quels choix pour la personne agÉe ? les troubles du …
TRANSCRIPT
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LES TROUBLES DU RYTHME:
MEDICAMENTS OU PACEMAKER?
LESQUELS
Prof L DE ROY
QUELS CHOIX POUR LA PERSONNE AGÉE ?
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• 1. Les antiarythmiques (AAD)• 2. Les anticoagulants (OAC)• 3. Les pacemakers (PM)• 4. Les défibrillateurs (DAI/ICD)• 5. La resynchronisation (CRT)
LES TROUBLES DU RYTHME:
MEDICAMENTS OU PACEMAKER?
LESQUELS
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Les Arythmies auriculairesLes Arythmies auriculaires
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4Go AS. et al. JAMA 2001;285:2370-2375.
0.1 0.2 0.4 0.9 1.01.7 1.7
3.0 3.4
5.0 5.0
7.3 7.2
10.39.1
11.1
0
2
4
6
8
10
12
< 55 55-59 60-64 65-69 70-74 75-79 80-84 ≥ 85
Age (years)
Prev
alen
ce %
AF Prevalence Increases with Age
Men
Women
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Guidelines ESC 2010 EHJ
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Classification des principaux antiarythmiques: Vaughan-WilliamsClassification des principaux antiarythmiques: Vaughan-Williams
Classe I Classe II Classe III Classe IV Autres ADisopyramide (Rythmodan ) β-bloquants Sotalol (Sotalex) Verapamil (Isoptine) Digitale(Lanoxin)
Quinidine (Kinidine-Durettes) Amiodarone Diltiazem (Tildiem) Adénosine (Cordarone) (Adenocor)
(Striadyne )
Procainamide (Pronestyl)
B
Lidocaine (Xylocaïne )
Mexiletine (Mexitil )
CPropafenone (Rytmonorm )
Flecaïnide (Tambocor )
(Apocard R )
Cibenzoline (Cipralan )
Dronedarone (Multacq )
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Guidelines ESC 2010 EHJ
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ANTIARYTHMIQUES et FONCTION RENALE
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L’isolation des veines pulmonaires
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JCE 2012N= 103 / 2754
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Guidelines for the management of AF EHJ 2010
LES ANTICOAGULANTS
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Guidelines for the management of AF EHJ 2010
LES ANTICOAGULANTS
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BAFTA TRIAL Lancet 2007
Coumariniques vs Aspirine dans la FA de la personne âgée > 75 ans
n: 973
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Guidelines for the management of AF EHJ 2010
Et le risque hémoragique ?
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RE-LY
Les Nouveaux
Antithrombines:
Dabigatran (Pradaxa)
Anti Xa:
Rivaroxaban (Xarelto) Apixaban (Eliquis)
• Efficacité et risques hémorragiques identiques• Pas de contrôles réguliers• Courte durée d’action et délai bref• Prix ?
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DABIGATRAN
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Les Bradycardies
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LA DYSFONCTION SINUSALE
Choix du Pacemaker : AAI ?VVI ?DDD ?
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SINUS NODE DISEASE
CTOPP: n: 2568 mean age: 73 ± 10
AAI
DDD
VVIOR
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SINUS NODE DISEASE
DANPACE (2011): n: 1415
mean age: 73
AAIR
DDDR
OR
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PACEMAKER CONFIGURATION: VVI or DDD?
LES BLOCS AURICULO-VENTRICULAIRES
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LES BLOCS AURICULO-VENTRICULAIRES
UKPACE NEJM 2005> 70y
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AM H J 2003N= 1588 ≥ 80 y
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ICD
LES DÉFIBRILLATEURS
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CIRC 2009
ALL CAUSE MORTALITY
N= 965
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COÛT EFFICACITÉ
Chan CIRC 2009Markov model
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L Basta AJGC 2006
• Evaluation éthique au cas par cas• Consentement éclairé• Problèmes de fin de vie
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Contre-indications
…..(07-2011)
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LA RESYNCHRONISATION CRT
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54.5%
39.3%
58.6%
Control N=145
<0.0010.55 (0.36-0.84)22.9%All cause mortality
0.00010.51 (0.36-0.73)32.5%All cause mortality or un-planned HF hospitalization
0.0150.67 (0.48-0.92)43.3%All cause mortality or un-planned CV hospitalization
P-valueHazard ratio
(95% CI)CRT
N=157
CARE-HF: Reductions in morbidity and mortality in elderly CRT patients
• CARE-HF sub-population of patients aged ≥70 years• CRT reduced mortality and morbidity versus medical treatment
alone (MT) in elderly patients
Mabo P et al. Circulation 2008;118:S949 (Abstract 8450). [CARE-HF, a Medtronic sponsored study]
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n = 15381
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Yancy C et al. J Cardiac Fail 2007;13(suppl):S158. Abstract 290.
Findings from IMPROVE HF:Underutilization of CRT in Elderly
• Underutilization of CRT is exaggerated in eligible elderly HF patients
Patients Receiving Recommended HF Therapies by Age Tertiles at Baseline (All Patients)
89,9
39,7
80,385,9
42,9
73,181,4
33,6
84,6
ACEI/ARB BetaBlocker
CRT (CRT-D/CRT-P)
Pat
ient
s (%
)
Age</=64Age 65-76Age>76
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CARE-HF: CRT improves QoL and cardiac function/status in the elderly
Minnesota Living w/ HF
4229 27
44 38 35
Baseline 3 Mo. 18 Mo.
• CARE-HF sub-population of patients aged ≥70 years
• Presented at AHA 2008
1. Laviolle et al. Circulation 2008;118:S950b (Abstract 48540). 2. Leclercq C, et al. Circulation 2008;118:S619b (Abstract 826)
P=0.50 P<0.001 P=0.001
■ CRT On ■ CRT Off
LVEF
26%37%
26% 31%
Baseline 18 Mo.
LVESV (mL)
217124
223 182
Baseline 18 Mo.
P<0.001P=0.53
P=0.40 P<0.001
1
2
2
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MIRACLE study program demonstrates CRT benefit in elderly patients
5,2%
3,0%4,0%
1,4%0,6%0,8%
Age <65 Age 65-75 Age >75
• MIRACLE + MIRACLE ICD• Mean change at 6 months• 839 patients: 368 < 65 years; 297 65 – 75 years; 174 > 75 years• No evidence of increased adverse event rates in most elderly group
Change in NYHA
-0,8 -0,8 -0,8-0,5 -0,5 -0,4
Age <65 Age 65-75 Age >75
LVESV Change (mL)
-43 -23-8-18 -1
4
Age <65 Age 65-75 Age >75
Absolute LVEF Change
Kron et al.J Interv Card Electrophysiol:2009 Jan 19. [Epub ahead of print Jan 19]
■ CRT On ■ CRT Off
P<0.001 P=0.002 P=0.004
P=0.008P<0.001
P=0.002
P<0.001P<0.001
P=0.06
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Do elderly patients benefit from CRT?
• Recent analyses of randomized controlled trials provide data on the efficacy and safety of CRT in the elderly– Extended survival, improved quality of life, and
improved cardiac function and status
• Guidelines are the same for elderly patients1
– Life expectancy >1 year
• CRT-P may be considered to extend survival and improve quality of life in select elderly patients where defibrillation is not desired
1. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol, 2008; 51:2085-2105.
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Number Needed to Treat To Save A LifeNNTx years = 100 / (% Mortality in Control Group – % Mortality in Treatment Group)
25
147,5
3 411 9
14 1420
2529 29
37
56
0
10
20
30
40
50
60
CARE-HF MUSTT MADIT MADIT II AVID SCD-HeFT SAVE CIBIS II MERIT HF Amiodorone HOPE
CR
T
CR
T-D
CR
T
ICD
Drugs
CRT
Adapted from Auricchio A, Abraham W. Circulation 2004; 109; 300-307.
(1Yr) (3Yr) (5Yr) (2.4Yr) (3Yr) (3Yr) (4Yr) (0.8Yr) (3.5Yr) (1Yr) (1Yr) (1.5Yr) (2Yr) (4 Yr)
COMPANION COPER-NICUS
CAP-RICORN
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COMPANION: CRT-D and CRT-P Incremental Cost-Effectiveness Ratios
• 2-year analysis of COMPANION study
• CRT-P ICER = $19,600 per Quality-Adjusted Life-Year (QALY)
• CRT-D ICER = $43,000 per QALY– Essentially getting two
therapies for one price• Well below generally accepted
benchmarks for therapeutic interventions of $50,000 - $100,000 per QALY
Feldman AM, et al. J Am Coll Cardiol 2005; 46: 2311 – 2321. [COMPANION sponsored by Guidant]
$19.600
$43.000
$0
$25.000
$50.000
$75.000
CRT-P CRT-D
Benchmark $50,000/QALY
Incremental Cost-Effectiveness Ratios of CRT-P/CRT-D ($/QALY)
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Effect of Starting Age and Device Longevity on Cost per QALY – Base case
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
55 60 65 70 75Age at Starting Treatment
Incr
emen
tal C
ost P
er Q
ALY
Gai
ned
€
CRT+MT vs MT CRT+ICD+MT vs CRT + MT CRT+ICD+MT vs MT
8 Years
5 Years7 Years
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Conclusions
• Long-term treatment with CRT-P appears highly cost-effective compared to medical therapy for any starting age
• The cost effectiveness of CRT-ICD compared to CRT-P is conditional on patient life expectancy and device longevity
• Where device longevity is adequate, and patient life expectancy with CRT-P is sufficient, CRT-ICD may also be considered cost-effective
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Ermis C Europace 2007Death: 22 vs 14%
≥ 75 Y
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INSUFFISANCE CARDIAQUE
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AF
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Results: Baseline Practice Characteristics
• By Age Tertiles (≤64y, 65-76y, >76y)– Younger patients more likely to attend multispecialty, hospital-
based, and transplant-affiliated outpatient clinics (P<.001 all comparisons).
– Younger patients also more likely to receive care from outpatient practices with a dedicated heart failure clinic, and with electrophysiologists on staff (P<.001 all comparisons).
• By Sex– Women were more likely than men (14.1% vs. 12.7%; P=.025) to
attend a transplant-affiliated outpatient clinic.– More women than men received care at practices with a device
clinic (82.8% vs. 80.4%; P<.001)
Yancy CW, et al. Am Heart J 2009;157:754-62
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Baseline Patient Characteristics by Age Tertile
<.0011.31.21.1Creatinine, median, mg/dL<.001547383254BNP, median, pg/mL<.001136130110QRS duration, median, ms
<.00164%64%58%Hypertension history
<.00141%32%20%Atrial fibrillation history
P>76 y
n=4,79165-76 yn=5,176
≤64 yn=5,307Characteristic
<.00167%73%73%Male<.00173%71%53%Ischemic etiology
<.00129%38%35%Diabetes
<.00142%43%34%Prior MI<.00135%37%22%CABG<.001252525LVEF, median, %
<.001120120120SBP, median, mm Hg<.001262218BUN, median, mg/dL
Yancy CW, et al. Am Heart J 2009;157:754-62
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Results: Older Patients Less Likely to Receive Guideline-Indicated HF Therapies
84%90%
46%
71%
39%
52%
66%
80%86%
34%
71%
43%
57%61%
73%
81%
27%
68%
34%
43%
57%
0%
25%
50%
75%
100%< 65y 65-76y >76y
ACEI/ARB Beta-blocker AldosteroneAntagonist
Anticoag.for Atrial Fib.
ICD HFEducation
Cardiac Resynch.
P<.001 P<.001
P<.001
P=.180
P=.028
P<.001P<.001
Elig
ible
pat
ient
s w
ith t
reat
men
t (%
)
Yancy CW, et al. Am Heart J 2009;157:754-62
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Results: Significant Differences when Stratified by Age and Sex
47%36% 42%43%
30%37%
0%
50%
100%< 65y 65-76y >76y
Cardiac Resynchronization
Males Females
P=.124 P=.010
50%44%32%34% 27%26%
0%
50%
100%< 65y 65-76y >76y
Males Females
Aldosterone Antagonist
P<.001 P<.001
48%53% 50%59%
32%48%
0%
50%
100%< 65y 65-76y >76y
ICD or CRT-D
Males Females
P<.001 P<.001
• When stratified by age and sex, differences in delivery of guideline-indicated care most striking for:– Aldosterone antagonist;– Cardiac resynchronization (CRT or
CRT-D)– ICD (ICD or CRT-D)
Yancy CW, et al. Am Heart J 2009;157:754-62
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Older and Female Patients Less Likely to Receive Some Care Measures
Adjusted odds ratio with 95% CI displayed
Care Measure
ACEI/ARB
ß-Blocker
Aldosterone Antagonist
Anticoagulation for AF*
Cardiac Resynchronization*
HF Education
ICD/CRT-D*
By Increasing Age
0,87
0,85
0,81
0,99
0,88
0,94
0,93
0,1 1 10
By Sex
1,14
0,93
0,79
1,44
1,04
1,42
1,16
0,1 1 10
FemalesMoreLikely
Conformity to Care Measures
MalesMoreLikely
YoungerMoreLikely
OlderMoreLikely
* Significant age and sex interaction
Yancy CW, et al. Am Heart J 2009;157:754-62
(per 10 years)
P<.0001
P<.0001
P<.0001
P=.0233
P<.0001
P=.0023
P=.0199
P=.2400
P=.0358
P=.0001
P=.7702
P<.0001
P=.0010
P=.7767
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Conclusions
• Females and the more elderly are less likely to receive certain guideline-recommended evidence-based heart failure treatments in the outpatient setting– Older patients received less pharmacologic therapy, less device
therapy, and less heart failure education.
– Women received less heart failure education and less device therapy.
Yancy CW, et al. Am Heart J 2009;157:754-62
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Aspirine: less effect after 75 y
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NEJM 2008
SSSAVB
n= 2568
CTOPP
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Age moyen: 86.2 ansn: 149
Comparable to data from younger but higher 30 d all cause mortality
JICE 2011
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DANPACE 2011n = 1415
AFDEATH
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MOST Total Mortality or Stroke
0 6 12 18 24 30 36 42 48 54 600.00
0.10
0.20
0.30
0.40
0.50
Months
Even
t Rat
e
P = 0.48Adjusted P = 0.32
Ventricular pacing
Dual-chamber pacing
Lamas G, et al. N Engl J Med 2002; 346: 1854-62.
No. at risk:Ventricular pacing
Dual-chamber pacing 996 934 897 813 678 557 431 320 218 125 391014 963 930 833 693 555 431 328 214 120 28
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MOST MOST ConclusionsConclusions
• In patients with SND, dual-chamber pacing In patients with SND, dual-chamber pacing (versus single-chamber ventricular pacing) (versus single-chamber ventricular pacing) REDUCESREDUCES newly diagnosed and chronic atrial newly diagnosed and chronic atrial fibrillationfibrillation, reduces the signs and symptoms of , reduces the signs and symptoms of heart failure, and slightly improves quality of heart failure, and slightly improves quality of life.life.
• Dual-chamber pacing did Dual-chamber pacing did NOTNOT improve the rate improve the rate of the primary endpoint of of the primary endpoint of mortality or freedom mortality or freedom from strokefrom stroke..
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SINUS NODE DISEASE
MOST: n: 2010mean age: 74 (67-80)
NS
DDD
VVI
OR
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Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation).
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Pacemaker ConfigurationsDDD
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♀ C. 70 y: recurrent syncope aVR
aVR
aVF
V1
V2
V3
V4
V5
V6
I
II
III
I
V
•AAI pacing 70/min•CAVB: 12 s asystole•Suspected level of block: nodal
♀ H. 71 y: syncope •ECG: Normal (PR 158 ms, QRS 88ms)
• CAVB :11 s asystole
•Supposed level of block: nodal
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Les stimulateurs cardiaques
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Battery
Connector
Hybrid
Telemetry antenna
Output capacitors
Reed (Magnet) switch
Clock
Defibrillation protection
Atrial connector
Ventricular connector
Resistors
Anatomy of a Pacemaker
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Kaszala K, Ellenbogen K AJGC 2006
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CIRC 2009
ICD AND AGE
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CIRC 2009
N= 965
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PENGO THROMBOSIS AND HEMOSTASISI 2011
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PENGO THROMBOSIS AND HEMOSTASISI 2011
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