Introduction The National Institute for Health and Clinical Excellence (NICE) published its guidance on implantable cardioverter defibrillators (ICD) for arrhythmias in technology appraisal TA95, January 2006. We audited the assessment of post myocardial infarction (MI) patients with regard to their arrhythmic risk and suitability for ICD implantation based on the primary prevention guidelines.
Methods All patients who had suffered an MI between 1st October 2007 and 31st March 2008 at the Royal Victoria Infirmary, Newcastle were included in the audit. Each original entry in the MINAP database for this period was retrospectively analysed and original echocardiogram reports reviewed and matched to each patient. The patients were divided into four distinct groups for further analysis based on their ejection fraction (EF).
Group 1: No echocardiogram. Excluding those that were not able to have echocardiograms (deaths, non-attenders) and those where assessment was not planned (frail, multiple co-morbidities), 183/191 (96%) had appropriate assessment of LV function post MI.
Group 2: 125 patients with EF >35%. No further analysis.
Group 3: 23 patients with EF 30–35%. Two had ICD for secondary prevention, two were non-attenders (DNA) and 10 did not have non sustained ventricular tachycardia (NSVT) on Holter monitoring. Eight (of the remaining 9) patients were frail with multiple co-morbidities and included one patient who had previously been declined an ICD and one who did not want resuscitation. Notes were unavailable for one patient.
Group 4: 35 patients with EF <30%. Nineteen patients were not suitable for ICD based on: death during index admission (4), improved EF on repeat echocardiogram (3), general frailty/co-morbidity (8), non-attendance (2), or ICD for secondary prevention (2). Five patients had QRS >120 ms and met criteria for ICD implantation but four of these had significant co-morbidity (two died within 6 months). One other patient was not referred for ICD for no apparent reason. One patient had troponin release secondary to aortic stenosis with normal coronaries.
Conclusions The vast majority of patients had assessment of LV function post MI. Almost all patients with EF 30–35% were assessed for ICDs provided there were no significant exclusions. Thirty of 35 (85%) patients with EF <30% were either assessed for ICD or excluded for other reasons. Patients being considered for ICD should generally have a life expectancy of ¡Ý1 year. Previous studies have looked at eligibility for primary prevention ICD based on echocardiogram/ECG/Holter monitoring but have not accounted for potential co-morbidity. In this cohort, there was significant co-morbidity accounting for the low number of patients who met all criteria for ICD implantation.
- Implantable cardioverter defibrillators
- primary prevention
- myocardial infarction
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