[First cardioverter defibrillator (ICD) shock : Diagnostic and therapeutic procedure]

Patients with an implantable cardioverter defibrillator (ICD) who receive an appropriate ICD shock are known to subsequently have a worse prognosis. Despite the knowledge about the poorer prognosis, in the guidelines there are no clear instructions on how to proceed after the occurrence of an adequate ICD shock. The ToVAMI concept represents a treatment regimen for patients with first appropriate ICD shock after ventricular tachycardia (VT) or ventricular fibrillation (VF) and consists of three steps: 1) To = trigger optimization with the following triggers summarized under the acronym ICD-STEMi (ischemia, compliance, decompensation, stress, technical issue, electrolyte/endocrinological disorder and medication intoxication), 2) VA = ventricular arrhythmia treatment and 3) MI = medicinal and interventional prognostic heart failure treatment. The treatment after the first ICD shock consists not only of ablation or antiarrhythmic treatment but also encompasses a comprehensive suite of diagnostic and therapeutic measures, which require a systematic approach. The systematic application of this regimen can increase the detection rate of trigger factors for VT/VF and essentially contributes to an optimized medicinal and interventional prognostic heart failure treatment. Approximately 10% of patients have no clinical symptoms of worsening heart failure or ischemia during the first ICD shock, despite objective evidence of progressive heart failure or ischemia. In these patients, the first VT/VF shock is the sole warning signal for worsening of the cardiac status. This underscores the need for a systematic diagnostic work-up and treatment after the first ICD shock.