Holter monitoring in the prognosis of sudden cardiac death – new eperiences and possibilities

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Slide 1 : Holter monitoring in the prognosis of sudden cardiac death – new eperiences and possibilities Beata Sredniawa MD, Zbigniew Kalarus MD, et al. I Department of Cardiology Silesian Medical University, Silesian Center for Heart Diseases, Zabrze, Poland Wiad Lek 2005;58:233-237
Slide 2 : The definition of Sudden Cardiac Death Sudden Cardiac Death (SCD) natural death due to cardiac causes, preceded by abrupt loss of consciousness within an hour of the onset of acute symptoms in the individual with or without diagnosed heart disease in the past Cardiovasc Clinics 1985;15:93-105
Slide 3 : Heart diseases predisposing to SCD ischaemic heart disease dilated and hypertrophic cardiomyopathy valvular heart diseases congenital heart diseases arrhythmogenic right ventricular dysplasia myocarditis Long QT syndrome Wolf-Parkinson-White syndrome J Electrocardiol 1988;21:46-55; Am J Cardiol 1997;79:1190-1193 Lancet 2001;357:420-4
Slide 4 : Markers of SCD assessed using Holter monitoring heart rate variability – (HRV) heart rate turbulence – (HRT) silent ischaemia QT interval late potentials – (LP) T-wave alternans J Electrocardiol 1988;21:46-55; Br Heart J 1994;71:16-21 J Am Coll Cardiol 1995;25:231
Slide 5 : Circadian pattern of SCD the most frequent time of SCD 7 - 9 AM (Framingham Heart Study) 8 - 11 AM (Beta-Blocker Heart Attack Trial) Am J Cardiol 1990;66:57-59
Slide 6 : The most frequent arrhythmic causes of SCD monomorphic ventricular tachycardia (degenerating to VF after 2.5 min of the onset) „torsade de pointes” (degenerating to VF after 34 s of the onset) ventricular fibrillation J Clin Hypertens 2000;2:14-19 ventricular tachyarrhythmias
Slide 7 : Arrhythmic harbingers of ventricular tachycardia (VT) one hour before VT episode increased number of ventricular ectopic beats the increase of complex ventricular arrhythmias J Clin Hypertens 2000;2:14-19
Slide 8 : The example of ventriculr tachycardia Sustained ventricular tachycardia recorded in Holter monitoring (own data base)
Slide 9 : HRV – interpretation and measurements reflects the status of autonomic nervous system in the heart qualititative assessment - histogram quantitative assessment - time domain analysis (24 hours) - frequency domain analysis (5 minutes periods) - non-linear analyses Heart 1997;77:532-538; Am J Cardiol 1992;69:891-8 Circulation 1992;85:164-71
Slide 10 : Diseases with decreased HRV myocardial infarction ischaemic heart disease chronic heart failure status after heart transplantation hypertension diabetes mellitus renal impairment chronic obstructive pulmonary diseases Circulation 2003;107;565-70; J Am Coll Cardiol 1991;18:1643-9 J Cardiovasc Electrophysiol 2002;13:1227-32; J Electrocardiol 2001;34 Suppl, 27-35
Slide 11 : The example of normal histogram Histogram obtained from healthy individual (wide basis) (own data base)
Slide 12 : The example of abnormal histogram Histogram of the patient with CHD and old MI (narrow basis) – depressed HRV (own data base)
Slide 13 : Prognostic significance of HRV value < 50 ms – 4-fold increase of mortality in long-term follow-up after MI value > 100 ms low risk of mortality SDNN (the most commonly applied HRV parameter) Am J Cardiol 1987;59:256-62
Slide 14 : HRV as independent risk factor of the death after MI Multicenter Post-Infarction Program – SDNN Autonomic Tone and Reflexes After Myocardial Infarction (ATRAMI) – HRV parameters reflecting vagal tone Lancet 1998;351:478-84
Slide 15 : Clinical usefulness of HRV risk stratification after MI (using time domain analysis) neuropathy assessment in diabetes mellitus PACE 2001;24:53-9
Slide 16 : Factors modulating HRV early revascularization in acute MI decreased EF in heart failure denervation after heart transplantation Heart 1997;77:532-538; J Heart and Lung Transp 2000;19:310-312
Slide 17 : Heart rate turbulence (HRT) – pathophysiology physiologic behaviour of sinus node after single ventricular ectopic beat reflects baroreflex sensitivity the modulation by parasympathetic activity Electrophysiol Rev 1999;3:53-6
Slide 18 : HRT parameters evaluated using Holter monitoring HRT early acceleration HRT onset late deceleration HRT slope values related to SCD after MI (independent factors) TO > 0% TS < 2.5 ms/RR interval Electrophysiol Rev 1999;3:53-6
Slide 19 : Characteristics of silent ischeamia duration time – up to dozens of minutes circadian rhythm – the most frequent occurence in the early morning and in the afternoon malignant episodes: - ST depression greater than 2 mm or total duration time within 24 hours > 60 minutes - silent ischaemia in high risk groups: multivessel CHD, CHF Wiad Lek 2000;53:611-6
Slide 20 : Prognostic significance of silent ischaemia marker of the occurence of major cardiac events in the course of CHD: reinfarction, urgent revascularization, SCD malignant episodes – significant worsening of the prognosis Wiad Lek 2000;53:611-6; Pol Merk Lek 1997;3:53-6
Slide 21 : Therapeutic options of silent ischaemia the reduction of duration time and the frequency of episodes atenolol Atenolol Ischemia Study (ASIST) atenolol, bisoprolol, diltiazem Total Ischemic Burden Bisoprolol Study (TIBS) the best reduction of morning ischaemia J Am Coll Cardiol 1995;25:231
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