Device-Therapie nach akutem Koronarsyndrom

Zusammenfassung

AV-Blöcke sind beim akuten Koronarsyndroms selten. Nur wenige Patienten benötigen eine Schrittmacherimplantation. Besonders beim Hinterwandinfarkt ist die Prognose gut. Die Häufigkeit anhaltender AV-Blockierungen hat durch die Akut-PTCA abgenommen.

Ventrikuläre Tachyarrhythmien sind in der Akutphase des Infarktes häufig. Treten sie als anhaltende Kammertachykardien oder Kammerflimmern > 48 Stunden nach Infarkt auf, können sie eine Indikation zur sekundärprophylaktischen ICD-Implantation darstellen. Primärprophylaktisch sollte ein Defibrillator implantiert werden, wenn die LV-EF auch > 40 Tage nach Infarkt ≤ 35 % beträgt.

Ist früh nach Infarkt eine Aggregatimplantation erforderlich, sollte bei hohem ventrikulärem Stimulationsbedarf oder Linksschenkelblock ein biventrikuläres System verwendet werden.

Abstract

Acute coronary syndromes are seldom accompanied by high degree AV blocks. Implantation of a permanent pacemaker is rarely necessary.

There is a high incidence of ventricular tachyarrhythmias during the acute phase of myocardial infarctions. Sustained VT or VF beyond 48 hours of the infarction indicate the need for an implantable cardioverter-defibrillator. If left ventricular ejecion fraction remains ≤ 35 % for > 40 days an ICD might be indicated for primary prophylaxis.

If early after infarction a device implantation becomes necessary, biventricular stimulation should be used if ventricular pacing is necessary or LBBB with markedly increased QRS-duration is present.

Schlüsselwörter

Akutes Koronarsyndrom - AV-Block - Schrittmacher - Defibrillator - kardiale Resynchronisationstherapie

Keywords

acute coronary syndrome - AV block - Pacemaker - cardioverter-defibrillator - cardiac resynchronization therapy

• Literatur

• 1 Al-Majed NS, McAlister FA, Bakal JA et al. Meta-analysis: cardiac resynchronization therapy for patients with less symptomatic heart failure. Ann Intern Med 2011; 154: 401-412
• 2 Auricchio A, Stellbring C, Buter C et al. Clinical efficacy of cardiac resynchronization therapy using left ventricular pacing in heart failure patients stratified by severity of ventricular conduction delay. J Am Coll Cardiol 2003; 42: 2109-2116
• 3 Authors/Task Force Members, Brignole M, Auricchio A, Baron-Esquivias G. et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: The Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J 2013; 34: 2281-2329
• 4 Authors/Task Force Members, Steg PG, James SK, Atar D. et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012; 33: 2569-2619
• 5 Behar S, Zissman E, Zion M et al. Prognostic significance of second-degree atrioventricular block in inferior wall acute myocardial infarction. SPRINT Study Group. Am J Cardiol 1993; 72: 831-834
• 6 Böcker D, Block M, Isbruch F et al. Benefits of treatment with implantable cardioverter-defibrillators in patients with stable ventricular tachycardia without cardiac arrest. Br Heart J 1995; 73: 158-163
• 7 Curtis AB, Worley S, Adamson PB et al. Biventricular pacing for atrioventricular block and systolic dysfunction. N Engl J Med 2013; 368: 1585-1593
• 8 Epstein A, Abraham W, Bianco N et al. Wearable cardioverter-defibrillator use in patients perceived to be at high risk early post myocardial infarction. J Am Coll Cardiol epub DOI DOI: 10.1016/j.jacc.2013.05.086.
• 9 Gang UJO, Hvelplund A, Pedersen S et al. High-degree atrioventricular block complicating ST-segment elevation myocardial infarction in the era of primary percutaneous coronary intervention. Europace 2012; 14: 1639-1645
• 10 Gasparini M, Auricchio A, Regoli F et al. Four-year efficacy of cardiac resynchronization therapy on exercise tolerance and disease progression: the importance of performing atrioventricular junction ablation in patients with atrial fibrillation. J Am Coll Cardiol 2006; 48; 734-743
• 11 Goldberger JJ, Passum R. Implantable cardioverter-defibrillator therapy after acute myocardial infarction. The results are not shocking. J Am Coll Cardiol 2009; 54: 2001-2005
• 12 Hayes DL, Boehmer JP, Day JD et al. Cardiac resynchronization therapy and the relationship of percent biventricular pacing to symptoms and survival. Heart Rhythm 2011; 8: 1469-1475
• 13 Hindman MC, Wagner GS, JaRo M et al. The clinical significance of bundle branch block complicating acute myocardial infarction. 1. Clinical characteristics, hospital mortality, and one-year follow-up. Circulation 1978; 58: 679-688
• 14 Hohnloser SH, Kuck KH, Dorian P et al. Prophylactic use of an implantable cardioverter defibrillator after acute myocardial infarction. N Engl J Med 2004; 351: 2481-2488
• 15 Kelly DJ, Gershlick T, Witzenbichler B et al. Incidence and predictors of heart failure following percutaneous coronary intervention in ST-segment elevation myocardial infarction: the HORIZONS-AMI trial. Am Heart J 2011; 162: 663-670
• 16 Khan NK, Goode KM, Cleland JG et al. Prevalence of ECG abnormalities in an international survey of patients with suspected or confirmed heart failure at death or discharge. Eur J Heart Fail 2007; 9: 491-501
• 17 Klein HU, Meltendorf U, Reek S et al. Bridging a temporary high risk of sudden arrhythmic death. Experience with the wearable cardioverter defibrillator. Pacing Clin Electrophyiol 2010; 33: 353-367
• 18 Meyer J, Merx W, Dörr R et al. Successful treatment of acute myocardial infarction shock by combined percutaneous transluminal coronary recanalization (PTCR) and percutaneous transluminal coronary angioplasty (PTCA). Am Heart J 1982; 103: 132-134
• 19 Raitt MH, Renfroe EG, Epstein AE et al. “Stable” ventricular tachycardia is not a benign rhythm: insights from the antiarrhythmics versus implantable defibrillators (AVID) registry. Circulation 2001; 103: 244-252
• 20 Solomon SD, Zelenkofske S, McMurray JJV et al. Sudden death with myocardial infarction and left ventricular dysfunction, heart failure, or both. N Engl J Med 2005; 352: 2581-2588
• 21 Steinbeck G, Andresen D, Seidl K et al. Defibrillator implantation early after myocardial infarction. N Engl J Med 2009; 361: 1427-1436
• 22 Tang AS, Wells GA, Talajic M et al. Cardiac resynchronization therapy for mild-to-moderate heart failure. N Engl J Med 2010; 363: 2385-2395
• 23 Tebbenjohanns J, Willems S, Antz M et al. Kommentar zu den „ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death – executive summary“. Kardiologe 2008; 2: 363-388
• 24 Zimetbaum PJ, Josephson ME. Use of the electrocardiogram in acute myocardial infarction. N Engl J Med 2003; 348: 933-940
• 25 Zishiri E, Williams S, Cronin E et al. Early risk of mortality after coronary artery revascularization in patients with left ventricular dysfunction and potential role oft he wearable cardioverter defibrillator. Circ Arrhythm Electrophysiol 2013; 6: 117-128