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Sinus mapping in patients with cardiac arrest and coronary disease--results and correlation with outcome
A H Kadish1, M E Rosenthal, J A Vassallo
1Clinical Electrophysiology Laboratory, Hospital of the University of Pennsylvania, Philadelphia 19104.
Insights
Patients with coronary artery disease and cardiac arrest often have inducible arrhythmias. Marked electrical abnormalities, even without inducible arrhythmias, predict recurrence and may require AICD implantation.
Area of Science:
- Cardiology
- Electrophysiology
- Cardiac Arrhythmias
Background:
- Coronary artery disease (CAD) is a leading cause of cardiac arrest.
- Identifying patients at risk for recurrent arrhythmias after cardiac arrest is crucial for management.
- Electrophysiological testing and endocardial mapping are used to assess arrhythmia substrates.
Purpose of the Study:
- To correlate electrophysiological testing and left ventricular endocardial mapping findings with clinical outcomes in patients with CAD and cardiac arrest.
- To identify predictors of arrhythmia recurrence and guide therapeutic strategies.
Main Methods:
- Sixty-one patients with CAD and cardiac arrest underwent electrophysiological testing and left ventricular endocardial mapping in sinus rhythm.
- Inducible sustained arrhythmias were categorized as uniform ventricular tachycardia or polymorphic ventricular tachycardia/ventricular fibrillation.
- Endocardial electrograms were analyzed for abnormalities and fractionation.
Main Results:
- Forty-one patients (67%) had inducible arrhythmias, while 20 did not.
- Patients with inducible arrhythmias showed a trend towards more abnormal and fractionated electrograms, though not statistically significant.
- Arrhythmia recurrence occurred in 27% of patients over a mean follow-up of 27 months.
- In patients without inducible arrhythmias, those with marked endocardial abnormalities had a higher recurrence rate.
- Patients without inducible arrhythmias and normal endocardial electrograms had a low recurrence rate with anti-ischemic therapy alone.
Conclusions:
- Patients with CAD and cardiac arrest can have significant endocardial electrical abnormalities even without inducible arrhythmias.
- Marked endocardial abnormalities in the absence of inducible arrhythmias identify a high-risk group for clinical recurrence.
- These findings suggest an unrecognized anatomic substrate for arrhythmia in some patients, warranting consideration for AICD implantation.
- Patients with normal endocardial electrograms may be managed effectively with anti-ischemic therapy.
Abstract:
Electrophysiological testing and left ventricular endocardial mapping in sinus rhythm were performed in 61 patients with coronary artery disease who presented with cardiac arrest in an attempt to relate the results of these studies to clinical outcome. Forty-one patients (67%) had inducible sustained arrhythmias (18 uniform ventricular tachycardia, 23 polymorphic ventricular tachycardia/ventricular fibrillation) and 20 had no inducible arrhythmia. Patients with inducible arrhythmia had 45% abnormal and 6% fractionated electrograms versus 31% and 0% for those without inducible arrhythmia (P greater than 0.05 for both comparisons). Sixteen of 59 patients (27%) with adequate follow-up had arrhythmia recurrence (11/39 [31%] with inducible arrhythmia and 5/20 [25%] without inducible arrhythmia) over a mean follow-up period of 27 months. Of five patients without inducible arrhythmia who experienced recurrence, two did so despite the anti-ischemic therapy. In the 20 patients without inducible arrhythmia, the 15 who remained arrhythmia-free had a mean of 78 +/- 22% normal sites versus 46 +/- 24% normal sites in those with recurrence (P greater than 0.05). We conclude that in patients with coronary artery disease and cardiac arrest: 1) patients without inducible arrhythmia have less marked endocardial electrical abnormality than those with inducible arrhythmia, 2) those patients who have marked endocardial abnormality despite the lack of inducible arrhythmia are at risk for clinical recurrence which suggests that these abnormalities may represent an anatomic substrate for arrhythmia which cannot be identified by programmed stimulation. These patients are candidates for AICD implantation and 3) patients with relatively normal endocardial electrograms do well with anti-ischemic therapy alone.
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