版权说明：本文档由用户提供并上传，收益归属内容提供方，若内容存在侵权，请进行举报或认领
文档简介
TheEPshow:
Riskstratificationforsuddendeath
TheEPshow:
RiskstratificatiRiskstratificationforsuddendeathRiskstratificationforsuddenHistoricallookatearlymarkersBeganduringthemid-1980swithaprospectivestudyofabout1000postinfarctionpatients
Measured24-hourHolterrecordingsforventricularprematurebeatfrequency
Determinedejectionfraction
Ascertainedseveralother
routineclinicalparametersMossHistoricallookatearlymarkeHistoricallookatearlymarkersFoundinverserelationshipbetweentheejectionfractionandtotalmortalityaswellassuddendeath
Cutpointbetween30%and40%
Recentstudies,includingMADITI
andII,grewoutofthisearlyworkMossHistoricallookatearlymarkeSerialelectrophysiologytestingMechanisticallydriven
Suddendeathinpostinfarctionpatientspredominatelyduetoventriculartachycardia
Ifyoucouldinduceventriculartachycardiaandintroduceadrugthatsuppressesthisability,youcouldmonitorefficacyGoldSerialelectrophysiologytestiReviewingCASTCardiacArrhythmiaSuppressionTrial(CAST)
LargerandomizedtrialthatlookedatwhethersuppressingventricularectopyafterMIreducessuddendeathTrialstoppedbecauseantiarrhythmicagentsassociatedwithincreasedmortalityReviewingCASTCardiacArrhythmReviewingCAST"Thissetthestageformovingfromantiarrhythmicagentstodevicetherapy."MossReviewingCAST"ThissetthestReviewingCASTCouldtheseresultsberelatedtothedrugsselected?
SubsequenttrialsconfirmedthatthiswasnotthecasePrystowskyReviewingCASTCouldtheseresuMADITIWouldanICDorconventionaltherapyimprovesurvivalinthishigh-riskpopulation?
Randomlyassigned196patientswithpriorMIand:
NYHAfunctionalclass1,2,or3
Aleftventricularejectionfraction<35%
Anepisodeofasymptomaticunsustainedventriculartachycardia
Inducible,nonsuppressibleventriculartachyarrhythmiaonelectrophysiologicstudyMADITIWouldanICDorconventMADITIfindingsGroupTotaldeathsCardiacdeathsDefibrillator1511Conventionaltherapy3927*Average27-monthfollow-up
MADITIfindingsGroupTotaldeaMADITIInhigh-riskpatientswithpriorMI,prophylactictherapywithanICDleadstoimprovedsurvivalcomparedwithconventionalmedicaltherapyMADITIInhigh-riskpatientswMUSTT
MulticenterUnsustainedTachycardiaTrial(MUSTT),arandomizedcontrolledtrial
Canelectrophysiologicallyguidedantiarrhythmictherapyreducetheriskofsuddendeath?
Lookedatcoronaryarterydiseasepatientswithaleftventricularejectionfraction<40%andasymptomaticunsustainedventriculartachycardiaMUSTT
MulticenterUnsustainedMUSTTEndpointCardiacarrestor
arrhythmiadeathEP-guided
therapy(%)25Noantiarrhythmic
therapy(%)32Relativerisk0.7395%CI0.53-0.99MUSTTEndpointCardiacarrestoMUSTTTherapywithimplantabledefibrillators,butnotwithantiarrhythmicdrugs,reducestheriskofsuddendeathinhigh-riskpatientswithcoronarydisease
MUSTTTherapywithimplantableUnsustainedVT"Ithinkit'sarelativelyweakriskstratifier.Andasyoupointout,itwasbothfrustratingandcumbersome."GoldUnsustainedVT"Ithinkit'saMADITIIRandomizedtrialevaluatingtheeffectofanimplantabledefibrillatoronsurvival
1232patientswithpriorMIandaleftventricularejectionfractionof<30%
Patientsrandomlyassignedina3:2ratiotoreceiveICDorconventionalmedicaltherapyMADITIIRandomizedtrialevaluMADITmortalityratesMADITmortalityratesMADITII"Thisreallyintroducedasimplifiedstratificationapproach."MossMADITII"ThisreallyintroduceMADITIIandCMS"TheytookaconservativepositionandsaidthattheyweregoingtoreimburseonlyforMADITIIpatientswhohadaQRSduration>120millisecondsandthattheywouldrevisitthiswhenSCD-HeFTdatawerepresented."MossMADITIIandCMS"TheytookacSCD-HeFTSuddenCardiacDeathinHeartFailureTrial(SCD-HeFT)
LargestofthetrialsinvolvingICDtherapywithalongerpatientfollow-upthanpreviousstudies
SCD-HeFTSuddenCardiacDeathiSCD-HeFTComparedall-causemortalityin
>2500patients
WithNYHAclass2to3HF
LVEF<35%
PatientsrandomizedtoreceiveICD,amiodarone,orplaceboontopofstandardmedicaltherapySCD-HeFTComparedall-causemorSCD-HeFTall-causemortality
SCD-HeFTall-causemortality
SCD-HeFTICDcutsall-causemortalityby23%in
NYHAclass2to3heartfailure
SCD-HeFTICDcutsall-causemorWhat'sapayertodo?"Thetrialsweredesignedspecificallytoanswerthemajorquestionofdefibrillatorsandtheirroletoreducetotalmortality.Ithinkthetrials,asyoupointout,areconcordantinthatregard,andIthinkthatitwouldbereasonablethatthatwouldbeanindicationforpaying."GoldWhat'sapayertodo?"ThetriaWhat'sapayertodo?"Gettingintosubsetswhenit'snotreallyprespecifiedthat'swhatyou'relookingforispotentiallyverytreacherousandcanbemisleading."MossWhat'sapayertodo?"GettingThefutureManyhavebecomecynicalasnoninvasivetestafternoninvasivetestfailedtoliveuptoitsexpectations
ButIremainoptimisticGoldThefutureManyhavebecomecynQuestionAretherepatientsinMADITIIwhoare:
"Toohealthy"tobenefitfromanICD?
"Toosick"forone?PrystowskyQuestionAretherepatientsinLatestlookatMADITIIThebenefitfromICDwasentirelyinthepatientswhocarriedoneormoreriskfactors
The20%ofthepopulationthatcarriednoriskfactorsachievednobenefitwhatsoeverMossLatestlookatMADITIIThebeSummarySeveraldecadesofresearchhaveputriskstratifierstothetest
Ejectionfractionremainssupremeasanoninvasivetest
We'veidentifiedthebenefactorsofICDtherapy
AndrealizedthatantiarrhythmicdrugstopreventsuddendeatharenotasimportantasoncethoughtSummarySeveraldecadesofreseInconclusionDespite
somanynoninvasivetestsfailingtoliveupto
expectations,
manystillshowpromiseHotoffthepress!Newsoon-to-be-publisheddatawillshowthatcombinationsofriskstratifiersmayhelppinpointpatientswhowillderivethemostandleastbenefitfromanICDPrystowskyInconclusionDespite
somanynTheEPshow:
Riskstratificationforsuddendeath
TheEPshow:
RiskstratificatiRiskstratificationforsuddendeathRiskstratificationforsuddenHistoricallookatearlymarkersBeganduringthemid-1980swithaprospectivestudyofabout1000postinfarctionpatients
Measured24-hourHolterrecordingsforventricularprematurebeatfrequency
Determinedejectionfraction
Ascertainedseveralother
routineclinicalparametersMossHistoricallookatearlymarkeHistoricallookatearlymarkersFoundinverserelationshipbetweentheejectionfractionandtotalmortalityaswellassuddendeath
Cutpointbetween30%and40%
Recentstudies,includingMADITI
andII,grewoutofthisearlyworkMossHistoricallookatearlymarkeSerialelectrophysiologytestingMechanisticallydriven
Suddendeathinpostinfarctionpatientspredominatelyduetoventriculartachycardia
Ifyoucouldinduceventriculartachycardiaandintroduceadrugthatsuppressesthisability,youcouldmonitorefficacyGoldSerialelectrophysiologytestiReviewingCASTCardiacArrhythmiaSuppressionTrial(CAST)
LargerandomizedtrialthatlookedatwhethersuppressingventricularectopyafterMIreducessuddendeathTrialstoppedbecauseantiarrhythmicagentsassociatedwithincreasedmortalityReviewingCASTCardiacArrhythmReviewingCAST"Thissetthestageformovingfromantiarrhythmicagentstodevicetherapy."MossReviewingCAST"ThissetthestReviewingCASTCouldtheseresultsberelatedtothedrugsselected?
SubsequenttrialsconfirmedthatthiswasnotthecasePrystowskyReviewingCASTCouldtheseresuMADITIWouldanICDorconventionaltherapyimprovesurvivalinthishigh-riskpopulation?
Randomlyassigned196patientswithpriorMIand:
NYHAfunctionalclass1,2,or3
Aleftventricularejectionfraction<35%
Anepisodeofasymptomaticunsustainedventriculartachycardia
Inducible,nonsuppressibleventriculartachyarrhythmiaonelectrophysiologicstudyMADITIWouldanICDorconventMADITIfindingsGroupTotaldeathsCardiacdeathsDefibrillator1511Conventionaltherapy3927*Average27-monthfollow-up
MADITIfindingsGroupTotaldeaMADITIInhigh-riskpatientswithpriorMI,prophylactictherapywithanICDleadstoimprovedsurvivalcomparedwithconventionalmedicaltherapyMADITIInhigh-riskpatientswMUSTT
MulticenterUnsustainedTachycardiaTrial(MUSTT),arandomizedcontrolledtrial
Canelectrophysiologicallyguidedantiarrhythmictherapyreducetheriskofsuddendeath?
Lookedatcoronaryarterydiseasepatientswithaleftventricularejectionfraction<40%andasymptomaticunsustainedventriculartachycardiaMUSTT
MulticenterUnsustainedMUSTTEndpointCardiacarrestor
arrhythmiadeathEP-guided
therapy(%)25Noantiarrhythmic
therapy(%)32Relativerisk0.7395%CI0.53-0.99MUSTTEndpointCardiacarrestoMUSTTTherapywithimplantabledefibrillators,butnotwithantiarrhythmicdrugs,reducestheriskofsuddendeathinhigh-riskpatientswithcoronarydisease
MUSTTTherapywithimplantableUnsustainedVT"Ithinkit'sarelativelyweakriskstratifier.Andasyoupointout,itwasbothfrustratingandcumbersome."GoldUnsustainedVT"Ithinkit'saMADITIIRandomizedtrialevaluatingtheeffectofanimplantabledefibrillatoronsurvival
1232patientswithpriorMIandaleftventricularejectionfractionof<30%
Patientsrandomlyassignedina3:2ratiotoreceiveICDorconventionalmedicaltherapyMADITIIRandomizedtrialevaluMADITmortalityratesMADITmortalityratesMADITII"Thisreallyintroducedasimplifiedstratificationapproach."MossMADITII"ThisreallyintroduceMADITIIandCMS"TheytookaconservativepositionandsaidthattheyweregoingtoreimburseonlyforMADITIIpatientswhohadaQRSduration>120millisecondsandthattheywouldrevisitthiswhenSCD-HeFTdatawerepresented."MossMADITIIandCMS"TheytookacSCD-HeFTSuddenCardiacDeathinHeartFailureTrial(SCD-HeFT)
LargestofthetrialsinvolvingICDtherapywithalongerpatientfollow-upthanpreviousstudies
SCD-HeFTSuddenCardiacDeathiSCD-HeFTComparedall-causemortalityin
>2500patients
WithNYHAclass2to3HF
LVEF<35%
PatientsrandomizedtoreceiveICD,amiodarone,orplaceboontopofstandardmedicaltherapySCD-HeFTComparedall-causemorSCD-HeFTall-causemortality
SCD-HeFTall-causemortality
SCD-HeFTICDcutsall-causemortalityby23%in
NYHAclass2to3heartfailure
SCD-HeFTICDcutsall-causemorWhat'sapayertodo?"Thetrialsweredesignedspecificallytoanswerthemajorquestionofdefibrillatorsandtheirroletoreducetotalmortality.Ithinkthetrials,asyoupointout,areconcordantinthatregard,andIthinkthatitwouldbereasonablethatthatwouldbeanindicationforpaying."GoldWhat'sapayertodo?"ThetriaWhat'sapayertodo?"Gettingintosubsetswhenit'snotreallyprespecifiedthat'swhatyou'relookingforispotentiallyverytreacherousandca
温馨提示
- 1. 本站所有资源如无特殊说明，都需要本地电脑安装OFFICE2007和PDF阅读器。图纸软件为CAD,CAXA,PROE,UG,SolidWorks等.压缩文件请下载最新的WinRAR软件解压。
- 2. 本站的文档不包含任何第三方提供的附件图纸等，如果需要附件，请联系上传者。文件的所有权益归上传用户所有。
- 3. 本站RAR压缩包中若带图纸，网页内容里面会有图纸预览，若没有图纸预览就没有图纸。
- 4. 未经权益所有人同意不得将文件中的内容挪作商业或盈利用途。
- 5. 人人文库网仅提供信息存储空间，仅对用户上传内容的表现方式做保护处理，对用户上传分享的文档内容本身不做任何修改或编辑，并不能对任何下载内容负责。
- 6. 下载文件中如有侵权或不适当内容，请与我们联系，我们立即纠正。
- 7. 本站不保证下载资源的准确性、安全性和完整性, 同时也不承担用户因使用这些下载资源对自己和他人造成任何形式的伤害或损失。
最新文档
- 2024企业工作计划参考范本（4篇）
- 土建监理工作职责职范本（4篇）
- 汛期非煤矿山安全生产工作方案电子版（二篇）
- 区块链技术在风险管理中的应用
- 大学学生会部门个人工作总结模板（6篇）
- 江苏省无锡江阴市华士片2025届物理九年级第一学期期中质量跟踪监视试题含解析
- 泸州市重点中学2025届化学九年级第一学期期中统考模拟试题含解析
- 辽宁省朝阳市第一中学2025届九年级物理第一学期期中教学质量检测试题含解析
- 部编版二年级语文上册第8课《古诗二首》教学课件
- 第二单元职业生涯发展条件与机遇试题
- 自动扶梯与自动人行道调试作业指导书(通用版)
- 反义疑问句(共14张PPT)
- 新概念英语第二册66课 (共28张PPT)
- 健美操单元教学计划及教案健美操单元教学计划
- N-甲基二乙醇胺合成工艺研究
- 冷库验收报告通用版
- 六年级毕业考最后一题集锦数学
- 锚杆检验批（精品范文）(共7页)
- 详解仿金电镀工艺配方与操作技巧
- —《万以内数的认识》整合与思考
- 大气高斯扩散知识讲解
评论
0/150
提交评论