impantable cardioverter defibrillators (icds) janet mccomb freeman hospital newcastle upon tyne

IMPANTABLE CARDIOVERTER

DEFIBRILLATORS (ICDs)Janet McComb

Freeman Hospital

Newcastle upon Tyne

“Chain of Survival”Cummins et al Circulation 1991;83:1832-1847.

rapid access

“Chain of Survival”Cummins et al Circulation 1991;83:1832-1847.

Eisenberg & Mengert, NEJM, 2001;344:1304-1313

Survival to leave hospital after out of hospital cardiac arrest: effect of arrest being witnessed

4%

24%

0%

5%

10%

15%

20%

25%

30%

not witnessed witnessed

41% not witnessed

rapid access

rapid CPR

“Chain of Survival”Cummins et al Circulation 1991;83:1832-1847.

Rea et al, Circulation, 2001;104:2413-2516.

0

0.5

1

1.5

2

2.5

3

No CPR dispatcherassisted CPR

bystander CPR

Survival after out of hospital arrest: effect of early CPR

OR 1.41 [1.19-1.66]

OR 2.15 [1.85-2.50]

Holmberg et al Eur Heart J 2001;22:511-519

Survival after out of hospital arrest: effect of quality of CPR

0%2%4%6%8%

10%12%14%16%18%20%

none other lay persons policeofficers

medicalpersonnel

ambulancestaff

Eisenberg & Mengert, NEJM, 2001;344:1304-1313

Survival to leave hospital after out of hospital cardiac arrest: initial rhythm

1%

12%

6%

34%

0%

5%

10%

15%

20%

25%

30%

35%

40%

not VF VF not VF VFnot witnessed witnessed

rapid access

rapid CPR

rapid defibrillation

“Chain of Survival”Cummins et al Circulation 1991;83:1832-1847.

Rapid defibrillation

Larsen et al Ann Emerg Med

1993;22:80-84

Eisenberg & Mengert, NEJM, 2001;344:1304-1313

Survival to leave hospital after out of hospital witnessed cardiac arrest due to VF: PAD

34% 33%40%

56% 59%

0%

10%

20%

30%

40%

50%

60%

70%

1990-1999,Seattle,

Eisenberg& Mengert

Qantas,O'Rourke

et al

AmericanAirlines,

Page et al

O'Hare,Caffrey et

al

Casino,Valenzuela

et al

Survival

6.2%

10.5%

3.3%4.8%

8.4%

2.4%

0%

2%

4%

6%

8%

10%

12%

overall PPV EMS

survival neurologically intact

Capucci et al Circulation 2002;106:1065-1070

Time from call to arrival

4.8

6.2

012345678

PPV EMS

min

utes

Impact of first responder volunteers

p=0.05

Myerburg et al Circulation 2002;106:1058-1064

Hospital survivors

24.0%

10.5%

0%

5%

10%

15%

20%

25%

police AED standard EMS

Survival to leave hospital after out of hospital witnessed VF: Impact of AEDs in police cars

Time from call to arrival

6.2

7.6

0

2

4

6

8

10

police AED standard EMS

min

utes

time from call to arrival

4

5

6

7

8

EMS AED

min

ute

s

survival: witnessed VF

0

10

20

30

40

50

EMS AED

% s

urvi

val t

o le

ave

hosp

ital

PiacenzaMiami-DadeGoteborg

Survival to leave hospital after out of hospital witnessed VF: Impact of PAD & AEDs in police cars

Page et al N Engl J Med 2000;343:1210

VF in 14 of 99 who had lost consciousness (and had an ECG recorded)6 (40%) survived to leave hospital

Eisenberg & Mengert, NEJM, 2001;344:1304

home 71%

nursing home 8%

public place 21%

Survival to leave hospital after cardiac arrest

3.7%

4.5%

6.0%

6.0%

6.1%

6.2%

6.2%

6.7%

7.6%

9.6%

12.4%

15.1%

0% 5% 10% 15% 20%

Paris 1993-1997

UK 1994-1995

Miami-Dade Co 1997-1999

West Yorkshire 1987-1997

Nottingham 1991-1994

Piacenza EMS 1999-2001

Maastricht 1991-1994

Scotland 1988-1994

Miami-Dade Co 1999-2001

Piacenza AED 1999-2001

Seattle 1989-1998

King Co 1983-2000

rapid access

rapid CPR

rapid defibrillation

“Chain of Survival”Cummins et al Circulation 1991;83:1832-1847.

11 seconds

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

The ICD comprises

RA lead

LV lead

RV leads

62 cc

Dual-chamber

35-Joule output

Active Can® electrode

Mortality reduction in ICD trials

54% 51%

31%

73%

39%

20%

38%

0%

10%

20%

30%

40%

50%

60%

70%

80%

MADIT MUSTT MADITII

Dutch AVID CIDS CASH

rela

tive

ris

k re

duct

ion

in

mor

talt

y

Primary prevention Secondary prevention

Myerberg et al Am J Cardiol 1997;80:10F-19F

10

20

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!

BRUGADA SYNDROME,LONG QT

LEFT VENTRICULAR FUNCTION?

RESUSCITATION FROM VT or VF

REVASCULARISATION + RISK FACTOR MODIFICATION, ASA, BLOCKERS, STATINS, etc

NORMAL

ACUTE ISCHAEMIA?CORONARY ARTERY DISEASE?

RVOT TACHYCARDIA, FASCICULAR TACHYCARDIA,PRE EXCITED AF,

CONSIDER ICD

NYHA IV

ACE I, SPIRONOLACTONE, BLOCKERS, DIGOXIN

NYHA I-III

AMIODARONE

REVASCULARISATION + RISK FACTOR MODIFICATION, ASA, BLOCKERS, STATINS, etc

ACUTE ISCHAEMIA?CORONARY ARTERY DISEASE?

ACE I, SPIRONOLACTONE, BLOCKERS, DIGOXIN

IMPAIRED

CONSIDER ICD

EP REFERRAL