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