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Vanish Trial.pptx
- 1. INTERPRETAÇÃO DE TRIALS RECENTES VANISH - VT Trail Resultado s Diagnósti co Questões Considerar Lembra r Dr. Henrique Maia Coordenador da Residência de Eletrofisiologia IHBDF Co-Fundador do ArritmoCardi
- 2. Grupos Resultado s Questões Considerar Lembra r 259 Pacientes 132 Pacientes 127 Pacientes • Infarto Prévio • CDI • Episódio de TV em 6 meses • Morte • Tempestade elétrica • Choque pelo CDI Ablação Endocárdica Com AMIO 127 Pacientes 132 Pacientes 4 Pacientes 11 Pacientes 4 8 Sem AMIO
- 3. ECG Grupos Resultado s Questões Considerar Lembra r Ablação 2 DAA 1 Clinicamente Instável • Ablação do substrato • Pace mapping • End point: Não indução TT Prévio Amiodarona< 300mg/dia •15d Amiodarona 800 mg /dia •7d Amiodarona 400 mg/dia •Amiodarona 300 mg/dia Sem TT prévio Amiodarona •15d Amiodarona 800mg/dia •30d Amiodarona 400mg/dia •Amiodarona 200mg/dia Clinicamente Tolerada • Mapeamento de ativação • Encarrilhamento • End point: Não indução TT Prévio Amiodarona =/> 300 mg/dia • Dose igual Amiodarona • Mexiletine 600mg/dia
- 4. >manutenç ão ECG Grupos Resultado s Questões Considerar Lembra r 15dias 30 dias >manutenç ão 800mg/dia 400mg/dia 200 mg/dia Amiodarona Amiodarona Amiodarona 15dias 7 dias 800mg/dia 400mg/dia 300 mg/dia Amiodarona Amiodarona Amiodarona Sem AMIO Prévio AMIO <300mg >manutenç ão 15dias 7 dias + Mexiletine + Mexiletine + Mexiletine Amiodarona Amiodarona Amiodarona Prévio AMIO =/>300MG >manutenç ão Prévio AMIO
- 6. ECG Grupos Resultado s Questões Considerar Lembra r Análise de subgrupos Mexiletine e Sotalol Sucesso a longo prazo Efeitos Colaterais Drazen JM et all . Statistics in medicine--reporting of subgroup analyses in clinical trials. N Engl J Med. 2007;357(21):2189-94. Não tiveram impacto nos resultados e tiveram comportamento similar ao da amiodarona isoladamente
- 7. ECG Grupos Resultado s Questões Considerar Lembra r Tratamento virgem de amiodarona: AMIODARONA = ABLAÇÃO Tratamento prévio com amiodarona: ABLAÇÃO> AUMENTO DA DOSE Efeitos Colaterais : AMIODARONA > ABLAÇÃO Mexitil e Sotalol : Inferiores a AMIODARONA e ABLAÇÃO In patients with prior myocardial infarction and recurrent episodes of VT or VF and failed or are intolerant of amiodarone or other antiarrhythmic medications catheter ablation is recommended. Dr. Henrique Maia Coordenador da Residência de Eletrofisiologia IHBDF Co-Fundador do ArritmoCardio
Notas do Editor
- "The clinical interpretation is that when patients experience ventricular arrhythmias despite antiarrhythmic drug therapy, catheter ablation should be considered and in some cases preferred, particularly among patients who have recurrent arrhythmias despite amiodarone," Sapp told heartwire . "Our next clinical question is, what should first-line therapy be?“ Dr John L Sapp Sapp said, "I do think this is clinically significant, and that's bolstered by the fact not only are you achieving better arrhythmia outcomes after ablation, but you also have fewer treatment-attributable adverse events [22 vs 51; P=0.002]." Patients who underwent ablation, however, stayed on their baseline dose of amiodarone to address new arrhythmias that may emerge, so ablation will not eliminate the need for amiodarone entirely, he added. "I hope that it will reduce the need for long-term and/or high-dose amiodarone for some patients.“ "we should not disregard this procedure because of no clear mortality benefit, because it seems to be very effective or at least more effective than antiarrhythmic drugs to use ablation to prevent shocks, which is a big problem for patients.“ In the 127 escalated-therapy and 132 ablation patients, appropriate ICD shocks occurred in 266 and 169 patients, respectively (P=0.28), and inappropriate shocks in 85 and 66, respectively (P=0.46). Notably, there were two cardiac perforations, three cases of major bleeding, and three vascular injuries with ablation and two deaths from pulmonary toxicity and one from hepatic dysfunction with escalated therapy. "the safety aspect was what really sold it to me. We all suspect that antiarrhythmic drugs have toxicity attached to them, but to have it pointed out so starkly as in this trial was very prominent. There were four deaths in the drug arm and none in the ablation arm—mind you, it's a sick population to be ablating in—but to have not a single death tells you how safe VT ablation has become.“ Dr Dhiraj Gupta Deeper DiveIn subgroup analyses, the rate of the primary outcome was significantly lower with ablation only among patients whose index arrhythmia occurred despite amiodarone at baseline (P=0.03 for interaction). Two-thirds of all patients were on amiodarone at baseline.