A cardiac electrophysiologist presented a medical case:
Life Vest Needed?
New onset Cardiomyopathy. Risk for Sudden Cardiac Death and Ventricular Tachycardia?
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Patient demographics
Gender
male
Age
43
Ethnicity
Occupation
Physician
Chief complaint or problem to solve
43 year old physician presented with CHF and a diagnosis of non-ischemic cardiomyopathy was made. He was started on appropriate medications for his low EF.

He did have some dizziness which was probably secondary to hypotension. Risk of arrhythmia was considered.

Would like to see what colleagues think about the following:

1/ Should we be concerned about arrhythmias in this gentleman.
2/ How long should we wait before considering an ICD.
3/ Would he benefit from a Life Vest (Zoll).



Case history
Patient presented with a 3 month history of progressive shortness of breath and fatigue.

Noted to have occasional dizziness and pre-syncope.

Still able to exercise and work.

PMH: Significant for only hypercholesterolemia, diet controlled.

Medication: Ibuprofen as needed.
No medication allergies.

SH: Exercises on a regular basis. Ran a Half marathon 6 months ago.

FH: Diabetes, type II

Examination: BP 100/60 (Orthostatic 80/50) P: 90 RR: 18

Peripheral edema +1

Significant for rales, soft S3 and MR murmur.

EKG: Revealed occasional PAC's and PVC's.

2D Echo: EF 20%, MR 2+

Cardiac Cath: No Coronary Artery Disease.

Diagnosis: Non-ischemic Cardiomyopathy

Treatment: Start ACEI and Carvedilol slowly because of hypotension.
Purpose of case discussion
Treatment decision: "What's the best treatment?"
Supplemental Materials

Dr. Jerome Zacks
Internal Medicine - Cardiology
8 doctors agree

In brief: Needs rapid evaluation

Although chronic hypertension is among the most common causes of nonischemic cardiomyopathy, there appears to be no hypertensive history in this case.
With an ejection fraction of 20%, sudden life-threatening arrhythmia is a significant risk. An implantable defibrillator must be considered urgently. A Zoll Vest could be considered if there is any delay in implanting a defibrillator. In addition, consideration should be given to a myocardial biopsy to search for an infiltrative cardiomyopathy. Diuretic, beta blocker and vasodilator therapy might be limited by a low blood pressure. If there is a wide QRS, resynchronization with a biventricular pacemaker might help restore ventricular function. The prognosis (and treatment) will be dependent upon the underlying cause of the cardiomyopathy.

In brief: Needs rapid evaluation

Although chronic hypertension is among the most common causes of nonischemic cardiomyopathy, there appears to be no hypertensive history in this case.
With an ejection fraction of 20%, sudden life-threatening arrhythmia is a significant risk. An implantable defibrillator must be considered urgently. A Zoll Vest could be considered if there is any delay in implanting a defibrillator. In addition, consideration should be given to a myocardial biopsy to search for an infiltrative cardiomyopathy. Diuretic, beta blocker and vasodilator therapy might be limited by a low blood pressure. If there is a wide QRS, resynchronization with a biventricular pacemaker might help restore ventricular function. The prognosis (and treatment) will be dependent upon the underlying cause of the cardiomyopathy.
Dr. Jerome Zacks
Dr. Jerome Zacks
Thank
Dr. Alan Heldman
Internal Medicine - Cardiology
7 doctors agree

In brief: Bridging the waiting period with a Wearable Defibrillator Vest

Is a wearable defibrillator (WCD) is indicated after diagnosis of NICM, but before criteria for an ICD are met? It is a common scenario.
Criteria for an ICD in patients with new NICM require waiting to assess the EF response to treatment (1). In one abstract appropriate shocks were delivered in 7% of pts with an initial diagnosis of NICM (2) -- higher than might have been predicted, as an ICD study in similar pts found a rate of SCD of 1% per year (2). The level of evidence (3) for use of the WCD during the waiting period is low (4) but the stakes may be high. We need more data and professional guidelines. (1) Bridging a Temporary High Risk of Sudden Arrhythmic Death. Experience with the WCD. PACE 2010 (2) Experience with WCD in NICM: A National Database Analysis. JACC 2014 (3) Grading the Strength of a Body of Evidence When Comparing Medical Interventions. Agency for Healthcare Research and Quality. (4) EFFECTIVENESS OF WCD. Int J of Technology Assessment in Health Care 2014

In brief: Bridging the waiting period with a Wearable Defibrillator Vest

Is a wearable defibrillator (WCD) is indicated after diagnosis of NICM, but before criteria for an ICD are met? It is a common scenario.
Criteria for an ICD in patients with new NICM require waiting to assess the EF response to treatment (1). In one abstract appropriate shocks were delivered in 7% of pts with an initial diagnosis of NICM (2) -- higher than might have been predicted, as an ICD study in similar pts found a rate of SCD of 1% per year (2). The level of evidence (3) for use of the WCD during the waiting period is low (4) but the stakes may be high. We need more data and professional guidelines. (1) Bridging a Temporary High Risk of Sudden Arrhythmic Death. Experience with the WCD. PACE 2010 (2) Experience with WCD in NICM: A National Database Analysis. JACC 2014 (3) Grading the Strength of a Body of Evidence When Comparing Medical Interventions. Agency for Healthcare Research and Quality. (4) EFFECTIVENESS OF WCD. Int J of Technology Assessment in Health Care 2014
Dr. Alan Heldman
Dr. Alan Heldman
Thank
Dr. Mary Callahan
Internal Medicine - Cardiology
4 doctors agree

In brief: Life vest

Yes in this individual with a cardiomyopathy, reduced ejection fraction and non-ischemic, I would recommend using a life vest for at least 3 months.
He or she needs to be treated for at least 3 months to see if the ejection fraction gets better and if not then and ICD or biV ICD should be placed

In brief: Life vest

Yes in this individual with a cardiomyopathy, reduced ejection fraction and non-ischemic, I would recommend using a life vest for at least 3 months.
He or she needs to be treated for at least 3 months to see if the ejection fraction gets better and if not then and ICD or biV ICD should be placed
Dr. Mary Callahan
Dr. Mary Callahan
Thank
Dr. Bennett Werner
Internal Medicine - Cardiology
4 doctors agree

In brief: Wait and see

Many people with new onset NIC will improve over the next 3-6 months.
ICD should not be initially used unless EF hasn't improved in 6 months. If there is hx of syncope or VT, a vest should be used. I would stop ACE-I and start Entresto (sacubitril/valsartan) based on Paradigm HF study. If you can tolerate it, I'd also add an aldosterone antagonist (spironolactone or eplerenone.) Any use of alcohol is verboten.

In brief: Wait and see

Many people with new onset NIC will improve over the next 3-6 months.
ICD should not be initially used unless EF hasn't improved in 6 months. If there is hx of syncope or VT, a vest should be used. I would stop ACE-I and start Entresto (sacubitril/valsartan) based on Paradigm HF study. If you can tolerate it, I'd also add an aldosterone antagonist (spironolactone or eplerenone.) Any use of alcohol is verboten.
Dr. Bennett Werner
Dr. Bennett Werner
Thank
1 comment
Dr. Koroush Khalighi
Agreed: 3 month is the minimum period, if standard/conventional medical Rx and risk reduction fails to improve LVEF.
Dr. Geoffrey Rutledge
Internal Medicine
3 doctors agree

In brief: Predict risk

Agree that supportive treatment with vasodilators and blood pressure control is initial treatment.
Normal EKG does not preclude higher risk of dysrhythmias! The cause of the cardiomyopathy may help predict risk of VF, and a Cardiac cine MRI may identify if significant fibrosis is present, or if this is ARVD(arrhythmogenic right ventricular dysplasia), or HCM (hypertrophic CM), where the risk is higher. Would consider use of ICD or life vest with evidence of increased risk (via Holter/other rhythm monitoring, or with MRI results, or endocardial biopsy results, or uncovering other family history).

In brief: Predict risk

Agree that supportive treatment with vasodilators and blood pressure control is initial treatment.
Normal EKG does not preclude higher risk of dysrhythmias! The cause of the cardiomyopathy may help predict risk of VF, and a Cardiac cine MRI may identify if significant fibrosis is present, or if this is ARVD(arrhythmogenic right ventricular dysplasia), or HCM (hypertrophic CM), where the risk is higher. Would consider use of ICD or life vest with evidence of increased risk (via Holter/other rhythm monitoring, or with MRI results, or endocardial biopsy results, or uncovering other family history).
Dr. Geoffrey Rutledge
Dr. Geoffrey Rutledge
Thank
Dr. Ripple Doshi
Internal Medicine - Cardiology
3 doctors agree

In brief: Yes , wear a LifeVest

Has PVCs and a non-ischemic cariomyopathy.
Would definitely recommend a LifeVest

In brief: Yes , wear a LifeVest

Has PVCs and a non-ischemic cariomyopathy.
Would definitely recommend a LifeVest
Dr. Ripple Doshi
Dr. Ripple Doshi
Thank
Dr. Koroush Khalighi
Cardiology - Cardiac Electrophysiology
2 doctors agree

In brief: 1. yes, 2. at least 3 month or 100 days. 3. ICD vest first 90-100 days

ICD vest is appropriate for 3 months before ICD implantation course.
The patient is at risk for SCD. Optimized medical Rx and risk reduction is essential.

In brief: 1. yes, 2. at least 3 month or 100 days. 3. ICD vest first 90-100 days

ICD vest is appropriate for 3 months before ICD implantation course.
The patient is at risk for SCD. Optimized medical Rx and risk reduction is essential.
Dr. Koroush Khalighi
Dr. Koroush Khalighi
Thank
Dr. Saptarshi Bandyopadhyay
Internal Medicine - Hospital-based practice
2 doctors agree

In brief: What is the QRS duration? Need more info. Given the age, ICD needed.

Pre-standing epidemiologic data suggests that arrhythmias are primary cause of mortality in the heart failure population.
The MADIT-HF trial investigated whether or not device therapy (Biventricular pacing with ICD) would be safe and effective compared to ICD alone in pts who met EKG criteria (BBB) & low EF. The trial is an overwhelmingly positive one. The benefit of device therapy on mortality was statistically significant in those with a moderately better EF (25-30%) as opposed to EF <25%, but it's still noteworthy (see image). The mortality benefit was seen up to 7 yrs out from the implant. (Mortality benefit probably would have been even greater, but about 50% of the enrollees were greater than 65 years of age & died from other causes). Given the young age (43 y.o.) & low EF of the patient (20%), I would think that device therapy should be offered unless the EKG characteristics, clinical condition, or patient preference absolutely precludes it.

In brief: What is the QRS duration? Need more info. Given the age, ICD needed.

Pre-standing epidemiologic data suggests that arrhythmias are primary cause of mortality in the heart failure population.
The MADIT-HF trial investigated whether or not device therapy (Biventricular pacing with ICD) would be safe and effective compared to ICD alone in pts who met EKG criteria (BBB) & low EF. The trial is an overwhelmingly positive one. The benefit of device therapy on mortality was statistically significant in those with a moderately better EF (25-30%) as opposed to EF <25%, but it's still noteworthy (see image). The mortality benefit was seen up to 7 yrs out from the implant. (Mortality benefit probably would have been even greater, but about 50% of the enrollees were greater than 65 years of age & died from other causes). Given the young age (43 y.o.) & low EF of the patient (20%), I would think that device therapy should be offered unless the EKG characteristics, clinical condition, or patient preference absolutely precludes it.
Dr. Saptarshi Bandyopadhyay
Dr. Saptarshi Bandyopadhyay
Thank
Dr. Derrick Lonsdale
Preventive Medicine
2 doctors agree

In brief: Beriberi heart disese

I suggest that you look for lactic acidosis and evidence of thiamine deficiency, particularly if his diet contains a lot of sweets or aalcohol

In brief: Beriberi heart disese

I suggest that you look for lactic acidosis and evidence of thiamine deficiency, particularly if his diet contains a lot of sweets or aalcohol
Dr. Derrick Lonsdale
Dr. Derrick Lonsdale
Thank
Dr. Clarence Grim
Internal Medicine - Endocrinology
1 doctor agrees

In brief: Cardiomyopathy

BE certain reversible causes have been excluded.
hypokalemia infiltrative diseases of myocardium review alcohol intake history carefully Using any athletic "potions" to improve performance. Consider cardiac biopsy to further define problem, Stop all OTC meds supplements etc

In brief: Cardiomyopathy

BE certain reversible causes have been excluded.
hypokalemia infiltrative diseases of myocardium review alcohol intake history carefully Using any athletic "potions" to improve performance. Consider cardiac biopsy to further define problem, Stop all OTC meds supplements etc
Dr. Clarence Grim
Dr. Clarence Grim
Thank
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