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Non servono gli antiaritmici? Prof Luigi Padeletti Università di Firenze Heart Failure & Co. Caserta, 29-30 aprile 2011.

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Presentazione sul tema: "Non servono gli antiaritmici? Prof Luigi Padeletti Università di Firenze Heart Failure & Co. Caserta, 29-30 aprile 2011."— Transcript della presentazione:

1 Non servono gli antiaritmici? Prof Luigi Padeletti Università di Firenze Heart Failure & Co. Caserta, aprile 2011

2 Sommario degli studi sul trattamento farmacologico Sospeso per numero eccessivo di decessi nel braccio di studio Encainide, flecainide/ placebo 1498 CAST-I 1 Nessuna variazione rispetto alla mortalit à globale Amiodarone/Placebo1200 CAMIAT 6 Nessuna variazione rispetto alla mortalit à globale Amiodarone/Placebo1500 EMIAT 5 Mortalità elevata in ambedue i bracci EPS-guidato/Holter- guidato 486 ESVEM 4 Sospeso per numero eccessivo di decessi nel braccio di studio d-sotalolo/Placebo546 SWORD 3 Nessuna variazione rispetto alla mortalit à globale Amiodarone/Placebo674 CHF-STAT 2 Risultato Risultato Disegno dello studio PazientiStudio 1 Echt, et al. N Engl J Med. 1991;324:781–8. 2 Singh, et al. N Engl J Med. 1995;333:77–82 (supported by Sanofi & Wyeth). 3 Waldo A.L. The Lancet; 1996;348:7–12. (supported by Bristol-Myers Squibb). 4 Mason J.W. N Engl J Med. 1993;329(7):452–8. (Supported by Bristol- Myers Squibb, Knoll Pharmaceutical, Boehringer-Ingelheim, Parke-Davis, and Ciba-Geigy). 5 Julian D.G. The Lancet. 1997;349:667–74.(Supported by Sanofi) 6 Cairns J.A. The Lancet. 1997;349:675–82.

3 Implanted Standby Defibrillators In fact, the implanted defibrillator system represents an imperfect solution in search of a plausible and practical application. Circulation, Volume XLVI, October 1972 Bernard Lown and Paul Axelrod

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5 1 The AVID Investigators. N Engl J Med. 1997;337: Kuck K. Circ.2000;102: Connolly S. Circ. 2000;101: % 28% 20% % Mortality Reduction w/ ICD Rx Secondary Prevention Trials: Reduction in Overall Mortality with ICD Therapy 3 Years

6 1 The AVID Investigators. N Engl J Med. 1997;337: Kuck K. Circ.2000;102: Connolly S. Circ. 2000;101: % 56% 28% 59% 20% 33% % Mortality Reduction w/ ICD Rx Secondary Prevention Trials: Reduction in Mortality with ICD Therapy 3 Years

7 1 Moss AJ. N Engl J Med. 1996;335: Buxton AE. N Engl J Med. 1999;341: Moss AF. N Engl J Med. 2002;346: % 55% 31% Primary Prevention Post-MI Trials: Reduction in Overall Mortality with ICD Therapy 27 Months39 Months20 Months % Mortality Reduction w/ ICD Rx

8 1 Moss AJ. N Engl J Med. 1996;335: Buxton AE. N Engl J Med. 1999;341: Moss AF. N Engl J Med. 2002;346: Moss AJ. Presented before ACC 51st Annual Scientific Sessions, Late Breaking Clinical Trials, March 19, , 4 54% 75% 55% 73% 31% 61% Primary Prevention Post-MI Trials: Reduction in Mortality with ICD Therapy 27 Months39 Months20 Months % Mortality Reduction w/ ICD Rx

9 1 Moss AJ. N Engl J Med. 1996;335: Buxton AE. N Engl J Med. 1999;341: Moss AJ. N Engl J Med. 2002;346: The AVID Investigators. N Engl J Med. 1997;337: Kuck K. Circ. 2000;102: Connolly S. Circ. 2000:101: ICD mortality reductions in primary prevention trials are equal to or greater than those in secondary prevention trials Reductions in Overall Mortality with ICD Therapy 54% 55% 31% 27 months39 months20 months 31% 28% 20% % Mortality Reduction w/ ICD Rx 3 Years 3

10 1 Moss AJ. N Engl J Med. 1996;335: Buxton AE. N Engl J Med. 1999;341: Moss AJ. N Engl J Med. 2002;346: Moss AJ. Presented before ACC 51st Annual Scientific Sessions, Late Breaking Clinical Trials, March 19, The AVID Investigators. N Engl J Med. 1997;337: Kuck K. Circ. 2000;102: Connolly S. Circ. 2000:101: ICD mortality reductions in primary prevention trials are equal to or greater than those in secondary prevention trials. 13, Reductions in Mortality with ICD Therapy 54% 75% 55% 76% 31% 61% 27 months39 months20 months 31% 56% 28% 59% 20% 33% % Mortality Reduction w/ ICD Rx 3 Years

11 MADIT II

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15 Reason for treatment with AADs in ICD recipients

16 Prognostic importance of defibrillator shocks in patients with heart failure

17 Benefits of adjuvant AADs in ICD patients

18 Post-infarto Betabloccanti: Effetti sulla mortalità YUSUF S. et al. Prog Cardiovas Dis, 1985; 17: BETABLOCCANTI PLACEBO RIDUZIONE 934/12438 (7.5%) 288/8115 (3.5%) 1124/11860 (9.5%) 401/7706 (5.2%) - 21% - 33% Mortalità Totale Morte Improvvisa 26 trials > pts

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20 Clinical Trial summarizing Benefits of AADs

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22 OPTIC Trial

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27 Side Effects of Beta-Blockers could be Beneficial

28 Conclusions Adjunctive AAD therapy often is necessary in many patients with ICDs for control of recurrent ventricular tachyarrhythmias and prevention of ICD shocks.

29 Conclusions Given the scarsity of safe and effective AADs for this indication, the decision of when to start an AAD in the patient with an ICD must be individualized.

30 Conclusions If AAD therapy is initiated, the potential for drug-related toxicities and device interactions must be recognized and anticipated.


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