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Published on: July 29, 2011
Practice viewpoints: AICD, who and when?
1Institute of Life Sciences, National Central University, Jhongli, Taoyuan, Taiwan; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA.
Insights
Automatic implantable cardioverter-defibrillators (AICD) prevent sudden cardiac death (SCD) but require better risk stratification. Identifying and correcting reversible causes of arrhythmias can avoid unnecessary AICD implantation, improving cost-effectiveness.
Area of Science:
- Cardiology
- Medical Devices
- Genetics
Background:
- Sudden cardiac death (SCD) prevention is crucial, with automatic implantable cardioverter-defibrillators (AICDs) being an effective but costly option.
- Atherosclerotic heart disease (ASHD) is a primary cause of SCD in adults, with varying SCD rates across racial/ethnic groups.
- Current risk stratification for AICD implantation in ASHD patients, particularly post-myocardial infarction, lacks specificity.
Purpose of the Study:
- To review the current landscape of AICD use for sudden cardiac death prevention.
- To emphasize the importance of identifying and addressing reversible causes of ventricular arrhythmias before AICD implantation.
- To highlight the need for improved risk stratification markers, including genetic factors, for AICD candidates.
Main Methods:
- Literature review and analysis of existing data on SCD causes and AICD efficacy.
- Discussion of diagnostic work-up protocols for identifying transient or reversible causes of lethal arrhythmias.
- Exploration of potential genetic markers for risk stratification in ASHD patients.
Main Results:
- Reversible causes of lethal ventricular tachyarrhythmias can often be corrected, potentially negating the need for AICD implantation.
- Left ventricular function status alone is insufficient for guiding AICD decisions in ASHD patients post-myocardial infarction.
- Development of better biological, physiological, or genetic markers is urgently needed for accurate patient selection.
Conclusions:
- Physicians must thoroughly evaluate patients for reversible causes of arrhythmias before considering AICD implantation.
- Enhanced risk stratification strategies, potentially incorporating genetic markers, are essential for optimizing AICD use and cost-effectiveness.
- Further research into genetic markers is warranted for precise SCD risk assessment in ASHD patients.
Abstract:
Automatic implantable cardioverter-defibrillator (AICD) is a costly but effective treatment modality for the prevention of sudden cardiac death (SCD). Causes of SCD are age-dependent, disease-specific and affected by racial/ethnic differences. Atherosclerotic heart disease (ASHD) is the most frequent underlying disease in individuals ≥35 years old. Available information suggests that Asians have a lower rate of SCD compared with African black individuals and Caucasians. Whether it is for secondary or for primary prevention, physicians should be educated to perform a thorough diagnostic work-up and be able to identify transient and/or reversible causes of lethal ventricular tachyarrhythmias such as acute myocardial infarction, residual ischaemia, electrolyte imbalance, adverse effect of drugs, valvular heart diseases, etc before contemplating AICD implantation. Correction of these reversible causes may avoid the necessity of AICD implantation. The status of left ventricular function is not sufficiently specific for guiding AICD implantation in ASHD patients after acute myocardial infarction. The urgent need is to develop better biological or physiological markers for risk stratification so that patients who would actually benefit from AICD implantation can be readily identified. Such an approach will make the use of AICD more cost-effective. Based on molecular genetic data obtained from patients with inherited structural cardiovascular diseases and malignant arrhythmogenic disorders in which the risk of SCD appears to be gene- and/or mutant-specific, a continuous search for genetic markers for better risk stratification is warranted in patients suffering from ASHD.
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