Congestive heart failure implantation of intracardiac defibrillator

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Editor(s)-In-Chief: James Chang, M.D., Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School [1] and C. Michael Gibson, M.S., M.D. [2], Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [3]

Overview

• 50% of heart failure patients die of sudden cardiac death.
• ICDs are indicated for patients with previous myocardial infarction and LVEF <30%, sustained ventricular tachycardia, inducible ventricular tachycardia.
• Morbidity/mortality benefit of ICD placement vs. anti-arrhythmic drug therapy is controversial.

Indications for an Intracardiac Defibrillator

1. The left ventricular ejection fraction (LVEF) is ≤ 35%

and

2. NYHA class II/III

OR

1. The left ventricular ejection fraction (LVEF) is ≤ 30%

and

2. There is a prior history of myocardial infarction (MI)

Background

• ICDs prevent sudden death in appropriately selected patients with heart failure and left ventricular systolic dysfunction irrespective of etiology.

• Implantation of an ICD for primary prevention of sudden death should be considered for patients with LVEF ≤ 35% who are in NYHA functional class II or III.

• ICD implantation is not appropriate or beneficial for patients in NYHA class IV (severely debilitated). In post-MI patients, implantation of an ICD should be performed no earlier than 40 days post-MI in patients with persistent moderate or severe left ventricular systolic dysfunction: LVEF ≤ 30% for asymptomatic (NYHA class I) patients or LVEF ≤ 35% for symptomatic (NYHA class II or III) patients.

• ICD implantation has NOT been demonstrated to prolong life in patients who are severely symptomatic or otherwise profoundly debilitated (NYHA class IV).

ACC/AHA Guidelines- Implantable cardioverter-defibrillator (DO NOT EDIT)

“

Class I 1. An implantable cardioverter defibrillator is recommended as secondary prevention to prolong survival in patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction (LVEF) who have a history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia. (91-93) (Level of Evidence: A) 2. Implantable cardioverter defibrillator therapy is recommended for primary prevention of sudden cardiac death to reduce total mortality in patients with non-ischemic dilated cardiomyopathy or ischemic heart disease at least 40 days post-myocardial infarction, a left ventricular ejection fraction (LVEF) less than or equal to 35%, and NYHA functional class II or III symptoms while receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year.(40,93–99) (Level of Evidence: A)

”

Vote on and Suggest Revisions to the Current Guidelines

• The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

• The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

• 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation

References

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