PubMed · 15017683
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Tsung O Cheng. 2004-03-11. Conditions associated with ST-segment elevation.. https://pubmed.ncbi.nlm.nih.gov/15017683/
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BACKGROUND: Although psychological stress is known to favor ventricular arrhythmic events, there is no evidence that stress management intervention decreases ventricular electrical instability in implantable cardioverter-defibrillator (ICD) patients. The aim of the study was to determine whether cognitive behavioral therapy (CBT) results in a decrease of arrhythmic events requiring ICD intervention through an improvement in sympathovagal balance. METHODS: Of 253 consecutive ICD patients (age 59 +/- 10 years, 64 men), 70 were randomly assigned to CBT (n = 35) or conventional medical care (n = 35). Measures of heart rate variability, psychological well-being, and quality of life were assessed at baseline, 3 months, and 1 year. The primary outcome was appropriate ICD shock. RESULTS: Although, it was not statistically different, the number of patients requiring shocks was less in the CBT group than in the conventional treatment group. At 3 months, among patients without antiarrhythmic drugs, none of the subjects in the CBT group had experienced arrhythmic events requiring ICD intervention, as compared with 4 in the control group (P < .05). At 12 months, there was no difference in the number of arrhythmic events requiring therapy between the CBT group versus the control group. Among heart rate variability indexes, daytime pNN 50 and nocturnal SDNN improved significantly in the CBT group, as compared with the control group. CONCLUSIONS: By decreasing anxiety and possibly improving sympathovagal balance, cognitive behavior therapy may decrease the propensity for ventricular arrhythmias in ICD patients. However, these effects appear to be limited over time.
PURPOSE OF REVIEW: The aim of this article is to forecast a major imminent change in the clinical practice of cardiac rhythm management, which is argued to be remote patient monitoring, its potential benefits to clinical practitioners and its barriers to widespread diffusion. RECENT FINDINGS: All four major manufacturers of cardiac rhythm management devices have recently introduced varying types of systems that allow remote patient monitoring. These remote patient monitoring systems promise more efficient patient management in today's clinical setting of rapidly growing numbers of patients with increasingly heterogeneous etiology, varying indications and comorbidities. The major differences between current systems are related to the degree of patient involvement in remote patient monitoring and limits on patient mobility. Other important factors that influence the value of remote patient monitoring are the degree to which remote follow-up would completely fulfill the requirements of an in-office follow-up and the inclusion of sensors that enable the prediction of major clinical events such as heart failure decompensation with a high degree of accuracy. SUMMARY: Even if the different remote patient monitoring systems currently available offer several clinical benefits such as early detection of cardiac events and complications, reduced follow-up costs and increased safety, the full potential of such systems requires the possibility to easily transfer relevant patient data to common patient databases that are linked to hospital information systems or electronic patient records. Only then will it be possible to gain a complete picture of patient conditions. This will require the development of common protocols for data communication and may involve issues of patient data ownership and integrity.
PURPOSE OF REVIEW: Clinical trials provide evidence that an empirical approach of implantable cardioverter-defibrillator implantation in all heart failure patients (ejection fraction </= 35%) with mild to moderate symptoms effectively reduces mortality rate as compared to the best available medical therapy. At least 50% of patients, however, will succumb to a non-arrhythmic demise and over half of all patients will not require device therapy over long-term follow-up. Thus, the approach of empiric implantable cardioverter-defibrillator implantation is costly in light of the considerable expense of device cost, implantation, and patient follow-up. This review discusses the prospect of genomic medicine as an approach to assess genetic susceptibility to sudden arrhythmic death in at-risk populations. RECENT FINDINGS: Through the past 10 years of primary prevention implantable cardioverter-defibrillator trials, the number of patients needed to treat to prevent a sudden death has risen from one in four patients to one in 14. Although numerous clinical tests exist for stratification, they are of low positive predictive value in assessing arrhythmic risk, and have not been prospectively validated as effective strategies in identifying arrhythmia-prone patients. Recent data from genetic studies identifying genes responsible for sudden cardiac death have compiled a list of relatively common genetic variations (polymorphisms). These polymorphisms, encoding for proteins known to be involved in cardiac electrophysiology, may contribute to arrhythmic risk in the milieu of heart failure. SUMMARY: Current clinical indications for implantable cardioverter-defibrillator implantation in primary prophylaxis of sudden cardiac death necessarily include a significant number of patients who may not benefit. The identification of common genetic variations causing an increased risk of vulnerability to ventricular arrhythmia in heart failure patients may optimize the use of medical resources through rapid identification of sub-populations at highest risk.