Zusammenfassung
Eine Erweiterung der Indikation für die Implantation von Defibrillatoren (ICD) ist in den letzten Jahren im eigentlichen Sinne nicht mehr erfolgt. Dennoch kann eine weitere Steigerung der Implantationszahlen durch die älter werdende Bevölkerung und eine zunehmende Rekrutierung unterversorgter Regionen für die nächsten Jahre erwartet werden. Obwohl die erste Defibrillatorimplantation in Deutschland mehr als 20 Jahre zurückliegt und die ICD-Therapie nach Leitlinien als medizinischer Standard in der Sekundär- und Primärprophylaxe gilt, gibt es noch wesentliche offene Fragen, die nur prospektiv zu klären sind: 1. Wann ist der richtige Zeitpunkt für die ICD-Implantation? 2. Können Prädiktoren mit vor allem negativem prädiktivem Wert verwendet werden, um Patienten die ICD-Therapie vorzuenthalten? 3. Muss die Risikostratifizierung, die zurzeit das Risiko zu einzelnen Zeitpunkten im Krankheitsverlauf wie ein Schnappschuss dokumentiert, den zeitlichen Verlauf des Risikos stärker einbeziehen? Hier wäre möglicherweise ein Umdenken von einer Risikostratifizierung im herkömmlichen Sinne auf eine Risikostratifizierung im Sinne einer Beobachtung notwendig. Eine adjuvante Therapie im Sinne einer Ablation von ventrikulären Tachykardien (VT) oder einer antiarrhythmischen Therapie zur Primärprävention von häufigen Episoden scheint nach der gegenwärtigen Datenlage angeraten. Der richtige Zeitpunkt für eine ergänzende Intervention ist aber noch unklar.
Abstract
An expansion of the indications for the implantation of defibrillators (ICD) has not occurred as such in recent years. Nevertheless, an increase in the number of implantation figures can be expected due to the aging population and an increasing recruitment of undersupplied regions in upcoming years. Although the first defibrillator was implanted over 20 years ago in Germany and that ICD therapy is considered as the medical standard in secondary and primary prophylaxis, there are still basic questions that can only be prospectively clarified: (1) when is the right point in time for ICD implantation? (2) Can predictors, especially those with a negative predictive value, be used to exclude patients from ICD therapy? (3) Should risk stratification, which documents the current risk for a single point in time during the illness like a snapshot, more strongly reflect the development over time of the risk? In this case, it is likely that a rethinking of risk stratification, in general, to risk stratification in the sense of observation would be necessary. An adjuvant therapy in the sense of ablation of ventricular tachycardia (VT) or antiarrhythmic therapy for primary prevention of frequently occurring episodes seems to be advised based on current data. However, the right point in time for a complementary intervention is still not clear.
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Der korrespondierende Autor weist auf Beziehungen zu folgenden Firmen hin: Biotronik, Medtronic, St. Jude Medical, Boston Scientific, Bioscience; Beratungs- und Referententätigkeiten, Honorare, Reisekostenübernahme, Drittmittel.
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Bänsch, D., Grönefeld, G. Der Patient mit chronischer Herzinsuffizienz. Herzschr. Elektrophys. 21, 112–116 (2010). https://doi.org/10.1007/s00399-010-0078-x
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DOI: https://doi.org/10.1007/s00399-010-0078-x