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Adhantoro Rahadyan Esnawan Antariksa Hospital

Adhantoro Rahadyan

Esnawan Antariksa Hospital

Adhantoro Rahadyan Esnawan Antariksa Hospital
 The indications for implantable cardioverter- defibrillators (ICDs) for the prevention of sudden cardiac death
 The indications for implantable cardioverter- defibrillators (ICDs) for the prevention of sudden cardiac death
 The indications for implantable cardioverter- defibrillators (ICDs) for the prevention of sudden cardiac death

The indications for implantable cardioverter-

defibrillators (ICDs) for the prevention of sudden cardiac death have rapidly expanded over the past

10 years based on several RCT

The optimal timing of defibrillator insertion after myocardial infarction remains unresolved

based on several RCT  The optimal timing of defibrillator insertion after myocardial infarction remains unresolved
based on several RCT  The optimal timing of defibrillator insertion after myocardial infarction remains unresolved
based on several RCT  The optimal timing of defibrillator insertion after myocardial infarction remains unresolved
based on several RCT  The optimal timing of defibrillator insertion after myocardial infarction remains unresolved
based on several RCT  The optimal timing of defibrillator insertion after myocardial infarction remains unresolved
Biochemical and electrophysiological factors  Acute myocardial ischaemia is accompanied by significant intracellular

Biochemical and electrophysiological factors

Acute myocardial ischaemia is accompanied by significant intracellular and extracellular ionic and metabolic alterations of the myocardial syncytium.

Extracellular changes include: elevated potassium, lysophosphoglycerides and adenosine concentrations, increased lactate and carbon dioxide production, acidosis, and catecholamine release. Concomitantly, intracellular changes include:

acidosis, elevated cyclic adenosine monophosphate (cAMP), and elevated

concentrations of calcium, magnesium, and sodium ion.*

Autonomic nervous system

The

pathophysiological

role

of

the

autonomic

nervous

system

(ANS)

in

arrhythmogenesis

has

been

firmly

established

both

experimentally

and

clinically . **

Within minutes of myocardial ischaemia there is a striking surge of sympathetic

nerve activity caused by a combination of pain, anxiety and reflex activation, which has been demonstrated to be inversely related to left ventricular ejection fraction

be inversely related to left ventricular ejection fraction * Corr PB, Yamada KA. Selected metabolic alterations
be inversely related to left ventricular ejection fraction * Corr PB, Yamada KA. Selected metabolic alterations
be inversely related to left ventricular ejection fraction * Corr PB, Yamada KA. Selected metabolic alterations

*Corr PB, Yamada KA. Selected metabolic alterations in the ischemic heart and their contributions to arrhythmogenesis. In: Zehender M, Meinertz T, Just H. (eds) Myocardial Ischaemia and Arrhythmia. New York: Steinkopff Darmstadt, 1994; 15

33

** Schwartz PJ. The autonomic nervous system and sudden death. Eur Heart

J1998; 19 (Suppl F): F7280 3 .

 In the post-infarction period, impaired vagal tone, as documented by decreased baroreflex sensitivity and
 In the post-infarction period, impaired vagal tone, as documented by decreased baroreflex sensitivity and

In the post-infarction period, impaired vagal tone, as

documented by decreased baroreflex sensitivity and heart

rate variability, has been associated with increased inducibility of sustained monomorphic ventricular tachycardia and with sudden death.***

***(La Rovere MT, Bigger Jr JT, Marcus FI, Mortara A, Schwartz PJ. Baroreflex sensitivity and heart-rate variability in prediction of total cardiac mortality after myocardial infarction. ATRAMI (Autonomic Tone and Reflexes After Myocardial Infarction) Investigators. Lancet 1998; 351: 47884)

 5% to 10% of hospitalized patients may develop ventricular tachycardia (VT)/ventricular fibrillation (VF), usually
 5% to 10% of hospitalized patients may develop ventricular tachycardia (VT)/ventricular fibrillation (VF), usually
 5% to 10% of hospitalized patients may develop ventricular tachycardia (VT)/ventricular fibrillation (VF), usually

5% to 10% of hospitalized patients may develop ventricular tachycardia (VT)/ventricular fibrillation (VF), usually within 48 hours

A study of 277 consecutive patients with NSTE-ACS who underwent cardiac catheterization within 48

hours found VT/VF occurring in 7.6% of patients, 60%

of which developed within 48 hours after admission

occurring in 7.6% of patients, 60% of which developed within 48 hours after admission 2014 AHA/ACC
occurring in 7.6% of patients, 60% of which developed within 48 hours after admission 2014 AHA/ACC
occurring in 7.6% of patients, 60% of which developed within 48 hours after admission 2014 AHA/ACC
occurring in 7.6% of patients, 60% of which developed within 48 hours after admission 2014 AHA/ACC

2014 AHA/ACC NSTE- ACS Guideline

 In the Valsartan in Acute Myocardial Infarction Trial (VALIANT), the risk of sudden death
 In the Valsartan in Acute Myocardial Infarction Trial (VALIANT), the risk of sudden death
 In the Valsartan in Acute Myocardial Infarction Trial (VALIANT), the risk of sudden death

In the Valsartan in Acute Myocardial Infarction Trial (VALIANT), the risk of sudden death was highest in the first 30 days after an MI ; 1.4% per month

In

mortality rates were higher in patients with VT

days, 1-year

patients

who

survived

at

30

(7.2%) or both VT and VF (7.1%) when compared

with the patients with either VF (2.9%)

1-year patients who survived at 30 (7.2%) or both VT and VF (7.1%) when compared with
1-year patients who survived at 30 (7.2%) or both VT and VF (7.1%) when compared with
1-year patients who survived at 30 (7.2%) or both VT and VF (7.1%) when compared with
1-year patients who survived at 30 (7.2%) or both VT and VF (7.1%) when compared with
1-year patients who survived at 30 (7.2%) or both VT and VF (7.1%) when compared with
Acute management of MI found a 90-day cardiovascular mortality rate of 9%  75% of
Acute management of MI found a 90-day cardiovascular mortality rate of 9%  75% of
Acute management of MI found a 90-day cardiovascular mortality rate of 9%  75% of

Acute management of MI found a 90-day

cardiovascular mortality rate of 9%

75% of the deaths judged to be coronary artery

disease-related nonsudden death,

9% coronary artery disease-related sudden death, and

4% due to sudden death not related to coronary

artery disease

9% coronary artery disease-related sudden death, and  4% due to sudden death not related to
9% coronary artery disease-related sudden death, and  4% due to sudden death not related to
9% coronary artery disease-related sudden death, and  4% due to sudden death not related to
9% coronary artery disease-related sudden death, and  4% due to sudden death not related to
9% coronary artery disease-related sudden death, and  4% due to sudden death not related to
In multivariate analysis  90 days, mortality was higher for patients with ventricular tachyarrhythmias compared
In multivariate analysis  90 days, mortality was higher for patients with ventricular tachyarrhythmias compared

In multivariate analysis

90 days, mortality was higher for patients with ventricular tachyarrhythmias compared with those

patients without ventricular tachyarrhythmias

(23.6% vs 3.6%, adjusted HR: 3.63; 95% CI: 2.59

5.09

compared with those patients without ventricular tachyarrhythmias (23.6% vs 3.6%, adjusted HR: 3.63; 95% CI: 2.59
compared with those patients without ventricular tachyarrhythmias (23.6% vs 3.6%, adjusted HR: 3.63; 95% CI: 2.59
compared with those patients without ventricular tachyarrhythmias (23.6% vs 3.6%, adjusted HR: 3.63; 95% CI: 2.59
compared with those patients without ventricular tachyarrhythmias (23.6% vs 3.6%, adjusted HR: 3.63; 95% CI: 2.59
compared with those patients without ventricular tachyarrhythmias (23.6% vs 3.6%, adjusted HR: 3.63; 95% CI: 2.59
 Medical  Revascularization  Cardiac Device ( ICD) Primary Prevention Secondary Prevention
 Medical  Revascularization  Cardiac Device ( ICD) Primary Prevention Secondary Prevention
 Medical  Revascularization  Cardiac Device ( ICD) Primary Prevention Secondary Prevention

Medical

Revascularization

Cardiac Device ( ICD)

 Medical  Revascularization  Cardiac Device ( ICD) Primary Prevention Secondary Prevention

Primary

Prevention

 Medical  Revascularization  Cardiac Device ( ICD) Primary Prevention Secondary Prevention

Secondary

Prevention

 Medical  Revascularization  Cardiac Device ( ICD) Primary Prevention Secondary Prevention
 Medical  Revascularization  Cardiac Device ( ICD) Primary Prevention Secondary Prevention
 Medical  Revascularization  Cardiac Device ( ICD) Primary Prevention Secondary Prevention
 Medical  Revascularization  Cardiac Device ( ICD) Primary Prevention Secondary Prevention
 Medical  Revascularization  Cardiac Device ( ICD) Primary Prevention Secondary Prevention
  Trial Year Patient LVEF Additional Study Features Hazard 95% CI p s Ratio* (n)
  Trial Year Patient LVEF Additional Study Features Hazard 95% CI p s Ratio* (n)
  Trial Year Patient LVEF Additional Study Features Hazard 95% CI p s Ratio* (n)
 

Trial

Year

Patient

LVEF

Additional Study Features

Hazard

95% CI

p

s

Ratio*

(n)

 

MADIT I

1996

196

< 35%

NSVT and EP+

0.46

(0.26-0.82)

p=0.009

MADIT II

2002

1232

< 30%

Prior MI

0.69

(0.51-0.93)

p=0.016

CABG-

1997

900

< 36%

+SAECG and CABG

1.07

(0.81-1.42)

p=0.63

Patch

DEFINITE

2004

485

< 35%

NICM, PVCs or NSVT

0.65

(0.40-1.06)

p=0.08

DINAMIT

2004

674

< 35%

6-40 days post-MI and Impaired HRV

1.08

(0.76-1.55)

p=0.66

SCD-HeFT

2006

1676

< 35%

Prior MI of NICM

0.77

(0.62-0.96)

p=0.007

AVID

1997

1016

Prior cardiac

NA

0.62

(0.43-0.82)

NS

arrest

CASH†

2000

191

Prior cardiac

NA

0.766

1-sided

arrest

p=0.081

CIDS

2000

659

Prior cardiac

NA

0.82

(0.60-1.1)

NS

arrest,

syncope

* Hazard ratios for death from any cause in the ICD group compared with the non-ICD group. Includes only ICD and amiodarone patients from CASH. ‡CI Upper Bound 1.112 CI indicates Confidence Interval, NS = Not statistically significant, NSVT = nonsustained ventricular tachycardia, SAECG = signal-averaged electrocardiogram.

Epstein A, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol 2008; 51:e162. Table

 ICD therapy is indicated before discharge in patients who develop sustained VT/VF more than
 ICD therapy is indicated before discharge in patients who develop sustained VT/VF more than

ICD therapy is indicated before discharge in patients who develop sustained VT/VF more than 48 hours after

STEMI, provided the arrhythmia is not due to transient

or reversible ischemia, reinfarction, or metabolic abnormalities*

Radiofrequency catheter ablation at a specialized ablation centre followed by the implantation of an ICD should be considered in patients with recurrent VT, VF

or electrical storms despite complete revascularization

and optimal medical treatment.**

complete revascularization and optimal medical treatment.** * 2013 ACC/AHA Guideline for the Management of ST-Elevation
complete revascularization and optimal medical treatment.** * 2013 ACC/AHA Guideline for the Management of ST-Elevation
complete revascularization and optimal medical treatment.** * 2013 ACC/AHA Guideline for the Management of ST-Elevation

*2013 ACC/AHA Guideline for the Management of ST-Elevation Myocardial Infarction ** 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death

 In patients within 90 days of revascularization who have previously qualified for the implantation
 In patients within 90 days of revascularization who have previously qualified for the implantation

In patients within 90 days of revascularization who have previously qualified for the implantation of an ICD for secondary prevention of sudden cardiac

death (resuscitated from cardiac arrest due to

ventricular tachyarrhythmia) and have abnormal left ventricular function, implantation of an ICD is recommended.

function, implantation of an ICD is recommended . HRS/ACC/AHA Expert Consensus Statement on the Use of
function, implantation of an ICD is recommended . HRS/ACC/AHA Expert Consensus Statement on the Use of
function, implantation of an ICD is recommended . HRS/ACC/AHA Expert Consensus Statement on the Use of
function, implantation of an ICD is recommended . HRS/ACC/AHA Expert Consensus Statement on the Use of

HRS/ACC/AHA Expert Consensus Statement on

the Use of Implantable Cardioverter-Defibrillator Therapy

 Aggressive therapy to reduce the risk of sudden cardiac death in the early period
 Aggressive therapy to reduce the risk of sudden cardiac death in the early period

Aggressive therapy to reduce the risk of sudden cardiac death in the early period after MI directed toward revascularization and improvement in

left ventricular function and clinical heart failure

can be a more prudent and effective strategy as compared with early ICD implantation

and clinical heart failure can be a more prudent and effective strategy as compared with early
and clinical heart failure can be a more prudent and effective strategy as compared with early
and clinical heart failure can be a more prudent and effective strategy as compared with early
and clinical heart failure can be a more prudent and effective strategy as compared with early
and clinical heart failure can be a more prudent and effective strategy as compared with early
2015 ESC Guidelines for the management of the management of patients with ventricular Arrhytmias and
2015 ESC Guidelines for the management of the management of patients with ventricular Arrhytmias and

2015 ESC Guidelines for the management of the management of patients with ventricular Arrhytmias and the prevention of suddent cardiac death

IIIIIIIII IIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
IIIIIIIII IIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
IIIIIIIII IIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
IIIIIIIII IIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
ICD therapy is indicated in patients who are survivors of
cardiac arrest due to ventricular fibrillation or
hemodynamically unstable sustained VT after evaluation
to define the cause of the event and to exclude any
completely reversible causes.
ICD therapy is indicated in patients with LVEF less than
35% due to prior MI who are at least 40 days post-MI and
are in NYHA functional Class II or III.
ICD therapy is indicated in patients with LV dysfunction due
to prior MI who are at least 40 days post-MI, have an LVEF
less than 30%, and are in NYHA functional Class I.

All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical

therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

and have reasonable expectation of survival with good functional capacity for more than 1 year. 2008
and have reasonable expectation of survival with good functional capacity for more than 1 year. 2008

2008 ACC/AHA Guideline

 ‘ Primary Prevention ’: ◦ Previous MI and all of the following:  Non-sustained
 ‘ Primary Prevention ’: ◦ Previous MI and all of the following:  Non-sustained
 ‘ Primary Prevention ’: ◦ Previous MI and all of the following:  Non-sustained

Primary Prevention’:

Previous MI and all of the following:

Non-sustained VT on 24 hour ECG monitoring

Inducible VT on electrophysiological testing

LV ejection fraction < 35%, NYHA Class > 3

A familial condition with a high risk of sudden death, e.g. Long QT, HOCM, Brugada syndrome, ARVD, repaired

tetralogy of Fallot

www.nice.org.uk September 2000

of sudden death, e.g. Long QT, HOCM, Brugada syndrome, ARVD, repaired tetralogy of Fallot www.nice.org.uk September
of sudden death, e.g. Long QT, HOCM, Brugada syndrome, ARVD, repaired tetralogy of Fallot www.nice.org.uk September
of sudden death, e.g. Long QT, HOCM, Brugada syndrome, ARVD, repaired tetralogy of Fallot www.nice.org.uk September
of sudden death, e.g. Long QT, HOCM, Brugada syndrome, ARVD, repaired tetralogy of Fallot www.nice.org.uk September
of sudden death, e.g. Long QT, HOCM, Brugada syndrome, ARVD, repaired tetralogy of Fallot www.nice.org.uk September
Implantasi DKI diharuskan pada :  1. Pasien dengan FEVKi ≤ 35% dan kelas fungsional
Implantasi DKI diharuskan pada :  1. Pasien dengan FEVKi ≤ 35% dan kelas fungsional
Implantasi DKI diharuskan pada :  1. Pasien dengan FEVKi ≤ 35% dan kelas fungsional

Implantasi DKI diharuskan pada:

1. Pasien dengan FEVKi 35% dan kelas fungsional II atau III

NYHA, yang disebabkan IM, paling cepat 40 hari setelah kejadian serangan jantung.

2. Pasien dengan FEVKi 30% dan kelas fungsional I NYHA,

yang disebabkan IM, paling cepat 40 hari setelah kejadian

serangan jantung.

3. Pasien yang selamat dari kejadian henti jantung karena FV

atau TV yang menetap dengan hemodinamik tidak stabil,

dan tidak ditemukan penyebabnya yang reversibe

PEDOMAN TERAPI MEMAKAI ALAT ELEKTRONIK KARDIOVASKULAR IMPLAN (ALEKA), PERKI 2014

ditemukan penyebabnya yang reversibe PEDOMAN TERAPI MEMAKAI ALAT ELEKTRONIK KARDIOVASKULAR IMPLAN (ALEKA), PERKI 2014
ditemukan penyebabnya yang reversibe PEDOMAN TERAPI MEMAKAI ALAT ELEKTRONIK KARDIOVASKULAR IMPLAN (ALEKA), PERKI 2014
ditemukan penyebabnya yang reversibe PEDOMAN TERAPI MEMAKAI ALAT ELEKTRONIK KARDIOVASKULAR IMPLAN (ALEKA), PERKI 2014
 In days of revascularization and who previously qualified for the implantation of an ICD
 In days of revascularization and who previously qualified for the implantation of an ICD
 In days of revascularization and who previously qualified for the implantation of an ICD

In

days of

revascularization and who previously qualified for the implantation of an ICD for primary prevention

of sudden cardiac death, and who have

undergone revascularization that is unlikely to

result in an improvement in LVEF >0.35, and who

are not within 40 days after an acute MI,

patients

who

within

are

90

implantation of an ICD can be useful

HRS/ACC/AHA Expert Consensus Statement onthe Use

of Implantable Cardioverter-DefibrillatorTherapy

Patients with prior MI within 30 days and LVEF < 30% randomized in a 3:2
Patients with prior MI within 30 days and LVEF < 30% randomized in a 3:2
ratio
71 US centers and 5 European centers
Implantable defibrillator (n=742)
Implantable defibrillator
(n=742)
Conventional medical therapy (n=490)
Conventional medical therapy
(n=490)
All Cause Mortality - Average follow-up of 20 months
All Cause Mortality - Average follow-up of 20 months
Stopped early by Data Safety Monitoring Board
Stopped early by Data Safety Monitoring Board
 Study terminated November 20, 2001  1232 patients randomised ◦ 742 defibrillator, 490 conventional
 Study terminated November 20, 2001  1232 patients randomised ◦ 742 defibrillator, 490 conventional
 Study terminated November 20, 2001  1232 patients randomised ◦ 742 defibrillator, 490 conventional

Study terminated November 20, 2001

1232 patients randomised

742 defibrillator, 490 conventional

Mean follow-up 20 months (range 6 days

- 53 months

105 deaths in ICD group (14.2%)

97 deaths in conventional group (19.8%)

31% reduction in risk of death with ICD

Moss et al New Engl J Med 2002; 346: 877-883

conventional group (19.8%)  31% reduction in risk of death with ICD Moss et al New
conventional group (19.8%)  31% reduction in risk of death with ICD Moss et al New
 ACE inhibitors used in 70%   blockers used in 70%  Statins used
 ACE inhibitors used in 70%   blockers used in 70%  Statins used

ACE inhibitors used in 70%

blockers used in 70%

Statins used in 68% 57% had previously had CABG

44% had previously had PTCA

MADIT-2 targeted patients who were considered

suitable for CABG / PTCA

Benefit of ICD is over & above benefit from revascularisation

who were considered suitable for CABG / PTCA ◦ Benefit of ICD is over & above
who were considered suitable for CABG / PTCA ◦ Benefit of ICD is over & above
who were considered suitable for CABG / PTCA ◦ Benefit of ICD is over & above
who were considered suitable for CABG / PTCA ◦ Benefit of ICD is over & above
who were considered suitable for CABG / PTCA ◦ Benefit of ICD is over & above
Death Avg. follow-up=20 months P=0.016 25% 19.8% Hazard 20% Ratio = 0.65 14.2% 15% 10%
Death Avg. follow-up=20 months P=0.016 25% 19.8% Hazard 20% Ratio = 0.65 14.2% 15% 10%
Death
Avg. follow-up=20 months
P=0.016
25%
19.8%
Hazard
20%
Ratio =
0.65
14.2%
15%
10%
5%
0%
Conventional
ICD
Therapy
Non Cardiac Cardiac Arrhythmic Non Arrhythmic 15% 13.7% 10.0% 9.4% 10% 5.5% 4.1% 5% 3.7%
Non Cardiac Cardiac Arrhythmic Non Arrhythmic 15% 13.7% 10.0% 9.4% 10% 5.5% 4.1% 5% 3.7%
Non Cardiac Cardiac Arrhythmic Non Arrhythmic 15% 13.7% 10.0% 9.4% 10% 5.5% 4.1% 5% 3.7%
Non Cardiac Cardiac Arrhythmic Non Arrhythmic 15% 13.7% 10.0% 9.4% 10% 5.5% 4.1% 5% 3.7%
Non Cardiac
Cardiac
Arrhythmic
Non Arrhythmic
15%
13.7%
10.0%
9.4%
10%
5.5%
4.1%
5%
3.7%
3.6%
3.5%
0%
Conv
Therapy ICD
Conv
Therapy ICD
Conv
Therapy ICD
Conv
Therapy ICD
 In a MADIT-II substudy of 951 patients with prior coronary revascularization, an ICD was
 In a MADIT-II substudy of 951 patients with prior coronary revascularization, an ICD was

In a MADIT-II substudy of 951 patients with prior coronary revascularization, an ICD was of benefit only in patients enrolled at least 6 months after

revascularization

patients enrolled at least 6 months after revascularization HRS/ACC/AHA Expert Consensus Statement onthe Use of
patients enrolled at least 6 months after revascularization HRS/ACC/AHA Expert Consensus Statement onthe Use of
patients enrolled at least 6 months after revascularization HRS/ACC/AHA Expert Consensus Statement onthe Use of

HRS/ACC/AHA Expert Consensus Statement onthe Use of Implantable Cardioverter-DefibrillatorTherapy

 674 patients 6 to 40 days post-MI with LVEF ≤ 35% and impaired cardiac
 674 patients 6 to 40 days post-MI with LVEF ≤ 35% and impaired cardiac

674 patients 6 to 40 days post-MI with LVEF ≤ 35% and impaired cardiac autonomic function Randomized to ICD therapy (n=332) or no ICD therapy (n=342)

Arrhythmic death ↓ in ICD group, but ↑ in nonarrhythmic death (6.1% per year vs. 3.5% per year, HR 1.75 (95% CI 1.11 to 2.76; p=0.016)

No difference in total mortality

death (6.1% per year vs. 3.5% per year, HR 1.75 (95% CI 1.11 to 2.76; p=0.016)
death (6.1% per year vs. 3.5% per year, HR 1.75 (95% CI 1.11 to 2.76; p=0.016)
 In DINAMIT , only 50% of the sudden deaths were attributable to arrhythmia, whereas
 In DINAMIT , only 50% of the sudden deaths were attributable to arrhythmia, whereas

In DINAMIT, only 50% of the sudden deaths were attributable to arrhythmia, whereas mechanical causes of SCD (eg, LV rupture, acute mitral

regurgitation) were observed in the other half of

patients.

regurgitation) were observed in the other half of patients. HRS/ACC/AHA Expert Consensus Statement onthe Use of
regurgitation) were observed in the other half of patients. HRS/ACC/AHA Expert Consensus Statement onthe Use of
regurgitation) were observed in the other half of patients. HRS/ACC/AHA Expert Consensus Statement onthe Use of
regurgitation) were observed in the other half of patients. HRS/ACC/AHA Expert Consensus Statement onthe Use of

HRS/ACC/AHA Expert Consensus Statement onthe Use of Implantable Cardioverter-DefibrillatorTherapy

 ICD therapy has clearly been shown to be effective in aborting sudden arrhythmic death
 ICD therapy has clearly been shown to be effective in aborting sudden arrhythmic death
 ICD therapy has clearly been shown to be effective in aborting sudden arrhythmic death

ICD therapy has clearly been shown to be effective in aborting sudden arrhythmic death

In patients with a prior Myocardial infarction and advanced left ventricular dysfunction, prophylactic implantation of defibrillator improves survival and

should be considered as a recommended therapy

prophylactic implantation of defibrillator improves survival and should be considered as a recommended therapy
prophylactic implantation of defibrillator improves survival and should be considered as a recommended therapy
prophylactic implantation of defibrillator improves survival and should be considered as a recommended therapy
prophylactic implantation of defibrillator improves survival and should be considered as a recommended therapy
prophylactic implantation of defibrillator improves survival and should be considered as a recommended therapy