ESC Congress 2017 In Review – Focus on Arrhythmias - 15

ESC Congress 2017

In Review

Arrhythmias

So, while LVEF remains the only predictor of SCD
that has been validated in RCTs, it has some limitations. Improved methodologies to target the highest
risk patients for ICD implant is a must and should be a
dynamic process.
Identifying the benefits and risks of ICD therapy
is necessary, but, according to Brian Olshansky, MD,
University of Iowa, Des Moines, Iowa, USA, critically
important is quality of life (QOL). ICD implantation both
improves, and challenges, the QOL of an ICD recipient
(Table 1). Concerns about poor QOL could deter recommendations for or use of an ICD implant.
Table 1. Quality of Life Components Related to ICD Implantation
Positives of ICDs

Negatives of ICDs

Lifesaving

Bodily image

Protection

Restrictions
Unexpected, painful shocks

QOL may also depend on the type of ICD implanted
(subcutaneous vs transvenous and single chamber vs
resynchronization). It is also important to recognize that
the ICD can affect more than just the patient; it can affect
the patient's partner as well [Dougherty CM J. Behav
Med. 2016].
European Guidelines recommend a discussion of
QOL issues before ICD implant and during disease progression in all patients. Additionally, after ICD implantation, assessment of psychological status and treatment
of distress is recommended in patients with recurrent
inappropriate shocks [Priori SG. Eur Heart J. 2015].
For some, ICD implantation leads to diminished QOL.
Discussions between patients and their doctor before, and
at select times after implantation is strongly recommended
to assuage future concerns. This can give patients, their
partners, and their family a proper perspective and provides
realistic expectations to ensure the happiest outcomes.

Tied to the healthcare system

QOL covers a broad range of subjectively evaluated mental and physical aspects of life. Several dozen
tools to measure QOL exist and the best to use for ICD
patients is uncertain. The widely used 36-Item Short
Form Survey (SF-36) questionnaire, a good benchmark
of QOL, can vary by pre-implant personality, anxiety,
depression, age, comorbidities, sex, social support, cultural beliefs and ICD indication among other issues.
QOL can change with age and with life circumstances. A
patient's attitude towards their ICD can change for better
or worse [Mark DB et al. N Engl J Med. 2008; Perini AP
et al. Am Heart J. 2017].
Data from primary prevention and secondary prevention trials have shown that for most ICD patients,
QOL is on par with those who do not receive ICDs. Most
data, however, show that frequent ICD shocks adversely
affect QOL (especially if there 5 or more) [Sears SF Jr,
Conti JB. Heart. 2002].
From the INTRINSIC RV Trial [Gopinathannair R. J
Interv Card Electrophysiol. 2017], researchers found: 1)
QOL improves over time post-ICD implant; 2) women
started with lower QOL but improved more over time
than men; 3) no difference in QOL with or without ICD
shocks; and 4) those under age 50 scored worse at baseline but improved the most over time.
Implantation of an ICD in paediatric age patients is
a concern; QOL scores are lower than even chronically
ill children. An ICD can be a big blow to a child leading
to avoidance of activities in up to 85%, especially for
females [Sears SF et al. Am J Cardiol. 2011]. However,
children may deal with their new ICD reality better than
parents think. ICD implantation now does not necessarily mean restriction as even competitive athletes can
and are now participating in sports [Lampert R et al.
Circulation. 2013].

Advances in Heart Failure
Devices
Written by Nicola Parry

Sudden cardiac death (SCD) is responsible for the
deaths of 325,000 individuals each year, said Valentina
Kutyifa, MD, PhD, University of Rochester Medical Center,
Rochester, New York, USA. However, since the 1990s,
significant medical advances have led to improved
medical therapies, including drugs such as eplerenone
and angiotensin receptor-neprilysin inhibitors that have
reduced the risk for cardiovascular (CV) death and SCD.
The introduction of implantable cardioverter-defibrillators (ICDs) and cardiac resynchronisation therapy
devices (CRT-Ds) has further shaped the landscape of
SCD prevention. Importantly, CRT-Ds have significantly
improved rates of heart failure (HF) hospitalisations and
survival, and reduced the risk for ventricular tachycardia (VT) and ventricular fibrillation (VF), thereby contributing to the decline of SCD in HF in recent decades
[Shen L et al. N Engl J Med. 2017].
In a symposium on ICDs and CRT-Ds, speakers shared
data from studies investigating use of these devices in
specific patient populations, and highlighted new trials
that may guide future developments in this setting.
Device Implantation in DCM
According to Georg Wolff, University Hospital Düsseldorf,
Düsseldorf, Germany, although ICD therapy is used for
primary prevention in patients with HF due to dilated
cardiomyopathy (DCM), the DANISH trial showed that
prophylactic ICD implantation was not associated with
significant improvement in all-cause mortality compared
with usual clinical care in that population [Køber L et al. N
Engl J Med. 2016].
Official Peer-Reviewed Highlights From ESC Congress 2017

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