Optimierte ICD-Therapie: Wie können inadäquate ICD-Schocks vermieden werden?

Abstract

ICD shocks can save lives but are associated with a reduced quality of life and may herald a deterioration of the underlying heart disease. Optimization of ICD programming can prevent inappropriate and unnecessary shocks which may be associated with an improved survival, as recent studies showed. This review provides recommendations on the use of enhanced detection criteria, antitachycardia pacing, tachycardia detection rates, and delayed tachycardia detection to minimize shock discharges in ICD patients.

Kernaussagen

Vermeidung von ICD-Schockabgaben bei gleichzeitiger Sicherstellung der (rechtzeitigen) Abgabe notweniger Schocks (Tab. [2]):

• Vermeidung inadäquater Schockabgaben durch Aktivierung der VT/SVT-Diskriminierung und spezieller Algorithmen zur Früherkennung von Elektrodendefekten

• Verlängerung der Tachykardiedetektion auf 30 konsekutive Intervalle in den Zonen bis 187/min und auf „30 aus 40“ Intervalle bei Zonen ≥ 188 /min

• viele ventrikuläre Tachyarrhythmien terminieren in diesem Zeitraum spontan

• Limitierung der ICD-Therapien auf Tachykardien > 187/min bei Patienten mit primärprophylaktischer Indikation möglich

• Cave: Bei Patienten mit sekundärprophylaktischer Indikation, vor allem bekannten monomorphen Tachykardien, unter Amiodaron-Therapie, nach Ablation von Kammertachykardien oder sehr niedriger linksventrikulärer Ejektionsfraktion Risiko für Tachykardien unterhalb der Detektionsfrequenz

• antitachykarde Stimulation (z. B. 2 Bursts à 8 Zyklen bei 85 – 88 % der Tachykardie-Zykluslänge) bis zu Frequenzen von 250 /min aktivieren, weil damit bei ca. 80 % der Patienten ICD-Schockabgaben vermieden werden können

• antitachykarde Stimulation während Aufladung des ICD zur Schockabgabe bei vielen Systemen aktivierbar

• ICD-Schocks auf maximale Energie programmieren, um während der Ladezeit Spontanterminierung von Tachykardien zu ermöglichen

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