猝死的危险分层英文ppt课件

Cliquez pour modifier les styles du texte,Deuxime niveau,Click to edit Master title style,EP show June 2004,EP show,The EP show:Risk stratification for sudden death,The EP show:Risk stratificati,Risk stratification for sudden death,Risk stratification for sudden,Historical look at early markers,Began during the mid-1980s with a prospective study of about 1000 postinfarction patients,Measured 24-hour Holter recordings for ventricular premature beat frequency,Determined ejection fraction,Ascertained several other routine clinical parameters,Moss,Historical look at early marke,Historical look at early markers,Found inverse relationship between the ejection fraction and total mortality as well as sudden death,Cut point between 30%and 40%,Recent studies,including MADIT I and II,grew out of this early,work,Moss,Historical look at early marke,Serial electrophysiology testing,Mechanistically driven,Sudden death in postinfarction patients predominately due to ventricular tachycardia,If you could induce ventricular tachycardia and introduce a,drug that suppresses this,ability,you could monitor,efficacy,Gold,Serial electrophysiology testi,Reviewing CAST,Cardiac Arrhythmia Suppression Trial(CAST),Large randomized trial that looked at whether suppressing ventricular ectopy after MI reduces sudden death,Trial stopped because antiarrhythmic agents associated with increased mortality,Reviewing CASTCardiac Arrhythm,Reviewing CAST,This set the stage for moving from antiarrhythmic agents to device therapy.,Moss,Reviewing CASTThis set the st,Reviewing CAST,Could these results be related to the drugs selected?,Subsequent trials confirmed that this was not the case,Prystowsky,Reviewing CASTCould these resu,MADIT I,Would an ICD or conventional therapy improve survival in this high-risk population?,Randomly assigned 196 patients with prior MI and:,NYHA functional class 1,2,or 3,A left ventricular ejection fraction,35%,An episode of asymptomatic unsustained ventricular tachycardia,Inducible,nonsuppressible ventricular tachyarrhythmia on electrophysiologic study,MADIT IWould an ICD or convent,MADIT I findings,Group,Total deaths,Cardiac deaths,Defibrillator,15,11,Conventional therapy,39,27,*,Average 27-month follow-up,MADIT I findingsGroupTotal dea,MADIT I,In high-risk patients with prior MI,prophylactic therapy with an ICD leads to improved survival compared with conventional medical therapy,MADIT IIn high-risk patients w,MUSTT,Multicenter Unsustained Tachycardia Trial(MUSTT),a randomized controlled trial,Can electrophysiologically guided antiarrhythmic therapy reduce the risk of sudden death?,Looked at coronary artery disease patients with a left ventricular ejection fraction,40%and asymptomatic unsustained ventricular tachycardia,MUSTTMulticenter Unsustained,MUSTT,End point,Cardiac arrest or arrhythmia death,EP-guided therapy(%),25,No antiarrhythmic therapy(%),32,Relative risk,0.73,95%CI,0.53-0.99,MUSTTEnd pointCardiac arrest o,MUSTT,Therapy with implantable defibrillators,but not with antiarrhythmic drugs,reduces the risk of sudden death in high-risk patients with coronary disease,MUSTTTherapy with implantable,Unsustained VT,I think its a relatively weak risk stratifier.And as you point out,it was both frustrating and cumbersome.,Gold,Unsustained VTI think its a,MADIT II,Randomized trial evaluating the effect of an implantable defibrillator on survival,1232 patients with prior MI and a left ventricular ejection fraction of,120 milliseconds and that they would revisit this when SCD-HeFT data were presented.,Moss,MADIT II and CMSThey took a c,SCD-HeFT,Sudden Cardiac Death in Heart Failure Trial(SCD-HeFT),Largest of the trials involving ICD therapy with a longer patient follow-up than previous studies,SCD-HeFTSudden Cardiac Death i,SCD-HeFT,Compared all-cause mortality in 2500 patients,With NYHA class 2 to 3 HF,LVEF,35%,Patients randomized to receive ICD,amiodarone,or placebo on top of standard medical therapy,SCD-HeFTCompared all-cause mor,SCD-HeFT all-cause mortality,SCD-HeFT all-cause mortality,SCD-HeFT,ICD cuts all-cause mortality by 23%in NYHA class 2 to 3 heart failure,SCD-HeFTICD cuts all-cause mor,Whats a payer to do?,The trials were designed specifically to answer the major question of defibrillators and their role to reduce total mortality.I think the trials,as you point out,are concordant in that regard,and I think that it would be reasonable that that would be an indication,for paying.,Gold,Whats a payer to do?The tria,Whats a payer to do?,Getting into subsets when its not really prespecified thats what youre looking for is potentially very treacherous and can be misleading.,Moss,Whats a payer to do?Getting,The future,Many have become cynical as noninvasive test after noninvasive test failed to live up to its expectations,But I remain optimistic,Gold,The futureMany have become cyn,Question,Are there patients in MADIT II who are:,Too healthy to benefit from an ICD?,Too sick for one?,Prystowsky,QuestionAre there patients i