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Ardian Rizal, MD

Department of Cardiology and Vascular Medicine


Medical Faculty of Brawijaya University
INTRODUCTION

O
U Non – Invasive
T PREDICTORS

L
I Invasive
PREDICTORS
N
E
GUIDELINES
1–3
Per 100.000
10-75
Per 100.000
3M <1%
Cases
In those 1 – in those 35 – Survival rate
worldwide
35 y.o. 64 y.o.
annually
Age
Etiology

• Over 35 yrs of age


• Coronary Heart Disease
• Under 35 yrs
• Cardiomyopathies
• Channelopathies
• Congenital Heart Disease
• Myocarditis
SCD is an important cause
of death after acute
myocardial infarction à
even after BB era

Prior SG, et al. Eur Heart J. 2001;22:1374-1450.


MERIT-HF Study Group. Lancet. 1999;353:2001-2007.Sweeney MO, PACE.
2001;24:871-888.
Clinical CAD

Primary Prevention

Sudden Cardiac
Arrest

Secondary Prevention

Survivor
Grundy SM, et al. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations. Circulation. 1999;100:1481–92.
Case Ilutration
History
¡ 52 y.o. woman
¡ Lives alone in rural community
¡ NYHA Class III
¡ PMHX: MI one year ago, echo on discharge
was 35%
¡ Medications: BB, ACE-I, lipid-lowering agent,
clopidorgrel, omega-3
Clinical Decisions
• Should this patient be referred for an ICD
evaluation?
• What factors enter into your decision?

• Is there anything else you’d want to know before


making the decision?
ICD
Primary Prevention

Primary Prevention à Risk Stratification is needed to


predict who will get the most benefit of ICD implantation
after MI

Several non invasive risk assessment have been proposed

T wave alternant, Heart Rate turbulent etc

Heart Rhythm, Vol 11, No 10, October 2014


European Heart Journal doi:10.1093/eurheartj/ehv316
} a periodic beat-to-beat variation in the amplitude or morphology of
the T wave on ECG

} It reflects spatiotemporal heterogeneity of repolarization that stems


from beat-to-beat alterations in intracellular calcium handling, which
is reflected in the shape and duration of the action potential at the
level of cardiac myocytes

Arrhythmia & Electrophysiology Review 2015;5(1):37–40


Nature Clinical Practice Cardiovascular Medicine (2005) 2, 522-528
Journal of Arrhythmia 30 (2014) 230–234
} The spectral method
} Modified moving average (MMA) method
} HRV is a physiological phenomenon of beat-to-beat variation in cardiac cycle
length, which is influenced by autonomic tone.
} Depressed HRV reflects autonomic disturbances, which may increase the risk of
lethal ventricular arrhythmias
Ways to Quantify HRV

Time Domain and Geometric Analyses

Frequency Domain Analysis

Non-Linear Analyses
} SDNN (estimate of overall HRV)

} HRV triangular index (estimate of overall HRV)

} SDANN (estimate of long-term components of HRV)

} RMSSD (estimate of short-term components of HRV)


} physiological phenomenon in response to a premature beat
The ABCD
(Alternans Before Cardioverter Defibrillator) Trial

J Am Coll Cardiol 2009;53:471–9