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Prognostic significance of nonsustained ventricular tachycardia after revascularization
Suneet Mittal1, David J Lomnitz, Sunil Mirchandani
1Department of Medicine, The New York Hospital-Cornell Medical Center, New York 10021, USA.
Insights
Patients with inducible ventricular tachycardia (VT) after revascularization may benefit from an implantable cardioverter defibrillator (ICD). Early arrhythmic events were common in inducible patients, suggesting a protective role for ICDs.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Previous trials (MADIT, MUSTT) suggest implantable cardioverter defibrillator (ICD) benefits patients with coronary artery disease, depressed left ventricular function, and inducible sustained ventricular tachycardia (VT).
- Management of patients with early post-revascularization nonsustained VT and inducible VT remains unclear.
Purpose of the Study:
- To evaluate outcomes of patients with nonsustained VT early after revascularization, focusing on inducible VT and ICD use.
- To assess the incidence of arrhythmic events and mortality in patients with and without inducible VT.
Main Methods:
- Prospective evaluation of 109 consecutive patients undergoing electrophysiologic testing for nonsustained VT within 5 days of revascularization.
- Patients with inducible VT received an ICD; noninducible patients received no specific antiarrhythmic treatment.
- Follow-up averaged 27 months to assess device therapy, VT/VF, and mortality.
Main Results:
- Sustained VT was inducible in 46% of patients, who received ICDs. Noninducible patients (58%) did not.
- During follow-up, 33% of ICD recipients received appropriate therapy.
- Freedom from VT/VF or sudden death was significantly higher in noninducible patients (97% at 1 year, 93% at 2 years) compared to inducible patients (84% at 1 year, 71% at 2 years).
- No significant difference in overall mortality was observed between groups.
Conclusions:
- Patients with early post-revascularization nonsustained VT and inducible VT experience a high rate of arrhythmic events.
- While not powered to show mortality benefit, a high rate of appropriate ICD therapy suggests a potential protective effect.
- Further research is warranted to confirm the role of ICDs in this specific patient population.
Introduction:
Two randomized trials (Multicenter Automatic Defibrillator Implantation Trial [MADIT] and Multicenter Unsustained Tachycardia Trial [MUSTT]) suggest that implantable cardioverter defibrillator (ICD) placement is associated with improved survival in patients with coronary artery disease, depressed left ventricular function, and nonsustained ventricular tachycardia (VT) who also have inducible sustained VT. However, neither study directly addresses the management of such patients who develop nonsustained VT early after revascularization.
Methods And Results:
We evaluated 109 consecutive patients who underwent electrophysiologic testing to evaluate nonsustained VT, which occurred 5 +/- 4 days following revascularization. Sustained monomorphic VT was inducible in 46 (42%) patients; these patients received an ICD. The remaining 63 (58%) noninducible patients received neither antiarrhythmic drug therapy nor an ICD. During 27 +/- 12 months of follow-up, 15 (33%) of 45 patients with an implanted ICD received at least one appropriate therapy from the device and 26 (24%) of the 109 study patients died. The 1- and 2-year freedom from ventricular tachycardia/fibrillation or sudden death in noninducible patients (97% and 93%) was significantly greater than that of inducible patients (84% and 71%; P = 0.001). However, no difference was observed in total mortality.
Conclusion:
Patients with nonsustained VT during the early postrevascularization period who have inducible VT have a high incidence of arrhythmic events. Although this study was not designed to assess the impact of ICD placement on the total mortality of inducible patients, the finding that one third of these patients received appropriate ICD therapy suggests that the device may have a protective effect in these patients.