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Applying Heart Rate Variability in Clinical Practice Following Acute Myocardial Infarction
Published in Herbert F. Jelinek, David J. Cornforth, Ahsan H. Khandoker, ECG Time Series Variability Analysis, 2017
Juha S. Perkiömäki, Heikki V. Huikuri
A vast majority of studies in post-AMI populations have shown that HR variability yields prognostic information indicating that reduced HR variability is associated with increased risk of mortality and adverse events. However, all the abovementioned factors modify the prognostic significance of HR variability variables. Therefore, it is very difficult to exactly generalize the findings to all real-world post-AMI populations. It is even more difficult to extrapolate the findings to an individual post-AMI patient. For these reasons, HR variability is not yet widely applied in practice as a guide for clinical decision making after AMI. The larger the studied post-AMI population, the greater the chance of finding a HR variability parameter as a statistically significant predictor of adverse events. This does not necessarily translate into clinical usefulness for individual post-AMI patients. It is further noteworthy that if a risk indicator is used in an individual patient's risk stratification, there should be a treatment option available that is beneficial particularly to the patient group, which was identified to be at risk. Many beneficial therapies, such as medications, are applied in the treatment of virtually all patients with AMI, if there are no contraindications and there is no need for finding subgroups that are at the greatest risk to start the treatments. The post-AMI patients who have experienced a life-threatening ventricular tachyarrhythmia after an acute phase without a transient cause need an implantable cardioverter-defibrillator (ICD) for secondary prophylactic reasons. The post-AMI patients with severely depressed left ventricular function but without any history of life-threatening ventricular tachyarrhythmias should receive a primary prophylactic ICD (Moss et al. 2002; Bardy et al. 2005). However, the majority of sudden arrhythmic deaths occur in the post-AMI patients with moderately decreased or well-preserved left ventricular function (Huikuri et al. 2001). It would therefore be beneficial to find risk indicators that could predict the risk for sudden arrhythmic death as accurately as possible, especially in patients with preserved left ventricular function, as most of these deaths could be prevented by implanting an ICD for primary prophylactic reasons. There are data to support the concept that HR variability predicts the risk for life-threatening arrhythmic events in post-AMI patients. An example of such data is the results of the Cardiac Arrhythmias and Risk Stratification after Acute Myocardial Infarction (CARISMA) study. In this study, the primary endpoint of ventricular fibrillation or symptomatic sustained ventricular tachycardia was detected using implantable loop recorders in post-AMI patients with left ventricular ejection fraction (LVEF) ≤40% measured from 3 to 21 days after AMI with follow-up for 2 years. Several HR variability parameters measured 6 weeks after AMI predicted the primary endpoint (Huikuri et al. 2009, Figure 19.1). After further research and developments, HR variability, particularly when combined with other risk indicators, has the potential to become a useful indicator of the risk for sudden arrhythmic death in post-AMI patients.
Ablation for the treatment of Brugada syndrome: current status and future prospects
Published in Expert Review of Medical Devices, 2020
Alessandro Rizzo, Carlo de Asmundis, Pedro Brugada, Mark La Meir, Gian-Battista Chierchia
Although effective for preventing sudden cardiac death, ICD carries a relevant risk of complications over the patient’s lifetime, particularly if the patient is young at the time of device implantation. If radiofrequency substrate ablation can truly provide long-term prevention of VT/VF in BrS, this may even become an alternative to ICD therapy, which does not prevent but only treats malignant ventricular arrhythmias.
Ventricular tachycardia ablation as an alternative to implantable cardioverter-defibrillators in patients with preserved ejection fraction: current status and future prospects
Published in Expert Review of Medical Devices, 2022
Philippe Maury, Maxime Beneyto, Pierre Mondoly, Hubert Delasnerie, Anne Rollin
ICD implantation still carries significant morbidity and early or late mortality. ICDs are anyway far from representing the perfect tool, which could be proposed in any case in the hope to avoid any arrhythmic event-related death and to prolong life.
Cardiac implantable electronic devices and cybersecurity
Published in Expert Review of Medical Devices, 2021
Bhakti Patel, Amgad N. Makaryus
There are numerous cardiac devices with remote/internet connection that patients rely on. The implantable cardioverter defibrillator (ICD) is a cardiac device that senses signals from the heart to monitor for potential arrhythmias. Once the ICD detects an abnormal tachyarrhythmia, it delivers defibrillation, or high-energy shocks to eliminate the arrhythmia as it is programmed [2]. The ICD is often implemented in patients who are at high risk for sudden cardiac death. In fact, in the United States, cardiac arrest causing sudden cardiac death outside of the hospital occurs in 356,500 patients per year [2]. Therefore, correct function of the ICD is of utmost importance as it is used for treatment in matter of life situations. In order to provide continued care, providers remotely access the data stored in a patient’s ICD device. According to a study by Health Quality Ontario, remote monitoring of ICDs improved patient outcomes in terms of fewer inappropriate shock deliveries and less in person clinic visits [3]. Remote monitoring is essential to the function of cardiac devices, as such, cybersecurity precautions should be in place in order to protect patient safety and health. Other cardiac devices with remote connection include the permanent pacemaker (PPM). A PPM utilizes functions to stimulate the heart in the event of bradycardia or atrioventricular block. About 1.25 million patients have a permanent pacemaker implanted worldwide [4]. Remote monitoring of the PPM allows providers to access data and verify that the device is accurately functioning. According to a study by Lopez-Liria et al., the timeframe in detecting and treating heart abnormalities with the PPM was shortened and the total number of clinical visits was significantly decreased for patients with pacemakers utilizing the remote monitoring ability [5]. While ICDs and PPMs are the most common ‘connected’ devices, many new developments in the field of cardiology will likely lead to other ‘smart’ devices that will allow remote access and query such as implantable loop recorders/monitors, cardiac implantable ventricular assist and valvular devices, and heart failure pressure-sensing devices implanted directly into the pulmonary artery.