Vorhofflimmern

Erstellt am 16 Oct 2018 19:36
Zuletzt geändert: 17 Jun 2019 12:32

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Vorhofflimmern und Defibrillatoren

Patients with paroxysmal or persistent AF did not show a significant increased risk of mortality or appropriate device therapy but demonstrated almost 3 times the risk of inappropriate device therapy.

Vorhofflimmern und ICD

Methods and Results:
A systematic MEDLINE search performed from inception through November 2016, supplemented by hand searching of reference lists, identified 62 eligible studies (227 998 patients) reporting on the association between AF and outcomes in HF patients; 36 studies included data on all-cause mortality, 30 on appropriate, and 17 on inappropriate ICD interventions. Hazard ratio, risk ratio, or odds ratio estimates were used based on data availability. Effect estimates were synthesized under a random-effects model. Implantable cardioverter-defibrillator-implanted HF patients with a history of AF had a 42% {combined effect estimate (cEE) 1.42 [95% confidence interval (CI) 1.28-1.57]} higher risk of all-cause mortality compared with patients with no AF history. Furthermore, AF patients had a higher risk of appropriate [cEE 1.44 (95% CI 1.27-1.64)] and inappropriate ICD interventions [cEE 2.05 (95% CI 1.75-2.44)].
Conclusion:
Atrial fibrillation history is statistically significantly associated with adverse major clinical outcomes in ICD-implanted HF patients. Patients with AF have a higher risk of all-cause mortality, appropriate, and inappropriate ICD interventions compared with patients with no AF history. Whether AF may have an independent deleterious effect on HF prognosis or may simply be a marker of HF severity should be further investigated.

Methods and Results
Literature was searched and 25 observational studies with 63 283 patients were included in this meta-analysis. We compared the outcomes of (1) all-cause mortality and appropriate shock therapy among AF and NSR patients who received ICD for either primary or secondary prevention and (2) all-cause mortality among AF patients with ICD versus guideline directed medical therapy. All-cause mortality (odds ratio, 2.11; 95% confidence interval, 1.73-2.56; P<0.001) and incidence of appropriate shock therapy (odds ratio, 1.77; 95% confidence interval, 1.47-2.13; P<0.001) were significantly higher in ICD patients with AF as compared to NSR. There was no statistically significant mortality benefit from ICD compared with medical therapy in AF patients (odds ratio, 0.69; 95% confidence interval, 0.42-1.11; P=0.12) based on a separate meta-analysis of 3 studies with 387 patients.
Conclusions
Overall mortality and appropriate shock therapy are higher in ICD patients with AF as compared with NSR . The impact of ICD on all-cause mortality in AF patients when compared to goal-directed medical therapy is unclear, and randomized controlled trials are needed comparing AF patients with ICD and those who have indications for ICD, but are only on medical therapy.

Conclusion
History of AF at the time of ICD implant identifies additional risk of HF and death. Newly detected AF is associated with significantly higher rates of death. The relationship between newly detected AF and inappropriate ICD shock or HF hospitalization is uncertain and requires further study.

Abstract
Inappropriate ICD shocks are associated with increased mortality. They also impair patients' quality of life, increase hospitalizations, and raise health-care costs. Nearly 80% of inappropriate ICD shocks are caused by supraventricular tachycardia. Here we report the case of a patient who received a single-lead dual-chamber sensing ICD for primary prevention of sudden cardiac death and experienced inappropriate ICD shocks. V-A time, electrogram morphology, and response to antitachycardia pacing suggested atrioventricular nodal reentry tachycardia, which was confirmed in an electrophysiology study. Inspired by this case, we performed a literature review to discuss mechanisms for discrimination of supraventricular tachycardia with 1:1 A:V relationship from ventricular tachycardia with 1:1 retrograde conduction.

Um die Wahrscheinlichkeit für das Auftreten [von] inadäquaten ICD-Schockabgaben zu reduzieren, hat ein implantierbarer Defibrillator zahlreiche Programmiermöglichkeiten, die die Unterscheidung zwischen ventrikulärer und supraventrikulärer Tachykardie ermöglichen, etwa Herzfrequenz, QRS-Morphologie, plötzlicher Beginn der Tachykardie und Stabilität der Tachykardie.
Eine solche Vielzahl an Diskrimminatoren steht der tragbaren Defibrillatorweste nicht zur Verfügung, da bei dieser die Detektion der Kammertachykardie durch das 60-sekündige Überschreiten der zuvor programmierten Kammertachykardiedetektionsfrequenz erfolgt. Vor der Abgabe des Schocks gibt die Defibrillatorweste zusätzlich einen akustischen Warnton ab, der es dem Patienten ermöglicht, die Schockabgabe durch einen Tastendruck zu unterbinden.
Hinter dieser Sicherheitsmaßnahme steckt die Überlegung, dass Rhythmusstörungen, die nach einer Dauer von mehr als 60 s nicht zu einer hämodynamischen Instabilität und Bewusstseinsverlust führen … aufgrund dieser Sicherheitsmaßnahme … ist die Wahrscheinlichkeit für das Auftreten inadäquater Schocks durch die Defibrillatorweste gering, jedoch nicht ausgeschlossen.
Weder der Patient noch der Notarzt können i. d. R. anhand von Anamnese, körperlicher Untersuchung oder EKG unterscheiden, ob es sich um einen adäquaten oder inadäquaten Schock gehandelt hat.

METHODS AND RESULTS:
A total of 1,411 consecutive patients of the prospective single-center ICD-registry Ludwigshafen who underwent an ICD implantation between 1992 and 2008 for primary or secondary prevention of sudden cardiac death were analyzed. During the median follow-up of 3 years, 297 (21%) patients experienced inappropriate ICD shocks. Sixty percent of patients had inappropriate shocks due to AF and 24% due to lead defect or T-wave oversensing. Multiple ICD shocks (≥2) triggered by AF were associated with a worse prognosis, whereas a single shock due to AF or 1 or multiple shocks resulting from lead failure were not. ICD shocks caused by AF occurred more often in tandem with a serious adverse event than in patients with a lead failure (15% vs 6%, P < 0.05).

CONCLUSION:
The German DEVICE registry demonstrates that patients with AF who receive ICD devices are older, have more co-morbidity and more severe heart failure. AF carries an independent 1.39 fold risk (95% CI 1.02-1.89) of death after one year in patients only with first ICD implantation.

Vorhofflimmern und WCD

On further follow-up (mean 12 ± 8 months), patients with suspected tachymyopathy had no sustained ventricular arrhythmias. Compared to … patients in the control group, no tachymyopathy patient died.

RESULTS:
The most common clinical indication for WCD-prescription (63%) was a new diagnosis of severely impaired LV function (LVEF ≤35%). The median wear time of the WCD was 54 days with a daily use of 23 h. Appropriate WCD therapy occurred in four patients (seven shocks for VF, one shock for VT). An ICD was finally implanted in 56 patients (55%). Improvement in LV function was the most common reason not to implant an ICD (HR 0.37; 95% CI 0.19-0.73; p = 0.004). Two patients had inappropriate shocks from their WCD due to atrial fibrillation/flutter. Five patients fitted with an ICD after the end of WCD therapy suffered VT/VF episodes. After wearing the WCD, six patients died (five ICD recipients and one non-ICD recipient).

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* Zitat nach: Bach, Otto: ''Über die Subjektabhängigkeit des Bildes von der Wirklichkeit im psychiatrischen Diagnostizieren und Therapieren''. In: Psychiatrie heute, Aspekte und Perspektiven, Festschrift für Rainer Tölle, Urban & Schwarzenberg, München 1994, ISBN 3-541-17181-2, (Zitat: Seite 1)

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