Berlin, Friday, October 12, 2018 – Sudden cardiac death is a previously undetectable death, often due to the onset of life-threatening cardiac arrhythmias. Risk stratification and the definition of adequate therapies are difficult, reports Prof. dr. Dr. med. Thomas Deneke (Bad Neustadt), speaker of the working group Rhythmology of the DGK on the occasion of the German Herztage in Berlin.
Nowadays, modern imaging techniques such as MRI can be used to identify patients at high risk of sudden cardiac death. Early programmed ventricular pacing in post-cardiac infarction patients is also a potential strategy to detect an increased risk of sudden cardiac death.
The implantable defibrillator (ICD) remains the preferred treatment for patients who have survived sudden cardiac death (secondary prevention). For the prevention of sudden cardiac death, the permanently implanted defibrillator (ICD) is the only effective treatment option in severely restricted left heart chamber pump function of the heart. In the last 30 years, however, the risk of sudden cardiac death has almost been halved by the developments in drugs for heart failure, and therefore the reduced pump function according to Prof. dr. Deneke is no longer a good indicator.
"Despite the high rate of sudden death following a myocardial infarction in patients with a low ejection fraction, implantable cardioverter defibrillators are not indicated 40 to 90 days after myocardial infarction," says Prof. Deneke. The VEST study1 investigated whether a portable cardioverter defibrillator could reduce the frequency of sudden deaths during this risky period. Patients with acute myocardial infarction and an ejection fraction of 35 percent or less were randomly assigned to a portable cardioverter defibrillator plus a guideline-compatible therapy (group of devices) or only guideline-adapted therapy (control group). Conclusion: in patients with a recent myocardial infarction and an ejection fraction of 35 percent or less, the portable cardioverter defibrillator did not result in a significantly lower frequency of cardiac arrhythmias. "However, this study has a number of shortcomings, including the motivation of patients: many in the device group did not wear the vest at all," according to Prof. Deneke. "Modern telemedicine follow-up after intensive patient training can improve this."
For catheterization sclerotherapy via sclerotherapy via the groin, in patients with arrhythmia of the ventricular tachycardia after myocardial infarction, there are now several studies showing that catheter ablation is more effective than any drug treatment for suppression of recent episodes of ventricular tachycardia . Prof. dr. Deneke: "But there was no effect in terms of better survival, the reason being that these studies were very sick patients who died of the progression of their heart disease and not of an arrhythmogenic event."
In patients without changes in the coronary arteries, ie without a previous heart attack, it seems that the successes of ablation, if performed in experienced centers of expertise, are also very good, says Prof. Deneke.
The number of kidnapped patients with ventricular tachycardia has tripled in the last decade. Between 5,000 and 6,000 ablations in ventricular tachycardia are performed each year in Germany. Some German centers have specialized in the treatment of these patients, which has significantly improved the care structure.
"Catheter ablation can replace an ICD in ventricular tachycardia, especially if the pump function of the left ventricle is not severely limited," says Prof. Deneke. "In principle, the method is intended as a therapy in addition to the ICD, because there is no research showing that there is an improvement in the prognosis in this setting."
1 Olgin JE et al, Wearable Cardioverter Defibrillator After Myocardial Infarction, September 27, 2018, N Engl J Med 2018; 379: 1205-1215 DOI: 10.1056 / NEJMoa1800781
The German Society for Cardiology – Cardiovascular Examination e.V. (DGK) with headquarters in Düsseldorf is a scientific non-profit medical association with more than 10,500 members. It is the oldest and largest cardiology company in Europe. The aim is to promote science in the field of cardiovascular disease, organize meetings, inform its members and develop guidelines. More information at www.dgk.org