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Programmed ventricular stimulation in survivors of acute myocardial infarction: long-term follow-up
B Brembilla-Perrot1, A T de la Chaise, S Briançon
1Cardiology A-B, CHU of Brabois, Vandoeuvre, France.
Insights
Programmed ventricular stimulation can predict arrhythmic events after acute myocardial infarction. Left ventricular ejection fraction below 30% and inducible ventricular tachycardia are key risk factors for cardiac death.
Area of Science:
- Cardiology
- Electrophysiology
- Clinical Research
Background:
- Sudden cardiac death (SCD) remains a significant concern in acute myocardial infarction (AMI) survivors.
- Identifying patients at high risk for ventricular tachyarrhythmias (VT) is crucial for timely intervention.
Purpose of the Study:
- To evaluate the prognostic significance of induced ventricular tachyarrhythmias using programmed ventricular stimulation in AMI survivors.
- To identify predictors of cardiac death, VT, and sudden death (SD) in this population.
Main Methods:
- Prospective evaluation of 492 AMI survivors undergoing programmed ventricular stimulation.
- Inclusion of Holter monitoring, signal-averaged ECG, and left ventricular ejection fraction (EF) assessment.
- Induction of sustained monomorphic VT (<270 bpm), ventricular flutter (VFI, >270 bpm), and ventricular fibrillation (VF) analyzed.
Main Results:
- Inducible VT (<270 bpm) and low EF (<30%) were significant predictors of total cardiac death.
- EF <30%, inducible VT (<270 bpm), and VFI predicted VT and SD.
- Risk of VT/SD was 4% (no VT), 12% (VFI), and 21% (VT <270 bpm).
- VT episodes occurred early and late (up to 4 years), while SD was confined to the first year post-AMI.
Conclusions:
- Sustained monomorphic VT induction predicts arrhythmic events up to 4 years post-MI.
- Sudden death risk decreases after the first year, but VT risk persists.
- Programmed stimulation is recommended for patients with abnormal non-invasive tests due to its limited positive predictive value.
Abstract:
The prognostic significance of ventricular tachyarrhythmias induced by programmed ventricular stimulation was evaluated in 492 consecutive survivors of acute myocardial infarction (AMI). Holter monitoring, signal-averaged electrocardiogram (ECG) and measurement of left ventricular ejection fraction (EF) were also performed. The protocol used up to 3 extrastimuli. Sustained monomorphic ventricular tachycardia (VT) < 270 beats/min, > 270 beats/min (ventricular flutter) (VFI), and ventricular fibrillation (VF) were induced in 99, 66 and 52 patients, respectively. Long term follow-up (mean 3.7 +/- 2.2 years) showed that most episodes of VT occurred during the first months following AMI (n = 14), but some patients (n = 6) could develop VT as late as 4 years after AMI. Sudden death (SD) (n = 22) always occurred during the first year following AMI. Multivariate analysis demonstrated that EF < 30% and induction of a VT < 270 beats/min were the only predictors for total cardiac death (P < 0.001). EF < 30%, induction of a VT < 270 beats/min and also of VFI (P < 0.05) were predictors for VT and SD: the risk was 4% in patients without inducible VT, 12% in those with inducible VF1, and 21% in those with inducible VT < 270 beats/min. In conclusion, induction of a sustained monomorphic VT < 270 beats/min or > 270 beats/min is a predictor of arrhythmic events during the first year as well as 4 years after myocardial infarction. However the risk of arrhythmic sudden death decreases after the first year, while the risk of VT persists. Because of the low positive predictive value of programmed stimulation (respectively 21% and 12% for the induction of a sustained VT and VFI), we recommended the indication of programmed stimulation in only the patients with one abnormal non-invasive investigation.