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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ischemic cardiomyopathy &#40;ICM&#41; is a well-defined entity&#46; A standard definition used in multicenter studies is the presence of systolic dysfunction associated with a history of myocardial infarction or revascularization &#40;coronary artery bypass grafting or percutaneous coronary intervention&#41;&#44; &#8805;75&#37; stenosis of the left main or proximal left anterior descending artery&#44; or &#8805;75&#37; stenosis of two or more epicardial vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Non-ischemic cardiomyopathy &#40;NICM&#41; includes every form of dilated cardiomyopathy without significant coronary disease and is a heterogeneous condition&#46; Idiopathic cardiomyopathy&#44; i&#46;e&#46; the etiology of which is unknown&#44; accounts for up to 50&#37; of cases&#46; There are many potential causes of NICM&#44; including infection&#44; immunologic conditions&#44; toxic injury&#44; genetic factors and tachycardiomyopathy&#46; Determining the prevalence of NICM is made difficult by heterogeneity in definitions and diagnostic criteria&#44; selection bias in study populations&#44; and geographic variation&#46; Likewise&#44; different studies targeting NICM&#44; or comparing these patients with those with ICM&#44; may report different results due to the inclusion of different types of patients&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The study by Marinheiro et al&#46; published in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> asks whether defibrillators are less useful in patients with non-ischemic heart disease&#46; This question was raised by the DANISH trial&#44; which suggested that defibrillator implantation is not of significant benefit for primary prevention patients with NICM&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> The answer is clear in the first sentence of the discussion&#58; 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class II&#44; and this subgroup effect was not anticipated before data analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> By contrast&#44; in the DEFINITE trial&#44; patients in NYHA class III derived the greatest benefit from ICD therapy&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> but no significant reduction in all-cause death was found&#46; DANISH was a contemporary prospective randomized multicenter trial performed in a country with an excellent healthcare system&#44; Denmark&#46; All of the country&#39;s ICD implantation centers were included and the vast majority of patients received optimal medical therapy&#58; target levels of beta-blockers&#44; angiotensin-converting enzyme inhibitors or angiotensin receptor blockers&#44; and mineralocorticoid receptor antagonists&#46; Furthermore&#44; 58&#37; of patients received cardiac resynchronization therapy &#40;CRT&#41; in accordance with current European guidelines&#46; This represents a major difference between the DANISH and SCD-HeFT trials&#44; as in the latter only 69&#37; and 20&#37; of enrolled patients received beta-blockers and mineralocorticoid receptor antagonists at baseline&#44; respectively&#44; and none received concomitant CRT&#46; It is thus reasonable to state that the results of DANISH may be a more accurate representation of the true benefits of the ICD in this patient population&#46; The management of heart failure patients with medical therapy and CRT has improved substantially over the last two decades&#44; which in turn has led to a reduction in the overall mortality observed in patients with NICM and&#44; as a result&#44; a reduction in the impact of the ICD&#46; Patients with NICM live longer nowadays&#44; and the cumulative burden of their comorbidities may result in a higher percentage of deaths due to non-cardiac or non-SCD rather than SCD&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">CRT has undoubtedly been one of the most important advances in the treatment of heart failure patients with prolonged QRS and severe left ventricular dysfunction&#46; This treatment should be considered before implanting an ICD in patients with NICM&#44; as the evidence supporting CRT in these patients appears to be stronger than that supporting the use of an ICD&#46; In a large European cohort of primary prevention patients receiving CRT&#44; Barra et al&#46; assessed the benefit of adding an ICD according to the underlying myocardial substrate&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Of a total of 5307 consecutive patients&#44; 4037 &#40;76&#46;1&#37;&#41; received a cardiac resynchronization therapy defibrillator &#40;CRT-D&#41;&#44; while the other 1270 &#40;23&#46;9&#37;&#41; received a cardiac resynchronization therapy pacemaker &#40;CRT-P&#41;&#46; The population was well balanced between ICM and NICM &#40;2682 patients with ICM and 2625 with NICM&#41;&#46; The primary endpoint of the study was all-cause mortality&#46; A secondary cause-of-death analysis was performed&#44; with a focus on SCD vs&#46; non-SCD and an assessment of the percentage excess mortality related to SCD&#46; The authors found that patients with ICM had a more favorable outcome as a group when implanted with CRT-D compared with CRT-P&#44; whereas in patients with NICM there was no significant difference in survival between those receiving CRT-D or CRT-P&#46; In patients with NICM&#44; the excess mortality of CRT-P compared with CRT-D was due to SCD in only 0&#46;4&#37; of cases&#44; compared with 8&#37; in those with ICM&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> These findings suggest that CRT-D is superior to CRT-P in ICM&#44; but not in NICM&#46; In the latter&#44; the use of CRT-D was not of significant benefit even in CRT patients whose general characteristics best match those of patients who would typically receive CRT-D&#44; that is&#44; younger patients with fewer comorbidities&#46; These results&#44; recently corroborated by Leyva et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a>&#44; reinforce the need for appropriate patient selection on the basis of the estimated risk of not only SCD but also non-SCD&#44; which is known to correlate with the degree of the patient&#39;s comorbidity and frailty&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> Patient selection on the basis of left ventricular ejection fraction &#40;LVEF&#41; alone is clearly insufficient and&#44; should we choose to rely on this measure only&#44; we will not be selecting the patients most likely to benefit from an ICD&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The PRE-DETERMINE Biologic Markers and Sudden Cardiac Death Study<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">9</span></a> is an ongoing multicenter prospective cohort study of patients with coronary heart disease with a history of myocardial infarction and&#47;or mild to moderate left ventricular dysfunction who do not fulfill consensus guideline criteria for ICD implantation on the basis of their LVEF and NYHA class&#46; Between July 2007 and November 2013&#44; 5761 patients were enrolled in 135 centers in the US and Canada&#46; The preliminary results suggested that a moderately reduced LV function &#40;LVEF 40&#37;-49&#37;&#41; was more strongly associated with sudden&#47;arrhythmic cardiac death&#44; while age and NYHA class II heart failure were more strongly associated with non-sudden death&#46; As in NICM&#44; younger patients should benefit most from an ICD due to a lower prevalence of the competing risk of non-SCD&#46; Although in this study the arrhythmic death risk was continuously and inversely associated with LVEF&#44; the relative risk was higher in patients with an LVEF of 40&#37;&#8211;49&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">9</span></a> Given that &#8805;70&#37; of individuals experiencing SCD have an LVEF greater than 35&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">10</span></a> integration of a more continuous assessment of LVEF into future risk stratification tools may improve prediction of sudden death&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study by Marinheiro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> assessed a real-life cohort of 281 patients who received an ICD over a period of ten years&#46; The authors specifically compared the outcome of patients with ICM &#40;66&#37;&#41; with that of patients with NICM &#40;33&#37;&#41;&#46; The latter&#44; who represented only one third of the study group&#44; were younger&#44; had less comorbidity and more often received CRT&#44; which could explain why their outcome was generally better&#46; The lack of statistical significance was also the result of an underpowered analysis&#46; Furthermore&#44; these patients were those with NICM who may still benefit from an ICD&#44; as suggested by the subgroup analysis of the DANISH trial&#46; Another criticism of the present study is that appropriate shocks were included in the analysis&#46; Several studies had demonstrated that the occurrence of appropriate shocks is not directly associated with SCD&#44; because most are triggered by ventricular tachycardia episodes that are not always fatal&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Identification of markers that uniquely discriminate sudden arrhythmic death &#40;SAD&#41; from non-SAD will be required to optimize absolute and proportional risk stratification in subpopulations targeted for sudden death prevention&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Hopefully&#44; in the near future more ICDs will be implanted in patients at risk of SCD&#44; but it will always be necessary to take into consideration the patient&#39;s comorbidities&#44; which define the underlying risk of non-SCD&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">There will probably be an expansion of the indications for ICD implantation in patients with ICM to less severe degrees of LV systolic dysfunction&#46; However&#44; this may not be the case for NICM&#46; The hope is for improvements in knowledge of the underlying pathophysiology&#44; in medical therapy&#44; in selection for CRT and stratification for SCD&#44; possibly by cardiac MRI or other means&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Perhaps an iPhone app will become available that will quickly and easily calculate our patients&#8217; risk of SCD&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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The implantable cardioverter-defibrillator according to underlying etiology: Why compare apples and oranges?
O cardioversor-desfibrilhador implantável segundo a etiologia subjacente: porque razão comparar alhos com bugalhos?
João Primo
Centro Hospitalar de Vila Nova de Gaia, Hospital da Luz Arrábida, Vila Nova de Gaia, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ischemic cardiomyopathy &#40;ICM&#41; is a well-defined entity&#46; A standard definition used in multicenter studies is the presence of systolic dysfunction associated with a history of myocardial infarction or revascularization &#40;coronary artery bypass grafting or percutaneous coronary intervention&#41;&#44; &#8805;75&#37; stenosis of the left main or proximal left anterior descending artery&#44; or &#8805;75&#37; stenosis of two or more epicardial vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Non-ischemic cardiomyopathy &#40;NICM&#41; includes every form of dilated cardiomyopathy without significant coronary disease and is a heterogeneous condition&#46; Idiopathic cardiomyopathy&#44; i&#46;e&#46; the etiology of which is unknown&#44; accounts for up to 50&#37; of cases&#46; There are many potential causes of NICM&#44; including infection&#44; immunologic conditions&#44; toxic injury&#44; genetic factors and tachycardiomyopathy&#46; Determining the prevalence of NICM is made difficult by heterogeneity in definitions and diagnostic criteria&#44; selection bias in study populations&#44; and geographic variation&#46; Likewise&#44; different studies targeting NICM&#44; or comparing these patients with those with ICM&#44; may report different results due to the inclusion of different types of patients&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The study by Marinheiro et al&#46; published in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> asks whether defibrillators are less useful in patients with non-ischemic heart disease&#46; This question was raised by the DANISH trial&#44; which suggested that defibrillator implantation is not of significant benefit for primary prevention patients with NICM&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> The answer is clear in the first sentence of the discussion&#58; &#8220;We found that implantation of an ICD in patients who had heart failure that was not caused by ischemic heart disease did not provide an overall survival benefit&#44; although the risk of sudden cardiac death was halved with an ICD&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Is it in fact reasonable to ask more of an ICD than merely to protect patients against sudden cardiac death &#40;SCD&#41;&#63; This is the only purpose of this type of device&#44; and the reason that it was developed&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Sudden Cardiac Death in Heart Failure Trial &#40;SCD-HeFT&#41; began randomizing patients in 1997 and included a total of 2521 subjects&#44; half of whom had NICM&#46; It is the only randomized trial involving patients with NICM in which a significant benefit with regard to all-cause mortality was reported in association with an ICD&#46; However&#44; this benefit was confined to patients in New York Heart Association &#40;NYHA&#41; class II&#44; and this subgroup effect was not anticipated before data analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> By contrast&#44; in the DEFINITE trial&#44; patients in NYHA class III derived the greatest benefit from ICD therapy&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> but no significant reduction in all-cause death was found&#46; DANISH was a contemporary prospective randomized multicenter trial performed in a country with an excellent healthcare system&#44; Denmark&#46; All of the country&#39;s ICD implantation centers were included and the vast majority of patients received optimal medical therapy&#58; target levels of beta-blockers&#44; angiotensin-converting enzyme inhibitors or angiotensin receptor blockers&#44; and mineralocorticoid receptor antagonists&#46; Furthermore&#44; 58&#37; of patients received cardiac resynchronization therapy &#40;CRT&#41; in accordance with current European guidelines&#46; This represents a major difference between the DANISH and SCD-HeFT trials&#44; as in the latter only 69&#37; and 20&#37; of enrolled patients received beta-blockers and mineralocorticoid receptor antagonists at baseline&#44; respectively&#44; and none received concomitant CRT&#46; It is thus reasonable to state that the results of DANISH may be a more accurate representation of the true benefits of the ICD in this patient population&#46; The management of heart failure patients with medical therapy and CRT has improved substantially over the last two decades&#44; which in turn has led to a reduction in the overall mortality observed in patients with NICM and&#44; as a result&#44; a reduction in the impact of the ICD&#46; Patients with NICM live longer nowadays&#44; and the cumulative burden of their comorbidities may result in a higher percentage of deaths due to non-cardiac or non-SCD rather than SCD&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">CRT has undoubtedly been one of the most important advances in the treatment of heart failure patients with prolonged QRS and severe left ventricular dysfunction&#46; This treatment should be considered before implanting an ICD in patients with NICM&#44; as the evidence supporting CRT in these patients appears to be stronger than that supporting the use of an ICD&#46; In a large European cohort of primary prevention patients receiving CRT&#44; Barra et al&#46; assessed the benefit of adding an ICD according to the underlying myocardial substrate&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Of a total of 5307 consecutive patients&#44; 4037 &#40;76&#46;1&#37;&#41; received a cardiac resynchronization therapy defibrillator &#40;CRT-D&#41;&#44; while the other 1270 &#40;23&#46;9&#37;&#41; received a cardiac resynchronization therapy pacemaker &#40;CRT-P&#41;&#46; The population was well balanced between ICM and NICM &#40;2682 patients with ICM and 2625 with NICM&#41;&#46; The primary endpoint of the study was all-cause mortality&#46; A secondary cause-of-death analysis was performed&#44; with a focus on SCD vs&#46; non-SCD and an assessment of the percentage excess mortality related to SCD&#46; The authors found that patients with ICM had a more favorable outcome as a group when implanted with CRT-D compared with CRT-P&#44; whereas in patients with NICM there was no significant difference in survival between those receiving CRT-D or CRT-P&#46; In patients with NICM&#44; the excess mortality of CRT-P compared with CRT-D was due to SCD in only 0&#46;4&#37; of cases&#44; compared with 8&#37; in those with ICM&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> These findings suggest that CRT-D is superior to CRT-P in ICM&#44; but not in NICM&#46; In the latter&#44; the use of CRT-D was not of significant benefit even in CRT patients whose general characteristics best match those of patients who would typically receive CRT-D&#44; that is&#44; younger patients with fewer comorbidities&#46; These results&#44; recently corroborated by Leyva et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a>&#44; reinforce the need for appropriate patient selection on the basis of the estimated risk of not only SCD but also non-SCD&#44; which is known to correlate with the degree of the patient&#39;s comorbidity and frailty&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> Patient selection on the basis of left ventricular ejection fraction &#40;LVEF&#41; alone is clearly insufficient and&#44; should we choose to rely on this measure only&#44; we will not be selecting the patients most likely to benefit from an ICD&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The PRE-DETERMINE Biologic Markers and Sudden Cardiac Death Study<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">9</span></a> is an ongoing multicenter prospective cohort study of patients with coronary heart disease with a history of myocardial infarction and&#47;or mild to moderate left ventricular dysfunction who do not fulfill consensus guideline criteria for ICD implantation on the basis of their LVEF and NYHA class&#46; Between July 2007 and November 2013&#44; 5761 patients were enrolled in 135 centers in the US and Canada&#46; The preliminary results suggested that a moderately reduced LV function &#40;LVEF 40&#37;-49&#37;&#41; was more strongly associated with sudden&#47;arrhythmic cardiac death&#44; while age and NYHA class II heart failure were more strongly associated with non-sudden death&#46; As in NICM&#44; younger patients should benefit most from an ICD due to a lower prevalence of the competing risk of non-SCD&#46; Although in this study the arrhythmic death risk was continuously and inversely associated with LVEF&#44; the relative risk was higher in patients with an LVEF of 40&#37;&#8211;49&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">9</span></a> Given that &#8805;70&#37; of individuals experiencing SCD have an LVEF greater than 35&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">10</span></a> integration of a more continuous assessment of LVEF into future risk stratification tools may improve prediction of sudden death&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study by Marinheiro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> assessed a real-life cohort of 281 patients who received an ICD over a period of ten years&#46; The authors specifically compared the outcome of patients with ICM &#40;66&#37;&#41; with that of patients with NICM &#40;33&#37;&#41;&#46; The latter&#44; who represented only one third of the study group&#44; were younger&#44; had less comorbidity and more often received CRT&#44; which could explain why their outcome was generally better&#46; The lack of statistical significance was also the result of an underpowered analysis&#46; Furthermore&#44; these patients were those with NICM who may still benefit from an ICD&#44; as suggested by the subgroup analysis of the DANISH trial&#46; Another criticism of the present study is that appropriate shocks were included in the analysis&#46; Several studies had demonstrated that the occurrence of appropriate shocks is not directly associated with SCD&#44; because most are triggered by ventricular tachycardia episodes that are not always fatal&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Identification of markers that uniquely discriminate sudden arrhythmic death &#40;SAD&#41; from non-SAD will be required to optimize absolute and proportional risk stratification in subpopulations targeted for sudden death prevention&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Hopefully&#44; in the near future more ICDs will be implanted in patients at risk of SCD&#44; but it will always be necessary to take into consideration the patient&#39;s comorbidities&#44; which define the underlying risk of non-SCD&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">There will probably be an expansion of the indications for ICD implantation in patients with ICM to less severe degrees of LV systolic dysfunction&#46; However&#44; this may not be the case for NICM&#46; The hope is for improvements in knowledge of the underlying pathophysiology&#44; in medical therapy&#44; in selection for CRT and stratification for SCD&#44; possibly by cardiac MRI or other means&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Perhaps an iPhone app will become available that will quickly and easily calculate our patients&#8217; risk of SCD&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Informação do artigo
ISSN: 08702551
Idioma original: Inglês
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2020 Dezembro 27 8 35
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2020 Outubro 16 18 34
2020 Setembro 13 9 22
2020 Agosto 14 7 21
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2020 Junho 26 12 38
2020 Maio 16 5 21
2020 Abril 14 17 31
2020 Maro 9 5 14
2020 Fevereiro 40 23 63
2020 Janeiro 26 6 32
2019 Dezembro 18 8 26
2019 Novembro 11 7 18
2019 Outubro 9 6 15
2019 Setembro 12 13 25
2019 Agosto 7 7 14
2019 Julho 7 9 16
2019 Junho 17 19 36
2019 Maio 18 6 24
2019 Abril 13 12 25
2019 Maro 9 15 24
2019 Fevereiro 6 10 16
2019 Janeiro 13 9 22
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