Systematic review for the 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death

Abstract

Evidence from 6 studies of 1138 asymptomatic patients were identified. Brugada syndrome with inducible VA on electrophysiological study was identified in 390 (34.3%) patients. To minimize patient overlap, the primary analysis used 5 of the 6 studies and found an odds ratio of 2.3 (95% CI: 0.63-8.66; p=0.2) for major arrhythmic events (sustained VAs, sudden cardiac death, or appropriate ICD therapy) in asymptomatic patients with Brugada syndrome and inducible VA on electrophysiological study versus those without inducible VA. Ten studies were reviewed that evaluated ICD use in older patients and 4 studies that evaluated unique patient populations were identified. In our analysis, ICD implantation was associated with improved survival (overall hazard ratio: 0.75; 95% confidence interval: 0.67-0.83; p<0.001). Ten studies were identified that evaluated ICD use in patients with various comorbidities including renal disease, chronic obstructive pulmonary disease, atrial fibrillation, heart disease, and others. A random effects model demonstrated that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.72; 95% confidence interval: 0.65-0.79; p<0.0001), and a second "minimal overlap" analysis also found that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.61-0.82; p<0.0001). In 5 studies that included data on renal dysfunction, ICD implantation was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.60-0.85; p<0.001).

Toward better risk stratification of asymptomatic Brugada Syndrome patients?

“…Specifically, the prognostic role of programmed ventricular stimulation (PVS) for evaluation of ventricular arrhythmia inducibility has shown inconsistent results. 2,3 However, EP testing with myocardial substrate mapping has recently shown interesting results for the assessment of arrhythmia inducibility. In 191 patients with BrS who underwent EP testing, arrhythmogenic substrate size was an independent predictor of inducibility, and substrate ablation prevented ventricular arrhythmia re-inducibility.…”

238th ENMC International Workshop: Updating management recommendations of cardiac dystrophinopathyHoofddorp, The Netherlands, 30 November - 2 December 2018

“…Not all patients benefit, however, and their deployment is a risk-benefit balance between prevention of sudden death and device-related complications [27,28] . Adults in NYHA functional class II/III, with LVEF < 35% have a class 1 indication for recommending defibrillator therapy [29] . The question remains whether this guidance is appropriate for adult patients with BDMD.…”

The Role of Palliative Care in the Cardiac Intensive Care Unit

“…ICDs are implanted for the primary or secondary prevention of sudden death [58]. Regarding the deactivation of ICDs, the issue is how to prevent frequent and painful interventions of the device without any substantial improvement in the duration and quality of residual life, at the end of life.…”