Les indications du défibrillateur implantable

Les indications du
Les indications du
défibrillateur implantable
défibrillateur implantable
N Sadoul, CHU de Nancy
N Sadoul, CHU de Nancy

Les indications du DAI
Les indications du DAI
♥
♥Médecine basée sur les preuves => Médecine basée sur les preuves =>
Indications du DAI reposent sur les grandes
Indications du DAI reposent sur les grandes
études
études  Il faut les conna Il faut les connaî ître !!! tre !!!
♥
♥Etudes de pr Etudes de pré évention primaire vention primaire
–
–Cardiopathies isch Cardiopathies isché émiques : MADIT, MUSTT, miques : MADIT, MUSTT,
CABG, MADIT 2, dinamit
CABG, MADIT 2, dinamit … …
–
–CMD: CMD: Amiovirt Amiovirt, CAT, , CAT, Definite Definite, ,
–
–CHF, NYHA II et III (CMD + CI) : SCD CHF, NYHA II et III (CMD + CI) : SCD HeFT HeFT
–
–CHF + QRS larges : CHF + QRS larges : Companion Companion et al. et al.
♥
♥Etudes de pr Etudes de pré évention secondaire vention secondaire
–
–Cardiopathies ischémiques+++ Cardiopathies ischémiques+++

Nicolas SADOUL
Nicolas SADOUL
DIU 2007
DIU 2007
Post MI pre
Post MI pre- -event trials before 2000 event trials before 2000
Trial
Trial Design Design Target
Target
Population
Population Therapies
Therapies
randomised
randomised Outcome
Outcome
MADIT
MADIT
Randomised,
Randomised,
total mortality
total mortality
n=196; EF<0.35,
n=196; EF<0.35,
NSVT
NSVT
EPS inducible
EPS inducible
PCA refractory
PCA refractory
ICD
ICD vs vs
conventional
conventional
Amio(74%)
Amio(74%)
ICD improved
ICD improved
survival by 46%
survival by 46%
p < 0.02
p < 0.02
CATBG
CATBG
Patch
Patch
Randomised,
Randomised,
total mortality
total mortality
n = 900,
n = 900,
EF<0.36, LPs+
EF<0.36, LPs+
CABG candidate
CABG candidate
CABG in all
CABG in all
ICD
ICD vs vs no no
therapy
therapy
No survival
No survival
benefit for ICD
benefit for ICD
MUSTT
MUSTT
Randomised,
Randomised,
total mortality
total mortality
n = 2204,
n = 2204,
EF<0.4, NSVT
EF<0.4, NSVT
Inducible : 767
Inducible : 767
(Non induc.:1435)
(Non induc.:1435)
No EP guided
No EP guided
therapy
therapy
EP guided
EP guided
therapy (AA,
therapy (AA,
ICD if PES+)
ICD if PES+)
27% reduction for
27% reduction for
patients with EP
patients with EP
guided therapy
guided therapy
>50% reduction
>50% reduction
for ICD
for ICD

CAD (MI
CAD (MI > >1 month), LVEF 1 month), LVEF < <0.3 0.3
R*
R*
ICD
ICD
(742)
(742)
Conventional
Conventional
(490)
(490)
+ EEP
+ EEP Follow
Follow- -up up
(mean
(mean : around 2 years) : around 2 years)
β
β- -, ACE , ACE
inhibitors, no
inhibitors, no
AA
AA
MADIT II trial
MADIT II trial (NEJM 2002;346:873 (NEJM 2002;346:873- -83) 83)
1
1232 patients : 3 :2 ratio 232 patients : 3 :2 ratio

Kaplan Meier estimates of the probability
Kaplan Meier estimates of the probability
of survival
of survival
P<0.007
P<0.007