IMPANTABLE CARDIOVERTER DEFIBRILLATORS (ICDs) Janet McComb Freeman Hospital Newcastle upon Tyne

“Chain of Survival” Cummins et al Circulation 1991;83:

rapid access “Chain of Survival” Cummins et al Circulation 1991;83:

Eisenberg & Mengert, NEJM, 2001;344: Survival to leave hospital after out of hospital cardiac arrest: effect of arrest being witnessed 41% not witnessed

rapid access rapid CPR “Chain of Survival” Cummins et al Circulation 1991;83:

Rea et al, Circulation, 2001;104: Survival after out of hospital arrest: effect of early CPR OR 1.41 [ ] OR 2.15 [ ]

Holmberg et al Eur Heart J 2001;22: Survival after out of hospital arrest: effect of quality of CPR

Eisenberg & Mengert, NEJM, 2001;344: Survival to leave hospital after out of hospital cardiac arrest: initial rhythm not witnessed witnessed

rapid access rapid CPR rapid defibrillation “Chain of Survival” Cummins et al Circulation 1991;83:

Rapid defibrillation Larsen et al Ann Emerg Med 1993;22:80-84

Eisenberg & Mengert, NEJM, 2001;344: Survival to leave hospital after out of hospital witnessed cardiac arrest due to VF: PAD

Capucci et al Circulation 2002;106: Impact of first responder volunteers p=0.05

Myerburg et al Circulation 2002;106: Survival to leave hospital after out of hospital witnessed VF: Impact of AEDs in police cars

Survival to leave hospital after out of hospital witnessed VF: Impact of PAD & AEDs in police cars

Page et al N Engl J Med 2000;343:1210 VF in 14 of 99 who had lost consciousness (and had an ECG recorded) 6 (40%) survived to leave hospital Eisenberg & Mengert, NEJM, 2001;344:1304 home 71% nursing home 8% public place 21%

Survival to leave hospital after cardiac arrest

rapid access rapid CPR rapid defibrillation “Chain of Survival” Cummins et al Circulation 1991;83:

11 seconds

one or more leads, which will sense the heart rhythm pace the heart defibrillate the heart a generator, which contains the electrical circuitry for this The ICD comprises

RA lead LV lead RV leads

u 62 cc u Dual-chamber u 35-Joule output u Active Can ® electrode

Mortality reduction in ICD trials Primary preventionSecondary prevention

Myerberg et al Am J Cardiol 1997;80:10F-19F

Emergencies in ICD patients Shocks Rhythm problems Cardiac problems Other emergencies

Emergencies in ICD patients: Other emergencies Treat as usual

Emergencies in ICD patients: Cardiac problems Heart failure is common, treat as usual Myocardial infarction occurs, treat as usual (ECG may be paced, making it more difficult to interpret)

Emergencies in ICD patients: Shocks Shocks may be appropriate, or inappropriate

Emergencies in ICD patients: Shocks Appropriate shocks VT or VF

Emergencies in ICD patients: Shocks Inappropriate shocks AF sinus tachycardia lead fracture lead displacement sensing problems

Double counting: sensing from RV & LV

Double counting: LV lead displacement

Emergencies in ICD patients: Shocks Patients having one or two shocks are advised to contact their ICD clinic within 24 hours if they feel well

Emergencies in ICD patients: Shocks Patients having multiple shocks are advised to contact their nearest CCU or 999

Emergencies in ICD patients: Shocks Monitoring & recording of rhythm is important (appropriate vs inappropriate) If the shocks are inappropriate the ICD can be disabled by placing a magnet over it

Emergencies in ICD patients: Shocks Inappropriate shocks AF sinus tachycardia lead fracture lead displacement sensing problems drugs programming /revision

Emergencies in ICD patients: Rhythm problems “the ICD isn’t working” treat rhythm problem as usual

Emergencies in ICD patients: Cardiac arrest “the ICD isn’t working” If the ICD doesn’t deliver a shock within seconds, treat as usual If the ICD shocks, but does not resuscitate, treat as usual

ICDs: conclusions Many of the patients you resuscitate should receive an ICD Many of the patients you thrombolyse should be assessed for an ICD

ICDs: conclusions Patients with ICDs should be treated in the usual way If the ICD does not appear to be working treat cardiac arrest in the usual way If the ICD is giving “inappropriate” shocks it can be disabled with a magnet

ICDs: conclusions The ICD will not hurt bystanders or those resuscitating a patient So, don’t be concerned, and treat the patient as normal!

BRUGADA SYNDROME, LONG QT LEFT VENTRICULAR FUNCTION? RESUSCITATION FROM VT or VF REVASCULARISATION + RISK FACTOR MODIFICATION, ASA,  BLOCKERS, STATINS, etc NORMAL ACUTE ISCHAEMIA? CORONARY ARTERY DISEASE? RVOT TACHYCARDIA, FASCICULAR TACHYCARDIA, PRE EXCITED AF, CONSIDER ICD NYHA IV ACE I, SPIRONOLACTONE,  BLOCKERS, DIGOXIN NYHA I-III AMIODARONE REVASCULARISATION + RISK FACTOR MODIFICATION, ASA,  BLOCKERS, STATINS, etc ACUTE ISCHAEMIA? CORONARY ARTERY DISEASE? ACE I, SPIRONOLACTONE,  BLOCKERS, DIGOXIN IMPAIRED CONSIDER ICD EP REFERRAL