ESC SC/E /EHRA Guid idelin lines on on Cardia rdiac c Pa - - PowerPoint PPT Presentation

ESC SC/E /EHRA

Guid idelin lines on

• n Cardia

rdiac c Pa Pacin cing

Pa Pano nos E.

• E. Vard

rdas

Profe fesso sor o

• f C

f Card ardio iolo logy Hera raklio lion U University y Ho Hosp spit ital Cret ete, G Greece eece

Rea Reaso sons ns fo for r Euro Europea ean n Guid uidelin elines? es?

Scien cientific ic rea reaso sons Cult Cultural a and nd p polit litica ical rea reaso sons

Rea Reaso sons ns Necessit Necessitating ing Unifo niform rm Euro Europea ean n Guid uideli elines nes

Scien cientific ic rea reaso sons

• Ra

Rapi pid evolu

• luti

tion

• n
• f
• f

curre urrent kn knowle

• wledge

in in cert certain scien cientif ific areas areas

• Resu

esults of

• f recen

ecent pu publis lished tria rials ls conc ncerni ning ng the he in indic ication ions for paci acing, mode

• de sel

select ection, cos cost effectiven eness, ess, follow

• llow-up

up

• Util

iliz ization ion

• f
• f prim

imary ry expe perie rience from rom ne new th thera rape peutic ic moda

• dalit

itie ies, firs irst dev evel eloped ed in in Eur urope

• pe (CRT)

CRT).

Rea Reaso sons ns Necessit Necessitating ing Unifo niform rm Euro Europea ean n Guid uideli elines nes

Cult Cultural and nd polit litica ical rea reaso sons

• The

he uni unified Euro rope pean guide guidelin lines support pport fr fruitful sci scien entific colla

• llabo

bora ration ion which ch wi will ll benefi fit the div divers erse Eu Europ ropean requ require rements

• The

he Europe ropean guide idelin lines ar are an an ex excep ceptional al worldwide rldwide am ambassad assador for

• r

the he Europe ropean scie cientif ific communi unity.

ES ESC/ C/EHRA RA Guid uidelin elines es

ESC SC guide uidelines lines co cover er tw two main main are areas as: the he first first inc inclu ludes es permanent rmanent pacing cing in in bradya adyarrhyt rrhythmi hmias, as, sy sync ncop

• pe

and and

• ther

her sp spec ecific ific condit nditions

• ns,

while while the he second second refe efers rs to to vent ventricu icular lar resync resynchronisat hronisatio ion as as an adjunct unct thera herapy in in patie ients with th HF HF

ES ESC/ C/EHRA RA pacing cing guid uidelines elines

Appendi endices ces The guide uidelines lines have have been een enriched enriched wit with tw two app appendi endices ces that hat refe efer not not only nly to to convent nventional

• nal

pacemaker cemaker fo follo llow-up up bu but also lso to to technic echnical al consid considerat eratio ions ns and and requi equiremen rements for imp implant lanting ing and and fo follo llow- up of CRT CRT device evices.

ES ESC/ C/EHRA RA Guid uidelin elines es

Ma Main in t topics ics Convent ventiona ional indicat atio ions ns fo for pacin cing. Pa Pacin cing fo for sp speci ecific ic co cond ndit itions. Ca Card rdiac resynchr nchroniz nizat ation

• n therapy

apy.

Co Conven nventio ional l ind indica icatio ions s fo for r pacing cing

The E ESC/EHR HRA 2 A 2007 Gui Guidelines  pres esent deta tailed definitions ns  follow llow an an up up-to to-date ate approac ach to to the the ev evaluati tion

• f

patient ents wi with th synco ncope.  ta take into to cons nsiderati tion the the resul ults of rece cent nt tria ials ls (MOST,

ST, CTO CTOPP, PASE, SE, DAVID ID etc tc) an

and the the tech technologi gical ad advances, pro rovidi iding

• lev

evel el of ev eviden ence in in mode select ctio ion.

• recomm

mmend ndations

• ns

fo for the he us use

• f

ne new alg lgori rithms (MP MPV, V, ANTI NTITA TACH CHY)

Sinu inus no node d e disea isease

Reco Recommendations f for

• r card

cardia iac pacin pacing in in SND ND

Co Conven nventio ional l ind indica icatio ions s fo for r pacing cing

ES ESC/E C/EHRA RA 2007 2007 vs vs ACC/A CC/AHA/H /HRS RS 2008 2008 Guidelin idelines  Dif Differe erences in in termi minology

• logy:
• e.g. AC

ACC/AHA/ /AHA/HR HRS QLs QLs use the the ter erm “advanced seco cond nd degree ee AV AV block ck” whi while in in the he ESC SC 2007 GL GLs we we us use the the ter terms “seco cond degree AV AV block Mo Mobitz I or II” II”

 Dif Differe erences in in clas classif ificatio ion and ran rankin ing:

• e.g. Fo

For asym ympto tomati atic pati atients nts with th 3rd

rd degr

gree ee AVB AVB paci acing is is cons nsidered ed to to be cl class IIa Ia, Lo LoE C in in ES ESC/E /EHR HRA 2007 GLs, while ile it it is is cla lassif ifie ied as I, I, Lo LoE B in in the the presence ence of SHD, D, or if if the the site te of block is is below AVN AVN an and IIa IIa, Lo LoE C if if ther there is is no no SHD in in the the ACC/ CC/ AHA/ AHA/HR HRS QLs Ls

Co Conven nventio ional l ind indica icatio ions s fo for r pacing cing

The E ESC/EHR HRA 2 A 2007 Gui Guidelines  pres esent deta tailed definitions ns  follow llow an an up up-to to-date ate approac ach to to the the ev evaluati tion

• f

patient ents wi with th synco ncope.  ta take into to cons nsiderati tion the the resul ults of rece cent nt tria ials ls (MOST,

ST, CTO CTOPP, PASE, SE, DAVID ID etc tc) an

and the the tech technologi gical ad advances, pro rovidi iding

• lev

evel el of ev eviden ence in in mode select ctio ion.

• recomm

mmend ndations

• ns

fo for the he us use

• f

ne new alg lgori rithms (MP MPV, V, ANTI NTITA TACH CHY)

Reco Recommen endatio ions s fo for r ca card rdia iac c pacing cing in ca in caro rotid id sinus sy sinus synd ndro rome me

Reco Recommen endatio ions s fo for r ca card rdia iac c pacing cing in V in VVS (ESC/E

/EHR HRA 2 2007 GLs GLs)

Reco Recommendatio ions fo for r ca card rdia iac p c pacin cing in in VVS

(ACC/A CC/AHA/HRS RS 2008 2008 GLs)  Si Signif gnific icantly ly symptom ptomatic tic neu eurocar cardio-geni nic syn syncope asso associ ciat ated ed with with bra rady dycardia rdia docu cumen ented ed spon ponta taneou

• usly

ly or

• r at

at the he time of

• f tilt

ilt- table table tes testi ting is is clas class IIb IIb Lo LoE B

Co Conven nventio ional l ind indica icatio ions s fo for r pacing cing

The E ESC/EHR HRA 2 A 2007 Gui Guidelines  pres esent deta tailed definitions ns  follow llow an an up up-to to-date ate approac ach to to the the ev evaluati tion

• f

patient ents wi with th synco ncope.  ta take into to cons nsiderati tion the the resul ults of rece cent nt tria ials ls (MOST,

ST, CTO CTOPP, PASE, SE, DAVID ID etc tc) an

and the the tech technologi gical ad advances, pro rovidi iding

• lev

evel el of ev eviden ence in in mode select ctio ion.

• recomm

mmend ndations

• ns

fo for the he us use

• f

ne new alg lgori rithms (MP MPV, V, ANTI NTITA TACH CHY)

Pa Pacema cemaker mo er mode select e selectio ion n in sinus no in sinus node e disea isease se

Pa Pacing cing fo for r sp specifi ecific co cond nditio ions New New cha chapters ers:

• Sleep

leep-apno apnoea syndr ndrome

• me
• Adenosine

sine- sensit sitive ive syndr ndrome

• me

Sleep leep-apn apnoea a syn yndr drom

• me

 Atria rial overd rdrive paci acing ng at at a rate of 15 b.p.m. highe her tha than the the mean no noct cturnal al he heart rate had a positi tive eff effect ect on sleep apno noea, reduci ucing both th

• bstructi

uctive an and ce centr ntral apno noeic ep episodes in in pati atients nts who ho wer ere al already paced aced for co conv nventi tiona nal indicati cations.

Gar arrigue S, e , et al

• al. N E

. N Engl J M Med 2 2002

 These positi tive resul ults, were re no not co conf nfirmed ed by other ther stud tudies es tha that included patients nts wi with th pur ure obstr tructive sleep ep apnoea.

Sim imantirakis EN N e al l . N N Engl l J Me Med d 2005 Krahn A hn AD, D, J J Am Col

• ll C

Cardi diol

• l 2006

 More re stud tudies are re ne need eded to to cla larif rify the the possible effe fect of atria rial paci acing on slee eep apno noea an and to to dete termine in in wh which ch sub ubgr group ups

• f patients

nts thi this approach ach might ht be benefi nefici cial.

Ad Adeno enosin sine- sensit sensitive sy ive synd ndro rome me

There ha has be been no no wel ell-desi esigned ed rando andomi mized ed st study ab able le to to det etermine ermine the he ut util ilit ity of pacing ing in in pat atient ients wit with a posit

• sitive

ive ATP ATP test est, thu hus no no definit efinitiv ive rec ecom- mend ndatio ions ns ca can be ma made.

Ca Card rdia iac c Resy Resynchro nchroniz izatio ion Thera Therapy

ES ESC/EH C/EHRA RA 2007 2007 Reco Recommendation for

• r th

the u e use of e of cardia cardiac res resynchroniz izatio ion th thera erapy by by CRT CRT-P an and CRT d CRT-D i in HF patien patients

He Heart failu ilure pati tients nts, who ho rema main sympto tomati tic in in NYH YHA classes III III – IV IV, despite opti timal al medical the therapy, with th:

• LVE

LVEF < 35 %

• QR

QRS > 120 ms ms

• LV

LV dilata tati tion

• Normal sinus

nus rhy hythm thm

• Cla

lass I, I, le level of evidenc ence A for CRT-P to to reduce ce morbid idit ity and morta tality

CRT CRT-D D is is an an acc acceptable option

• ption f

for

• r patien

patients w who

• hav

ave ex expec pectancy of

• f surv

rvival > 1 1 year year

Ca Card rdia iac c Resy Resynchro nchronisa isatio ion Thera Therapy

Th The ES e ESC/EH C/EHRA RA 2007 2007 GLs

From rom a theo heoret etica cal poin int of vi view ew it it may may be mo more re app approp ropriat riate to to targ arget et me mechani chanical cal dyss yssynchr ynchrony, ny, rat rather her than han el elect ectrical rical conduc uctio ion dela elay Howev wever, er, th the ex exist isten ence ce

• f

mechanical chanical dyss yssynchr ynchrony ny in in HF has has not not yet yet been een est establ ablis ished hed as as a pat atient ient sel selec ection cr crit iterio erion fo for CRT CRT

CRT fo CRT for sp r specifi ecific issues issues

ES ESC/E C/EHRA RA 2007 2007 Guidelin idelines Clas Class Lo LoE

Pati tients nts with th mild ild HF or

• r asymp

mptoma tomatic LV LV sys ystolic ic dysfunc functi tion

III III C

Pati tients nts with th per ermanen ent AF AF and nd in indic dicat ation of AVJ AVJ abla blatio ion

IIa IIa C

Pati tients nts with th bradyc bradycardi ardic in indic icat ations for

• r

pa pacemaker im impla plantatio ion

IIa IIa C

Pati tients nts who who alre lready dy ha have ve a pace acemak aker im impla planted

IIa IIa C

Shou

• uld all

ll CRT pa patie ients ha have ve an IC ICD ba back-up up?

I B

Ca Card rdia iac c Resy Resynchro nchroniz izatio ion Thera Therapy

ES ESC/EH EHRA 2 A 2007 vs ACC/AHA/H AHA/HRS 2 2008 G Guidelines es

 Th Ther ere are re many ny sim imila larit itie ies in in cla lassific ication tion, rankin nking and patien patient selec election crite criteria ria  Howev ever er

• In

In the the ACC/AHA /AHA/HR HRS 2008 GLs GLs, LV LV dilata tation is is no not incl cluded in in the the selecti ection crit riteri ria

• In

In the he ACC/AHA/ /AHA/HR HRS 2008 GLs GLs, AF AF is is a cla lass IIa IIa LoE B ind ndica cati tion while ile in in ES ESC/ C/EHRA 2007 GL GLs only pati atient nts with th AF AF who who are re cand ndidates tes for AVJ VJ ab ablat ation have a cl class IIa IIa Lo LoE C indica cati tion

Issues ssues to b be a e addressed ressed in in the fut he future ure

 Pa Patien ient select selectio ion crit criteria eria

• Elect

ectrical cal or

• r mecha

hani nical as asyn ynchro rony

 Mild Mild hea heart rt fa failu ilure re (R

(REVERSE stud tudy)

 No No hea heart rt fa failu ilure

• Pacem

cemak aker er depen dependent patien patients

• Patie

ients ts with dys dyssynchrony

Conclus clusions ns

 The he rec ecen ently pub ublishe hed Guide idelin lines from rom both both side ides

• f
• f

the he Atla tlantic tic, based ased

• n
• n

the he lat atest est sci scien entific ev eviden ence ce con

• ntribu

tribute te to to the he im improv proved manageme ment nt of

• f PM

PM candida ndidate tes  Undou doubte btedly ly, the he ra rapid id ad advan ances ces in in our ur sci scien entific fiel eld re require quire the he freq equen ent upda pdating ing of

• f su

such ch GLs GLs to to in inclu lude de all ll the he fact acts tha hat are re im impo porta rtant for conte tempora porary ry ev evide idence-based ased medic edicin ine  Our ur ne next tar arget et is is the he im imple lementa tation ion

• f
• f

ES ESC/E C/EHRA RA 2007 2007 GLs GLs