Fan Wuqiang, Khalighi Koroush
Department of Medicine, Easton Hospital, Easton, PA, USA ; School of Medicine, Drexel University, Philadelphia, PA, USA.
School of Medicine, Drexel University, Philadelphia, PA, USA ; EP Laboratory, Cardiovascular Institute, Easton Hospital, Easton, PA, USA.
J Community Hosp Intern Med Perspect. 2014 Apr 14;4(2). doi: 10.3402/jchimp.v4.23909. eCollection 2014.
Implantable cardioverter defibrillators (ICDs) are indeed beneficial in selected patients as evidenced by multiple large randomized controlled trials (RCTs) since 1980. A systematic method for stratification of patients and hospital-wide criteria/guidelines to ascertain appropriate device implantation became necessary.
Major ICD/CRT (cardiac resynchronization therapy) clinical studies and relevant guidelines were reviewed, and an institution-wide inclusion and exclusion criteria for ICD/CRT was formulated. A retrospective analysis of selected cases was performed to discuss the criteria and special clinical situations.
We have translated the evolving ICD/CRT studies into a standard of care at our hospital by formulating a standard, practical, and update-to-date ICD inclusion and exclusion criteria. Thirteen cases were selected to represent major indications and contraindications of ICDs in our practice. These cases cover indications of ICD for secondary prevention of sudden cardiac death (SCD), primary prevention of SCD in patients with CHF resulted from either ischemic or non-ischemic cardiomyopathy, as well as for infiltrative cardiomyopathy and inherited conditions. We discussed the application of CRT in patients with CHF associated with prolonged QRS duration. We then covered the potential benefits of ICD with/without CRT in certain special populations of patients that have not been adequately evaluated by currently available RCTs; these include alcoholic, elderly, female, and ESRD/HD patients. Finally, we addressed risks, complications and contraindications of ICD, as well as application of an external wearable defibrillator in AMI, or status post-CABG patient during the mandatory waiting period for an ICD.
Establishment of the ICD/CRT criteria represents a practical translation of emerging CRTs and helps to standardize patient care in our hospital. It also improves cost-effectiveness as well as appropriate utilization of institute and device resources.
自1980年以来，多项大型随机对照试验（RCT）证明，植入式心脏复律除颤器（ICD）对特定患者确实有益。因此，需要一种系统的患者分层方法以及全院范围的标准/指南来确定合适的设备植入。
回顾了主要的ICD/CRT（心脏再同步治疗）临床研究及相关指南，并制定了全院范围的ICD/CRT纳入和排除标准。对选定病例进行回顾性分析，以讨论这些标准及特殊临床情况。
我们通过制定标准、实用且最新的ICD纳入和排除标准，将不断发展的ICD/CRT研究转化为我院的护理标准。选取了13个病例来代表我院ICD的主要适应证和禁忌证。这些病例涵盖了ICD用于心脏性猝死（SCD）二级预防、缺血性或非缺血性心肌病所致心力衰竭患者SCD一级预防的适应证，以及浸润性心肌病和遗传性疾病的适应证。我们讨论了CRT在QRS波时限延长的心力衰竭患者中的应用。然后，我们探讨了在某些尚未得到现有RCT充分评估的特殊患者群体中，有/无CRT的ICD的潜在益处；这些群体包括酗酒者、老年人、女性以及终末期肾病/血液透析患者。最后，我们阐述了ICD的风险、并发症和禁忌证，以及体外可穿戴除颤器在急性心肌梗死患者或冠状动脉旁路移植术后患者在ICD强制等待期的应用。
ICD/CRT标准的建立是对新兴CRT研究的实际转化，有助于规范我院的患者护理。它还提高了成本效益，并促进了机构和设备资源的合理利用。
