Zusammenfassung
Bei Patienten, die bereits einen Herzstillstand, eine hämodynamische Beeinträchtigung oder eine Synkope aufgrund von ventrikulären Tachyarrhythmien überlebt haben, wird die Implantation eines ICD als Sekundärprophylaxe bezeichnet. Ziel ist es, eine Übersicht zur Studienlage bei der ICD-Therapie aus sekundärprophylaktischen Gründen zu geben.
Die Implantation eines ICD zur Sekundärprävention von lebensbedrohlichen ventrikulären Tachykardien ist effektiv bei der Verhinderung des plötzlichen arrhythmogenen Todes. Die Gesamtmortalität wurde durch den ICD relativ um 28% gesenkt. Es zeigt sich zwar ein moderater Benefit durch die ICD-Therapie zur Sekundärprävention, aber nur in einem engen Rahmen bei einer EF (Ejektionsfraktion) zwischen 20 und 35%.
Die bisherigen Studien wurden vorwiegend bei Patienten mit hämodynamisch instabiler Tachyarrhythmie durchgeführt und der Nutzen des ICD gezeigt. Bei Patienten mit stabiler ventrikulärer Tachyarrhythmie ist der Nutzen weniger eindeutig, und alternative Therapieverfahren müssen in die Differenzialtherapie einbezogen werden. Aufgrund des demografischen Wandels mit der Zunahme der älteren Patienten ist es von besonderer Bedeutung, die Frage nach der Sicherheit, Wirksamkeit und Kosten-Nutzen-Effektivität gerade beim älteren Patienten zu stellen. Die Empfehlungen der Leitlinien sind wichtig und sollten uns als Richtschnur dienen. Dennoch sollte die Indikation für einen ICD individuell nach einer Risiko-Nutzen-Abwägung gestellt werden und der Patient und dessen Angehörige in diese Entscheidung mit einbezogen werden.
Abstract
Patients who survive out-of-hospital cardiac arrest or symptomatic ventricular tachyarrhythmias are at considerable risk of recurrence of these events and ultimately death. The implantation of an implantable cardioverter defibrillator (ICD) in patients with previous sustained ventricular tachyarrhythmias (VT) is considered secondary prevention of sudden cardiac death. The purpose of this review is to summarize the most important trials on secondary prevention with an ICD.
The results from a meta-analysis showed a relative-risk reduction of 28% in overall mortality. Compared with amiodarone, an ICD provided maximal benefit for those patients with an ejection fraction between 20% and 35%. The results of the ICD trial demonstrate that there is clear evidence for the effectiveness of an ICD in patients with unstable VT; however, for patients with stable VT the results are less clear. Data on older patients are scant, and whether the survival benefit observed in the middle aged and younger-old also extend to older elderly patients with a more limited life span is less clear. Therefore, as the population becomes older, it is important to evaluate the safety, effectiveness, and the cost effectiveness of ICD implantation in this population.
Guidelines are important and helpful to guide clinical decisions, but the indication for an ICD still remains an individual decision after evaluation of the risks and benefits for the individual patient. However, the patient needs to be involved, which emphasizes the importance of dialogue between the patient and physician.
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Der korrespondierende Autor weist auf folgende Beziehungen hin: Vortragshonorare von St. Jude Medical.
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Seidl, K., Strauss, M. & Kleemann, T. ICD-Therapie zur Sekundärprävention. Herzschr. Elektrophys. 21, 96–101 (2010). https://doi.org/10.1007/s00399-010-0075-0
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DOI: https://doi.org/10.1007/s00399-010-0075-0