the icd and prevention of sudde death international … · outcome of hcm patients first evaluated...
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INTERNATIONAL HCM SUMMIT
Boston, MA October 2017
HYPERTROPHIC CARDIOMYOPATHY A Contemporary and Treatable Genetic Disease: Diagnosis, Heart Failure Management, and Prevention of Sudden Death
INTERNATIONAL HCM SUMMIT
HCM Summit VI
The ICD and Prevention of Sudden Death
Barry J. Maron MD HCM Institute Tufts Medical Center Boston MA.
Arrhythmogenic (Unstable) Myocardial Substrate in HCM
Sudden Death
Progressive Heart Failure
AF &
Stroke
End- Stage
Profiles in Prognosis for HCM
Benign/Stable (normal longevity)
HCM (36%)
Coronary Anomalies
(17%) M
yoca
rditi
s (6
%)
ARVC
(4%
) Aortic Rupture (3%) AS (3%)
Dilated CM (2%)
WPW (2%)
Sudden Death in Young Athletes
Maron, BJ et. al. Circulation 2009; 119:1085-1092
What Counts in HCM
Outcome
% LGE
SD Risk Factors
Apical Aneurysm
AF
Age
↓ EF
LV Obstruction
Magnitude LVH
Highest
Intermediate
Lowest
2° prevention Cardiac arrest/sustained VT
1° prevention Family history HCM-SD Unexplained syncope Multiple-repetitive NSVT (Holter) Abnormal exercise BP response LGE ≥ 15% of LV mass Massive LVH ≥ 30 mm LV apical aneurysm
Rare subgroups/potential arbitrators End-stage (EF < 50%) Marked LV outflow obstruction (rest) Modifiable Intense competitive sports CAD LGE ≥ 15% of LV mass Age ≥ 60y
Alcohol septal ablation (some pts)
ICD
2011 US/CANADA ACC/AHA Guidelines For HCM
0 2 4 6 8
10 12 14 16
<15 16-19 20-24 25-29 ≥30 Max. LV Wall Thickness (mm)
% P
atie
nts
With
SC
D
Hypertrophy Counts in HCM: Relation Between LV Thickness & SD
Spirito et al NEJM 2000;342:1778
Highest
Intermediate
Lowest
2° prevention Cardiac arrest/sustained VT
1° prevention Family history HCM-SD Unexplained syncope Multiple-repetitive NSVT (Holter) Abnormal exercise BP response LGE ≥ 15% of LV mass Massive LVH ≥ 30 mm LV apical aneurysm
Rare subgroups/potential arbitrators End-stage (EF < 50%) Marked LV outflow obstruction (rest) Modifiable Intense competitive sports CAD LGE ≥ 15% of LV mass Age ≥ 60y
Alcohol septal ablation (some pts)
ICD
2011 US/CANADA ACC/AHA Guidelines For HCM
0
10
20
30
40
50
60
70
Alive Non-CardiacDeath
Non-HCMCardiacDeath
EmbolicStroke
HeartFailure
SCD
% o
f HC
M C
ohor
t
65%
13% 12%
2% 1%
0.2%/y
Outcome of HCM Patients First Evaluated ≥ 60 Years
1%
HCM Death
Age Counts And Aging is Good in HCM
Maron ety al Circ
Maron et al Circulation 2013;127:585
TheESC-HCMpredic0onformulaforSDisasfollows:ProbabilitySCDat5years=1–0.998exp(Prognos0cindex);wherePrognos0cindex=[0.15939858xmaximalLVwallthickness(mm)]–[0.00294271xLVmaximalwallthick-ness2(mm2)]+[0.0259082xleWatrialdiameter(mm)]+[0.00446131xmaximal(rest/Valsalva)LVou[lowtractgradient(mmHg)]+[0.4583082xfamilyhistorySCD]+[0.82639195xNSVT]+[0.71650361xunexplainedsyncope]–[0.01799934xageatclinicalevalua0on(years)].
% P
atie
nts
With
/With
out
ICD
Inte
rven
tion/
Sudd
en D
eath
Appropriate ICD
Intervention
No Appropriate ICD
Intervention
ESC Risk Score
<4% <4% 4-6% 4-6% >6% >6% Risk/5y Risk/5y
<4% 4-6% >6% Risk/5y
Sudden Death
Limitations in ESC Sudden Death Risk Score (n=1649)
60%
26%
63%
9%
Maron et al AJC 2015;116:757
Prevention of Sudden Death in HCM
Dr. Michele Mirowski
N Engl J Med 1980;303:322.
ICD Performance in HCM 506
103
5.5%/y
Follow-up = 3.7 ± 3 years
ICD discharge rate
Appropriate Shocks (20%)
11%/y 4%/y
2º prevention 1º prevention
VT/VF
Maron et al JAMA 2007;298
0
1
2
3
4
5
6
7
1 2 ≥ 3
No. of Risk Factors for Primary Prevention
Rat
e of
App
ropr
iate
Inte
rven
tions
pe
r 100
per
son-
yr
3.8 3.0
4.1
Overall p=0.88
Appropriate Shocks (35%)
Maron et al JAMA 2007;298:405
ICD in HCM for Children / Adolescents
224
43
4.4% / yr
13%/yr 3%/y
No. Patients
Appropriate ICD Discharge (19%)
2° prevention 1° prevention
Follow-up= 4.3 ± 3.3 yr
Initial shock 9-23 y (mean= 17 y)
Maron et al. JACC 2013;61:1527
≤ 3 4 - 6
7 - 10 11-20
21-30 31-40 51-60
>90
Duration (months)
No.
Pat
ient
s
0 2 4 6 8
10 12 14 16
61-70 71-90
41-50
ICD in HCM: Time to First Shock
Maron et al JAMA 2007;298:405
HCM is Unpredictable
HCM—ICD Registry
29 (6%)
14
14
1
Deaths
ICD Malfunction
End-stage Embolic stroke
Cancer, sepsis, renal diseases, suicide, CAD,
accidents
No HCM
HCM
HCM- Arrhythmias
(nl EF)
Maron, BJ et. al. JAMA 2007;298:405
Expectations For HCM Patients After ICD Shocks
ICD shock
1%
0%
20%
30%
Sudden/HF Death
HF Hospitalization
HCM (@6 y)
CAD (MADIT II) @1 year:
Life-saving Prolongation of Life Maron BJ et al
In press
High risk
Some risk
Cardiologist
Patient
Autonomy
TRANSPARENCY / FULL DISCLOSURE / INFORMED CONSENT
?
Risk Factors Primary Prevention Decision Tree: ICD In HCM
Preservation of Life Recalls
Inappropriate Shocks Infection
Thrombosis
Lead Complications (5%/y)
Preservation of Life
Recalls Inappropriate Shocks
Infection Thrombosis
Lead Complications (5%/y)
Contemporary CV treatment options offer HCM patients a reasonable
aspiration for reduced mortality and extended longevity. The ICD has altered clinical course for many
patients creating the possibility of normal life expectancy even for
those @ high risk .
Decrease in Annual HCM Mortality Over 50 Years
4-6% (1975)
1.5-2.0%
0.5% (2017)
2000 (2000)