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ICD-Therapie zur Primärprävention des plötzlichen Herztods

Der Patient nach Myokardinfarkt

ICD therapy for the primary prevention of sudden cardiac arrest

The patient after a myocardial infarction

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Herzschrittmachertherapie + Elektrophysiologie Aims and scope Submit manuscript

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Zusammenfassung

Die ICD-Therapie stellt einen wesentlichen Fortschritt in der Behandlung von Patienten mit hochgradig eingeschränkter linksventrikulärer Funktion nach Myokardinfarkt dar. Während die ICD-Implantation auch noch im Langzeitverlauf (>5 Jahre) nach Myokardinfarkt eine sinnvolle Option darstellt, sind diese Patienten früh nach Infarkt dem „kompetitiven“ Risiko eines arrhythmogenen und nicht-arrhythmogenen kardial bedingten Todes ausgesetzt, und die Verhinderung des plötzlichen Herztodes wird wegen eines dadurch erhöhten Risikos für einen nicht-arrhythmischen kardialen Tod zunichte gemacht (Konversionstheorie). Eine ICD-Implantation sollte bei Postinfarktpatienten mit einer linksventrikulären Ejektionsfraktion (LVEF) ≤30% daher möglichst frühestens zu einem Zeitpunkt von 30−40 Tagen nach Infarkt erfolgen. Unklar ist, wie das nicht unbeträchtliche Risiko für einen plötzlichen Herztod innerhalb der ersten 30−40 Tage nach Infarkt abgedeckt werden sollte. Weiterhin ist unklar, ob es sinnvoll ist, Patienten mit einer reduzierten Ventrikelfunktion nach Infarkt und einem zusätzlichen speziellen Risiko (nicht-anhaltende Kammertachykardien, Vorhofflimmern, Schenkelblock etc.) über die LVEF hinaus mit einem ICD zu behandeln und wie eine Risikostratifizierung aussehen sollte. In jedem Fall sollte eine ICD-Therapie rechtsventrikuläre Stimulation und Schocktherapie soweit wie möglich vermeiden.

Abstract

ICD therapy represents a major advance in the treatment of patients with severely impaired left ventricular function after myocardial infarction. While an ICD implantation also remains a valuable option late (>5 years) after myocardial infarction, patients early after this event are at a competitive risk of arrhythmogenic and nonarrhythmogenic cardiac death. Prevention of sudden cardiac death in patients early after myocardial infarction, therefore, just converts the mode of death in a significant number of patients from sudden to nonsudden cardiac death (conversion theory). In patients with a left ventricular ejection fraction (LVEF) of ≤30% after myocardial infarction, implantation of the ICD should, therefore, be postponed to at least 30–40 days after the event. It is, however, not clear how the risk of sudden cardiac death should be approached during this post infarction phase. Similarly, it is not clear if patients with a reduced LVEF post infarction and additional specific risks (nonsustained ventricular tachycardia, atrial fibrillation, bundle branch block, etc.) beyond this single criterion may also benefit from ICD implantation and which risk factors may be relevant. In any case, ICD therapy should avoid right ventricular pacing and shock discharges whenever possible.

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  1. Klinik für Innere Medizin – Kardiologie & Angiologie, Evangelisches Krankenhaus Bielefeld, Burgsteig 13, 33617, Bielefeld, Deutschland

    C.W. Israel

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Israel, C. ICD-Therapie zur Primärprävention des plötzlichen Herztods. Herzschr. Elektrophys. 21, 102–108 (2010). https://doi.org/10.1007/s00399-010-0084-z

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  • DOI: https://doi.org/10.1007/s00399-010-0084-z

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