and CV hospitalizations

– Target Population:

• NYHA Class III and IV

• EF 35%

• QRS 120ms (intrinsic or paced)

ICDs Do Save Lives

goals of management - monterey, ca · 674 high-risk patients with recent mi 6-40 days lvef ≤35%...

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