Congestive heart failure implantation of intracardiac defibrillator

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ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
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Sudden Cardiac Death Prevention
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Patients at high risk for developing heart failure (Stage A)
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Congestive heart failure end-of-life considerations

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Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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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] Edzel Lorraine Co, DMD, MD[4]

Overview

Fifty percent of patients with heart failure die of sudden cardiac death. ICDs are indicated for patients with previous myocardial infarction and an LVEF <30%, sustained ventricular tachycardia, inducible ventricular tachycardia. The morbidity and mortality benefit of ICD placement compared with anti-arrhythmic drug therapy is controversial.

Indications for an Intracardiac Defibrillator

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

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) [2]

Background

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

2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [3]

ICDs and CRTs

Class I
"1. In patients with nonischemic DCM or ischemic heart disease at least 40 days post-MI with LVEF ≤ 35% and NYHA class II or III symptoms or chronic GDMT, who have reasonable expectation of meaningful survival for >1 year, ICD therapy is recommended for primary prevention of SCD to reduce total mortality. [4][5][6][7][8][9][10][1][11](Level of Evidence: A) "
Value Statement:High Value
"2. A transvenous ICD provides high economic value in the primary prevention of SCD particularly when the patient's risk of death caused by ventricular arrhythmia is deemed high and the risk of non-arrhythmic death (either cardiac or noncardiac) is deemed low based on the patient's burden of comorbidities and functional status. [12][13][14][15][16][17] (Level of Evidence: A) "
Class I
"3. In patients at least 40 days post-MI with LVEF ≤ 30% and NYHA class I symptoms while receiving GDMT, who have reasonable expectation of meaningful survival for > 1 year, ICD therapy is recommended for primary preve≤ntion of SCD to reduce total mortality. [2] (Level of Evidence: B-R) "
"4. For patients who have LVEF ≤ 35%, sinus rhythm, LBBB with a QRS duration ≥150ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT, CRT is indicated to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL.[18][19][20][21][22][23] (Level of Evidence: B-R) "
Value Statement:High Value
"5. For patients who have LVEF ≤ 35%, sinus rhythm, LBBB with a QRS duration of ≥ 150ms, and NYHA class II, III, or ambulatory class IV symptoms on GDMT, CRT implementation provides high economic value. [24][25][26][27][28][29] (Level of Evidence: B-NR) "
Class IIa
"6.For patients who have LVEF ≤ 35%, sinus rhythm, a non-LBBB pattern with a QRS duration ≥ 150ms, and NYHA class II, III, or ambulatory class IV symptoms on GDMT, CRT can be useful to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL. [18][19][20][21][22][23][30][31][32][33][34][35] (Level of Evidence: B-R) "
"7. In patients with high-degree or complete heart block and LVEF of 36% to 50%, CRT is reasonable to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL. [36][37] (Level of Evidence: B-R) "
"8. For patients who have LVEF ≤ 35%, sinus rhythm, LBBB with a QRS duration of 120 to 149 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT, CRT can be useful to reduce total mortality reduce hospitalizations, and improve symptoms and QOL. [18][19][20][21][22][23][30][31][32][33][34][35] (Level of Evidence: B-NR) "
"9. In patients with AF and LVEF ≤ 35% on GDMT, CRT can be useful to reduce total mortality, improve symptoms and QOL, and increase LVEF, if: a) the patient requires ventricular pacing or otherwise meets CRT criteria and b) atrioventricular nodal ablation or pharmacological rate control will allow near 100% ventricular pacing with CRT. [18][19][20][21][22][23][30][31][32][33][34][35] (Level of Evidence: B-NR) "
"10. For patients on GDMT who have LVEF ≤ 35% and are undergoing placement of a new or replacement device implantation with anticipated requirement for significant (>40%) ventricular pacing, CRT can be useful to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL. [18][19][20][21][22][23][30][31][32][33][34][35] (Level of Evidence: B-NR) "
"11. In patients with genetic arrhythmogenic cardiomyopathy with high-risk features of sudden death, with EF ≤ 45%, implantation of ICD is reasonable to decrease sudden death. [38][39](Level of Evidence: B-NR) "
Class IIb
"12. For patients who have LVEF ≤ 35%, sinus rhythm, a non-LBBB pattern with QRS duration of 120 to 149 ms, and NYHA class III or ambulatory class IV on GDMT, CRT may be considered to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL. [18][19][20][21][22][23][30][31][32][33][34][35] (Level of Evidence: B-R) "
"13.For patients who have LVEF ≤ 30%, ischemic case of HF, sinus rhythm, LBBB with a QRS duration ≥ 150ms, and NYHA class I symptoms on GDMT, CRT may be considered to reduce hospitalizations and improve symptoms and QOL. [18][19][20][21][22][23][30][31][32][33][34][35] (Level of Evidence: B-R) "
Class III (No Benefit)
"14. In patients with QRS duration < 120 ms, CRT is not recommended. [38][39][40][41][42][43](Level of Evidence: B-R) "
"15. For patients with NYHA class I or II symptoms and non-LBBB pattern with QRS durati150 ms, CRT is not recommended.[18][19][20][21][22][23][30][31][32][33][34][5][6][7][8][9][10][1][11][18][19][20][21][22][23] (Level of Evidence: C-LD) "

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External Links

References

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