Zusammenfassung
Die Einführung des implantierbaren Kardioverter-Defibrillators (ICD) in die klinische Routine der Primär- und Sekundärprävention ventrikulärer Arrhythmien hat zu einer deutlichen Reduktion der Mortalität von Patienten mit hochgradig eingeschränkter linksventrikulärer Funktion geführt. Trotz des immensen Benefits dieser Therapie stellt im klinischen Alltag neben den adäquaten ICD-Therapien vor allem der hohe Anteil inadäquater Therapien ein großes Problem dar. Tachykard übergeleitetes Vorhofflimmern ist dabei neben supraventrikulären Tachykardien, Artefaktsensing und elektromagnetischen Interferenzen die häufigste Ursache für inadäquate ICD-Schocks. Da sowohl adäquate als auch inadäquate ICD-Schocks paradoxerweise die Mortalität erhöhen, kommt der Vermeidung von ICD-Therapien eine entscheidende Bedeutung zu. Neben den klassischen erweiterten Detektionskritieren (Stabilität, Onset und Morphologie des Kammerkomplexes) sowie den firmenspezifischen Zweikammer-ICD-Algorithmen gelingt eine Therapiereduktion vor allem durch Erhöhung der Detektionsfrequenz für ventrikuläre Tachykardien und Programmierung einer langen Detektionsdauer. Dies konnte eindrucksvoll in den neueren Studien wie MADIT-RIT, ADVANCE-III und PROVIDE gezeigt werden. Ein erhöhtes Risiko für Synkopen ist durch die Therapiereduktion nicht zur befürchten. Zusätzlich zur optimierten Programmierung kann der Anteil von adäquaten ICD-Therapien durch Antiarrhythmika und durch eine Katheterablation beeinflusst werden.
Abstract
Implantation of an internal cardioverter defibrillator (ICD) has become the routine therapy for primary and secondary prevention of ventricular arrhythmia due to its proven reduction of mortality. Despite the significant benefits for patients with highly reduced left ventricular function, ICD therapy, especially inappropriate ICD therapy, is a major concern in the daily routine. Causes of inappropriate ICD therapy can be divided into supraventricular arrhythmia, sensing problems and electromagnetic interference, with atrial fibrillation being the most common cause of inappropriate ICD shocks. As appropriate and inappropriate ICD therapies both seem to be associated with an increased mortality, physicians should focus on avoiding ICD therapy. Apart from enhanced detection criteria, such as stability, onset and QRS morphology as well as dual-chamber ICD algorithms, reduction of ICD therapy can safely be achieved by programming higher detection rates and prolonged detection as recent studies such as MADIT-RIT, ADVANCE III and PROVIDE were able to show. Antiarrhythmic drug therapy and catheter ablation of ventricular arrhythmia are further possibilities to reduce ICD therapy, especially in patients with repetitive ICD shocks due to recurrent ventricular arrhythmia.
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Einhaltung ethischer Richtlinien
Interessenkonflikt. J. Vogler, N. Gosau, J. Moser und B.A. Hoffmann: kein Interessenkonflikt. S. Willems: Referententätigkeiten: Biosense Webster, Boston Scientific, St. Jude Medical, Sanofi-Aventis, Bristol-Myers Squibb; Beratertätigkeit: Boehringer Ingelheim, Bayer. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Vogler, J., Gosau, N., Moser, J. et al. Aktuelle Strategien zur Vermeidung von ICD-Therapien. Kardiologe 8, 393–398 (2014). https://doi.org/10.1007/s12181-014-0605-9
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DOI: https://doi.org/10.1007/s12181-014-0605-9