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ABSTRACT: Bei Patienten, die bereits einen Herzstillstand, eine hämodynamische Beeinträchtigung oder eine Synkope aufgrund von ventrikulären
Tachyarrhythmien überlebt haben, wird die Implantation eines ICD als Sekundärprophylaxe bezeichnet. Ziel ist es, eine Übersicht
zur Studienlage bei der ICD-Therapie aus sekundärprophylaktischen Gründen zu geben.
Die Implantation eines ICD zur Sekundärprävention von lebensbedrohlichen ventrikulären Tachykardien ist effektiv bei der Verhinderung
des plötzlichen arrhythmogenen Todes. Die Gesamtmortalität wurde durch den ICD relativ um 28% gesenkt. Es zeigt sich zwar
ein moderater Benefit durch die ICD-Therapie zur Sekundärprävention, aber nur in einem engen Rahmen bei einer EF (Ejektionsfraktion)
zwischen 20 und 35%.
Die bisherigen Studien wurden vorwiegend bei Patienten mit hämodynamisch instabiler Tachyarrhythmie durchgeführt und der Nutzen
des ICD gezeigt. Bei Patienten mit stabiler ventrikulärer Tachyarrhythmie ist der Nutzen weniger eindeutig, und alternative
Therapieverfahren müssen in die Differenzialtherapie einbezogen werden. Aufgrund des demografischen Wandels mit der Zunahme
der älteren Patienten ist es von besonderer Bedeutung, die Frage nach der Sicherheit, Wirksamkeit und Kosten-Nutzen-Effektivität
gerade beim älteren Patienten zu stellen. Die Empfehlungen der Leitlinien sind wichtig und sollten uns als Richtschnur dienen.
Dennoch sollte die Indikation für einen ICD individuell nach einer Risiko-Nutzen-Abwägung gestellt werden und der Patient
und dessen Angehörige in diese Entscheidung mit einbezogen werden.
Patients who survive out-of-hospital cardiac arrest or symptomatic ventricular tachyarrhythmias are at considerable risk of
recurrence of these events and ultimately death. The implantation of an implantable cardioverter defibrillator (ICD) in patients
with previous sustained ventricular tachyarrhythmias (VT) is considered secondary prevention of sudden cardiac death. The
purpose of this review is to summarize the most important trials on secondary prevention with an ICD.
The results from a meta-analysis showed a relative-risk reduction of 28% in overall mortality. Compared with amiodarone, an
ICD provided maximal benefit for those patients with an ejection fraction between 20% and 35%. The results of the ICD trial
demonstrate that there is clear evidence for the effectiveness of an ICD in patients with unstable VT; however, for patients
with stable VT the results are less clear. Data on older patients are scant, and whether the survival benefit observed in
the middle aged and younger-old also extend to older elderly patients with a more limited life span is less clear. Therefore,
as the population becomes older, it is important to evaluate the safety, effectiveness, and the cost effectiveness of ICD
implantation in this population.
Guidelines are important and helpful to guide clinical decisions, but the indication for an ICD still remains an individual
decision after evaluation of the risks and benefits for the individual patient. However, the patient needs to be involved,
which emphasizes the importance of dialogue between the patient and physician.
SchlüsselwörterPlötzlicher Herztod-Implantierbarer Kardioverter/Defibrillator (ICD)-Sekundärprophylaxe
KeywordsSudden cardiac death-Implantable cardioverter defibrillator (ICD)-Secondary prevention
Herzschrittmachertherapie & Elektrophysiologie 04/2012; 21(2):96-101.
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ABSTRACT: We report the case of a 63-year-old man with ischemic cardiomyopathy having an implantable cardioverter defibrillator (ICD) implanted for repeated ventricular tachycardia (VT). After several revisions of the ICD lead, a thrombosis of the left venous system was diagnosed. A right pectoral ICD device was implanted, and a sufficient defibrillation threshold (DFT) could not be achieved during the operation. Thus, a further defibrillation lead was implanted into the coronary sinus, which successfully terminated ventricular fibrillation.
Herzschrittmachertherapie & Elektrophysiologie 06/2011; 22(2):121-3.
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ABSTRACT: Patients who survive out-of-hospital cardiac arrest or symptomatic ventricular tachyarrhythmias are at considerable risk of recurrence of these events and ultimately death. The implantation of an implantable cardioverter defibrillator (ICD) in patients with previous sustained ventricular tachyarrhythmias (VT) is considered secondary prevention of sudden cardiac death. The purpose of this review is to summarize the most important trials on secondary prevention with an ICD. The results from a meta-analysis showed a relative-risk reduction of 28% in overall mortality. Compared with amiodarone, an ICD provided maximal benefit for those patients with an ejection fraction between 20% and 35%. The results of the ICD trial demonstrate that there is clear evidence for the effectiveness of an ICD in patients with unstable VT; however, for patients with stable VT the results are less clear. Data on older patients are scant, and whether the survival benefit observed in the middle aged and younger-old also extend to older elderly patients with a more limited life span is less clear. Therefore, as the population becomes older, it is important to evaluate the safety, effectiveness, and the cost effectiveness of ICD implantation in this population. Guidelines are important and helpful to guide clinical decisions, but the indication for an ICD still remains an individual decision after evaluation of the risks and benefits for the individual patient. However, the patient needs to be involved, which emphasizes the importance of dialogue between the patient and physician.
Herzschrittmachertherapie & Elektrophysiologie 06/2010; 21(2):96-101.
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ABSTRACT: The aim of the study was to evaluate the prognostic impact of successful cardioversion (CV) compared to failed CV in patients with atrial fibrillation (AF) and organic heart disease. A total of 471 consecutive patients with organic heart disease from the prospective single center anticoagulation registry ANTIK who underwent CV of AF or atrial flutter were analyzed. 417 patients (89%) could be successfully cardioverted. In 54 patients (11%) CV failed, these patients remained in AF. After 5 years there were 92 (24%) deaths among patients with restored sinus rhythm at index admission and 20 (38%) deaths among those who remained in AF after CV (unadjusted OR 1.9, 95% CI 1.1-3.6). After adjustment for age, gender and ejection fraction, successful CV was not associated with a beneficial effect on mortality (OR 0.72, 95% CI 0.43-1.21). Thus, successful CV is not an independent predictor of mortality on multivariate analysis. However, it remains a marker for a better prognosis in patients with organic heart disease as these patients have a lower unadjusted longterm mortality.
Clinical Research in Cardiology 03/2007; 96(2):103-8. · 2.95 Impact Factor
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ABSTRACT: Einleitung: Daten zur Prognose der Herzinsuffizienz stützen sich bislang auf bevölkerungsepidemiologische und retrospektive
krankenhausepidemiologische Untersuchungen sowie klinische Interventionsstudien. Alle diese Quellen sind nur eingeschränkt
auf den klinischen Alltag übertragbar.
Fragestellung: Wie ist die Prognose von Patienten mit linksventrikulärer Dysfunktion unter der therapeutischen Bedingungen
der neunziger Jahre?
Setting: Nichtuniversitäres Herzzentrum der Maximalversorgung.
Patienten und Methodik: Seit Januar 1995 konsekutiver und vollständiger Einschluß von allen stationären Patienten mit einer
linksventrikulären Dysfunktion in ein Register und Nachbeobachtung. Einschlußkriterium: echokardiographisch linksventrikuläre
Ejektionsfraktion ≤45% oder mindestens mittelschwer reduziert. Ausschlußkriterium: keines.
Ergebnisse: Patientenzahl 512, Alter 64 Jahre, 77% männlich, mittlere NYHA-Klasse 2,5, linksventrikuläre Ejektionsfraktion
31%, Ätiologie: 58% koronare Herzkrankheit, 28% dilatative Kardiomyopathie. Medikamentöse Therapie mit 91% ACE-Hemmern, ACE-Hemmern-Dosis
52% der Zieldosis, 42% β-Blocker, 70 % Diuretika und 63% Digitalis. Nichtmedikamentöse Therapie: 15% ICD, 7% Schrittmacher.
Nachbeobachtungsvollständigkeit: 95,5 %der Patienten, Einjahresmotalität: 64/489 Patienten (13,9%). Determinanten der Mortalität:
NYHA III/IV, EF <30%, Neoplasma, Alter >75 Jahre.
Schlußfolgerung: 1998 beträgt die Einjahressterblichkeit von Patienten mit linksventrikulärer Dysfunktion 13,9% unter der
oben genannten medikamentösen Therapie und einem hohen Anteil implantierter Defibrillatoren. Die Einjahressterblichkeit ist
somit immer noch hoch, wobei die prognoseverbessernde Potenz der medikamentösen Therapie im klinischen Alltag noch nicht vollkommen
ausgeschöpft wird.
Background: Prognostic data heart failure rely on epidemiological studies or large clinical trials. These data are not to
transfer easily on everyday practice.
Objective: To assess the prognosis of left ventricular dysfunktion under the therapeutic conditions of the 1990s.
Setting: Nonuniversity tertiary care hospital.
Patients and methods: Since January 1995 consecutive and complete registry of all inpatients presenting with a left ventricular
dysfunktion (EF<45%). No exclusion criteria.
Results: n = 512, mean age 64 years, 77% male, mean NYHA class 2.5, left ventricular EF 31%. Etiology: 58% coronary heart
disease, 28% dilated cardiomyopathy. Medical treatment consisting of 91% ACE inhibitors, ACE inhibitor dosage 52% of the recommended
dose, 42% β-blockers, 70% diuretics, and 63% digitalis. Follow-up completeness 95.5%. Oneyear mortality 64/489 patients (13.9%).
Determinants of mortality: NYHA III/IV, EF <30%, malignant disease, age >75 years.
Conclusion: In spite of the afore-mentioned medical treatment and a proportion of 14.8% implanted defibrillators in 1998,
the one-year mortality of verticular dysfunktion is as high 13.9%. In everyday practice the prognostic effect of ACE inhibition
an β-blockade is not completely utilized.
Zeitschrift für Kardiologie 04/1999; 88(1):14-22. · 0.97 Impact Factor
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ABSTRACT: Prognostic data on heart failure rely on epidemiological studies or large clinical trials. These data are not to transfer easily on everyday practice.
To assess the prognosis of left ventricular dysfunction under the therapeutic conditions of the 1990s.
Nonuniversity tertiary care hospital.
Since January 1995 consecutive and complete registry of all inpatients presenting with a left ventricular dysfunction (EF < 45%). No exclusion criteria.
n = 512, mean age 64 years, 77% male, mean NYHA class 2.5, left ventricular EF 31%. Etiology: 58% coronary heart disease, 28% dilated cardiomyopathy. Medical treatment consisting of 91% ACE inhibitors, ACE inhibitor dosage 52% of the recommended dose, 42% beta-blockers, 70% diuretics, and 63% digitalis. Follow-up completeness 95.5%. One-year mortality 64/489 patients (13.9%). Determinants of mortality: NYHA III/IV, EF < 30%, malignant disease, age > 75 years.
In spite of the aforementioned medical treatment and a proportion of 14.8% implanted defibrillators in 1998, the one-year mortality of ventricular dysfunction is as high as 13.9%. In everyday practice the prognostic effect of ACE inhibition and beta-blockade is not completely utilized.
Zeitschrift für Kardiologie 01/1999; 88(1):14-22. · 0.97 Impact Factor
