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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. “Chain of Survival” Cummins et al Circulation 1991;83:1832-1847. rapid access Survival to leave hospital after out of hospital cardiac arrest: effect of arrest being witnessed 30% 24% 25% 20% 41% not witnessed 15% 10% 5% 4% 0% not witnessed witnessed Eisenberg & Mengert, NEJM, 2001;344:1304-1313 “Chain of Survival” Cummins et al Circulation 1991;83:1832-1847. rapid access rapid CPR Survival after out of hospital arrest: effect of early CPR 3 2.5 2 1.5 1 OR 1.41 [1.19-1.66] 0.5 OR 2.15 [1.85-2.50] 0 No CPR dispatcher bystander CPR assisted CPR Rea et al, Circulation, 2001;104:2413-2516. Survival after out of hospital arrest: effect of quality of CPR 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% none other lay persons police officers medical personnel ambulance staff Holmberg et al Eur Heart J 2001;22:511-519 Survival to leave hospital after out of hospital cardiac arrest: initial rhythm 40% 34% 35% 30% 25% 20% 15% 12% 10% 5% 6% 1% 0% not VF VF not witnessed not VF VF witnessed Eisenberg & Mengert, NEJM, 2001;344:1304-1313 “Chain of Survival” Cummins et al Circulation 1991;83:1832-1847. rapid access rapid CPR rapid defibrillation Rapid defibrillation Larsen et al Ann Emerg Med 1993;22:80-84 Survival to leave hospital after out of hospital witnessed cardiac arrest due to VF: PAD 70% 60% 50% 40% 56% 59% 40% 34% 33% 1990-1999, Seattle, Eisenberg & Mengert Qantas, O'Rourke et al 30% 20% 10% 0% American Airlines, Page et al O'Hare, Caffrey et al Casino, Valenzuela et al Eisenberg & Mengert, NEJM, 2001;344:1304-1313 minutes Impact of first responder volunteers Time from call to arrival 8 7 6 5 4 3 2 1 0 p=0.05 Survival 6.2 4.8 12% 10% 8% 6% 10.5% 8.4% 6.2% 4.8% 3.3% 2.4% 4% 2% 0% PPV EMS overall survival PPV EMS neurologically intact Capucci et al Circulation 2002;106:1065-1070 Survival to leave hospital after out of hospital witnessed VF: Impact of AEDs in police cars Time from call to arrival Hospital survivors 10 25% 7.6 minutes 8 24.0% 20% 6.2 6 15% 10.5% 4 10% 2 5% 0 0% police AED standard EMS police AED standard EMS Myerburg et al Circulation 2002;106:1058-1064 Survival to leave hospital after out of hospital witnessed VF: Impact of PAD & AEDs in police cars time from call to arrival minutes 7 6 5 4 EMS AED % survival to leave hospital 8 survival: witnessed VF 50 40 30 20 10 0 EMS AED Piacenza Miami-Dade Goteborg VF in 14 of 99 who had lost consciousness (and had an ECG recorded) 6 (40%) survived to leave hospital Page et al N Engl J Med 2000;343:1210 nursing home 8% public place 21% home 71% Eisenberg & Mengert, NEJM, 2001;344:1304 Survival to leave hospital after cardiac arrest King Co 1983-2000 15.1% Seattle 1989-1998 12.4% 9.6% Piacenza AED 1999-2001 7.6% Miami-Dade Co 1999-2001 Scotland 1988-1994 6.7% Maastricht 1991-1994 6.2% Piacenza EMS 1999-2001 6.2% Nottingham 1991-1994 6.1% West Yorkshire 1987-1997 6.0% Miami-Dade Co 1997-1999 6.0% 4.5% UK 1994-1995 3.7% Paris 1993-1997 0% 5% 10% 15% 20% “Chain of Survival” Cummins et al Circulation 1991;83:1832-1847. rapid access rapid CPR rapid defibrillation 11 seconds The ICD comprises 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 RA lead RV leads LV lead 62 cc Dual-chamber 35-Joule output Can® electrode Active relative risk reduction in mortalty Mortality reduction in ICD trials 80% 73% 70% 60% 54% 51% 50% 40% 39% 38% 31% 30% 20% 20% 10% 0% MADIT MUSTT MADIT II Primary prevention Dutch AVID CIDS CASH Secondary prevention 10 20 Myerberg et al Am J Cardiol 1997;80:10F-19F 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! RESUSCITATION FROM VT or VF EP REFERRAL RVOT TACHYCARDIA, FASCICULAR TACHYCARDIA, PRE EXCITED AF, LEFT VENTRICULAR FUNCTION? IMPAIRED NYHA I-III NORMAL BRUGADA SYNDROME, LONG QT NYHA IV CONSIDER ICD ACE I, SPIRONOLACTONE, BLOCKERS, DIGOXIN ACE I, SPIRONOLACTONE, BLOCKERS, DIGOXIN ACUTE ISCHAEMIA? CORONARY ARTERY DISEASE? ACUTE ISCHAEMIA? CORONARY ARTERY DISEASE? REVASCULARISATION + RISK FACTOR MODIFICATION, ASA, BLOCKERS, STATINS, etc REVASCULARISATION + RISK FACTOR MODIFICATION, ASA, BLOCKERS, STATINS, etc AMIODARONE CONSIDER ICD