21Ο ΕΤΗΣΙΟ ΣΕΜΙΝΑΡΙΟ ΣΥΝΕΧΙΖΟΜΕΝΗΣ ΙΑΤΡΙΚΗΣ ΕΚΠΑΙΔΕΥΣΗΣ ...

21Ο ΕΤΗΣΙΟ ΣΕΜΙΝΑΡΙΟ ΣΥΝΕΧΙΖΟΜΕΝΗΣ ΙΑΤΡΙΚΗΣ ΕΚΠΑΙΔΕΥΣΗΣ ...

5o KA Evaggelismos Hospital, Athens Sotirios Xydonas, MD, PhD, FESC, FHFA Heart Failure Unit Electrophysiology and Pacing Laboratory Cardiology Department, Evaggelismos Hospital, Athens

Conflict of Interest Honoraria for lectures: Bayer, Boehringer-Ingelheim, Novartis, Pfizer, Servier Honoraria for advisory boards: Boehringer-Ingelheim, Novartis, Servier This presentation is intended for non-promotional scientific purposes only and may contain information on products or indications currently under investigation and/or that have not been approved by the regulatory authorities. This presentation represents exclusively the views of the speaker. This presentation is accurate at the time of presentation.

Any data about non-Novartis products are based on publicly available information at the time of presentation. Anatomic substrate and pathophysiology of Arrhythmias and SCD in HFrEF Scar Fibrosis PVCs Electrolyte

imbalance Ischemia QT interval changes J Clin Med 2018;7:436. Secondary Prevention Secondary prevention trials Meta-analysis: ICD vs Amiodarone

50% 28% AVID, CASH, CIDS CAD 75-83% AVID, CASH, CIDS

Eur Heart J 2000;21:20712078. Recommendations for ICD in patients with HF Eur Heart J 2015;36:27932867. Eur Heart J 2016;37:21292200. Primary Prevention Primary Prevention

Eur Heart J 2016;37:2129-200. Eur Heart J 2015;36:27932867. Eur Heart J 2016;37:267315. Eur Heart J 2018;39:119177. MADIT-II IHD N Engl J Med 2002;346:877-83.

SCD-HeFT IHD vs. NIHD 52% 21% shock only

N Engl J Med 2005;352:225-37. SCD-HeFT NYHA N Engl J Med 2005;352:225-37. RCTs evaluating the role of ICD in primary prevention of patients with NIDCM

Eur Heart J Suppl. 2019;21:B5B6. doi:10.1093/eurheartj/suz005 Eur J Heart Fail. 2019 May 26. doi: 10.1002/ejhf.1531. [Epub ahead of print] Eur J Heart Fail. 2019 May 26. doi: 10.1002/ejhf.1531. [Epub ahead of print] 2-year cause-specific mortality and non-fatal vascular events Conceptual representation of Absolute and Relative risk JGF Cleland et al. Eur Heart J 2019;40:21282130.

NYHA and Sudden Cardiac Death NYHA II benefit more from ICD than NYHA III Am Heart J 2017;191:2129. NT-proBNP and ICDs Wet patients do not appear to benefit from ICDs JGF Cleland et al. Eur Heart J 2019;40:21282130.

Sudden Death in HF Where are we now? Eur Heart J 2015;36:19901997. Lancet 1999;353: 2001-07. Declining Risk of Sudden Death in HF

Over a period of 19 years the rate of sudden death has declined by 44%. N Engl J Med 2017;377:41-51. Declining Risk of Sudden Death in Heart Failure Annual Rates and Cumulative Incidence Rates of Sudden Death N Engl J Med 2017;377:41-51. Eur J Heart Fail. 2019 May 26. doi: 10.1002/ejhf.1531. [Epub ahead of print]

Changes in Use and Dose f GDMT over 12m among pts with HFrEF Contemporary US Outpatient Practice Epub: 2019 Mar 29, J Am Coll Cardiol 2019;73:2365-83. Remodeling Arrhythmia episodes reduction 23

Clin Res Cardiol 2019;108:1074-1082. Mortality benefit Episodes reduction Shocks VT / NSVT 24 Heart Rhythm 2018;15:395-402.

Ventricular Repolarization in HFrEF ECG ventricular repolarization indices Acta Cardiol. 2018 Dec 4:1-6. doi: 10.1080/00015385.2018.1535818. [Epub ahead of print] Risk Stratification Circulation 2017;136:215231.

Risk Stratification Manolis AS. Expert Rev Cardiovasc Ther. 2017;15:315-325. CMR LGE and Ventricular events J Am Coll Cardiol Img 2016;9:104655. Midwall CMR LGE and Sudden Cardiac Death

Circulation 2017;135:21062115. Risk Stratification in HFrEF Non Invasive Risk Factors (NIRF)

presence of late potentials (2/3 criteria) frequent PVCs (30/hr) NSVT (1/24 hr) Abnormal HR turbulence (onset 0% and slope2.5 ms) positive T wave alternans (65 V) reduced deceleration capacity (4.5 ms)

decreased HRV (SDNN<70 ms) prolonged QTc interval (>460 ms in males and >480 ms in females) Gatzoulis KA, Sideris A, Kanoupakis E, Sideris S, Nikolaou N, Antoniou CK, Kolettis TM. Ann Noninvasive Electrocardiol. 2017;22:e12430. Case , 53 LVEF=30%, NYHA I

, 10 = SR, PR 190ms, IVCD, QRS 144ms, 65/min Holter : PVCs 5.600, NSVT: 0 SAECG: 1 3 12/2018 Ramipril 5mg od, Bisoprolol 5mg od, Spironolactone 50mg od, Frusemide 40mg bd Case

- X -

X X X

- ARNI v CRT-P CRT-D ?

53 104/70 mmHg 62 bpm

NT-proBNP 442pg/ml 4,6mEq/L

e-GFR 92ml/min/1,73m2 o Ramipril 5mg od o Bisoprolol 5mg od o Spironolactone 50mg od o Frusemide 40mg bd

Late potentials (2/3 criteria) PVCs (30/hr) NSVT (1/24 hr) abnormal HR turbulence (onset 0% and slope2.5 ms)

positive T wave alternans (65 V) reduced deceleration capacity (4.5 ms) decreased HRV (SDNN<70 ms) prolonged QTc interval (>460 ms in males and >480 ms in females) CRT

Eur Heart J 2016;37:21292200. Cardiac and non-Cardiac Death in CRT patients Cardiac Death & LBBB Cardiac Death & non-LBBB Non - Cardiac Death & LBBB Non-Cardiac Death & non-LBBB

Europace 2015;17:1816-1822. Non LBBB and PR interval Death or Heart Failure Circ Heart Fail 2016;9:e002667. Take home messages

ICD therapy for LVEF35% for primary prevention is under consideration especially in NIDCM. An unmet need for use of non-invasive risk stratification has emerged and various Risk algorithms are under evaluation.

The evidence of CRT benefit in patients with non LBBB is weak, particularly in patients with QRS<150ms and NYHA I-II. Take home messages Awaiting for robust SCD risk score algorithms from RCTs in HFrEF patients, we should keep in mind that:

ICDs are most effective at preventing sudden arrhythmic death for patients who have some increased risk of arrhythmias but, more importantly are otherwise at low risk. Rather than trying to identify patients at high risk of sudden death, clinicians should be selecting patients at low risk of death for any other reason.

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