Prediction of cardiac death in patients with a very low ejection fraction after myocardial infarction: A Cardiac Arrhythmia Suppression Trial (CAST) study

doi:10.1016/0002-8703(95)90064-0

American Heart Journal

Volume 130, Issue 4, October 1995, Pages 685-691

https://doi.org/10.1016/0002-8703(95)90064-0 Get rights and content

Abstract

The Cardiac Arrhythmia Suppression Trial (CAST) database was analyzed with a Cox proportional hazards regression model to predict the mortality of patients with very poor left ventricular systolic function (ejection fraction ≤.20). Predictors of total death or cardiac arrest were (relative risk), QRS duration ( $1.10 10$ msec increase), coronary artery bypass grafting (0.38), basal heart rate ( $1.26 10$ min⁻¹ increase), diastolic blood pressure ( $0.79 10$ mm Hg increase), diabetes mellitus (1.59), EF ( $0.94 1$ U increase), and ease of suppression (the ability to suppress ambient ventricular ectopy on the lowest dose of the first randomly chosen CAST drug) (0.64). Predictors of arrhythmic death or arrhythmic cardiac arrest included thrombolysis (0.44), coronary artery bypass grafting (0.38), diuretic use (1.71), heart rate ( $1.21 10$ min⁻¹ increase), calcium channel blocker use (1.69), and QRS duration ( $1.10 10$ msec increase). Thus easily measurable clinical and laboratory variables help predict prognosis in this clinically important subgroup. The pathophysiologic basis for and the clinical implications of the ease of ventricular arrhythmia suppression correlating with prognosis requires further study.

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2023, American Journal of Cardiology
Citation Excerpt :
Our finding that elevated HR at rest was associated with arrhythmic mortality, all-cause mortality, and VT requiring appropriate shock is supported by previous studies. Elevated HR at rest has been previously shown to be a risk factor for adverse cardiovascular outcomes, particularly in patients with heart failure or acute coronary syndrome,13–17 with β-blocker use being protective.18 In patients with ICDs, increased HR is associated with mortality.19
The VEST (Vest Prevention of Early Sudden Death Trial) showed a trend toward decreased sudden death and lower overall mortality with a wearable cardioverter-defibrillator (WCD) in the postmyocardial infarction (post-MI) period. However, it is unclear which patients should receive WCD therapy. We aimed to identify the risk factors for arrhythmic death, all-cause mortality, and ventricular tachyarrhythmias requiring appropriate shock to identify patients most likely to benefit from a WCD. The VEST trial included patients with acute MI with ejection fraction ≤35%. Using logistic regression, 7 risk factors were evaluated for association with arrhythmic death, all-cause mortality, and appropriate shock. Among 2,302 participants, 44 had arrhythmic death (1.9%) and 86 died of any cause (3.7%). Among 1,524 participants randomized to WCD, 20 experienced appropriate shock (1.3%) over 90 days. In the multivariable analyses, lower systolic blood pressure (SBP; odds ratio [OR] 1.64 per 10 mm Hg) and higher heart rate at discharge (OR 1.19 per 10 beats/min) were associated with arrhythmic death. Lower SBP (OR 1.37) and higher heart rate (OR 1.10) were associated with all-cause mortality. Higher heart rate (OR 1.20) was associated with appropriate shock. Patients with both SBP ≤100 and heart rate ≥100 were at increased odds of arrhythmic death (OR 4.82), all-cause mortality (OR 3.10), and appropriate shock (OR 6.13). In patients with acute MI and reduced ejection fraction, lower SBP and higher heart rate at discharge were strongly associated with arrhythmic death and all-cause mortality. In conclusion, these risk factors identify a select group at high risk of adverse events in a setting where WCD therapy is reasonable.
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Resynchronization of the intra- and interventricular conduction by biventricular pacing has been suggested in patients with end-stage heart failure. We present a case in which extracorporeal circulation could only be weaned after placement of an additional left ventricular pacing wire. Biventricular stimulation led to normal motion of the anterior wall and a previously bulging interventricular septum; this improved the hemodynamic situation significantly.
Concomitant β-blocker therapy is associated with a lower occurrence of ventricular arrhythmias in patients with decompensated heart failure
2002, Journal of Cardiac Failure
Citation Excerpt :
However, data from the Cardiac Arrhythmia Suppression Trial study indicate that heart failure status appears to be a more significant predictor than ejection fraction.26,27 Ejection fraction predicts ventricular arrhythmia particularly in patients with no history or no clinical heart failure, and the utility of this variable diminishes once its value declines to <20%.26,28 Therefore, the inclusion of this variable in the multivariate analysis in our population (decompensated heart failure requiring hospitalization and intravenous vasoactive drugs) is unlikely to produce significantly different results.
Background: Ventricular arrhythmias are nearly universally present in patients with advanced congestive heart failure (CHF) and represent an important cause of mortality in these patients. One of the putative mechanisms for the salutary effects of β-blockers on sudden death mortality in heart failure is their ability to suppress ventricular arrhythmias. However, supporting data in patients with CHF are sparse, especially in the setting of excessive neurohumoral activation associated with symptomatic decompensated heart failure. Methods and Results: We studied 236 patients (159 men; mean age, 61 ± 14 years) admitted for decompensated CHF. Fifty patients were receiving β-blockers at the time of the study. The severity of ventricular arrhythmia was assessed by 24-hour Holter recordings by using several prospectively defined measures of ventricular ectopy. All measures of ventricular ectopy were lower in patients receiving β-blockers. The average hourly total premature ventricular beats (PVCs), hourly ventricular couplets, repetitive PVCs, and frequency of ventricular tachycardia episodes were 15% (P =.02), 75% (P <.05), 72% (P <.05), and 87% (P =.01) lower in patient receiving β-blockers, respectively. In a multivariate regression analysis, the negative relationship between β-blockers and the average hourly PVCs (P =.03), the frequency of ventricular pairs (P =.03), repetitive PVCs (P <.05), and ventricular tachycardia episodes (P =.01) remained significant and independent. Conclusions: Concomitant β-blocker therapy during heart failure decompensation is associated with a marked reduction in complex ventricular ectopy and episodes of ventricular tachycardia. This effect of β-blockers may play an important protective role by preventing serious ventricular arrhythmias during transient increases in sympathetic activity.
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Prognostic value of thrombolysis, coronary artery patency, signal- averaged electrocardiography, left ventricular ejection fraction, and Holter electrocardiographic monitoring for life threatening ventricular arrhythmias after a first acute myocardial infarction
1997, American Journal of Cardiology
Prognostic studies after acute myocardial infarction (AMI) have mainly been performed in the prethrombolytic era. Despite the fact that modern management of AMI has reduced mortality rates, the occurrence of malignant ventricular arrhythmias in the late phase of AMI remains an important issue. We prospectively studied 244 consecutive patients (97 treated with thrombolytics) who survived a first AMI. All patients underwent time domain signal-averaged electrocardiography (vector magnitude: measurements of total QRS duration, terminal low [<40 μV] amplitude signal duration, and root-mean-square voltage of the last 40 ms of the QRS complex), Holter electrocardiographic monitoring, and cardiac catheterization. Late life-threatening ventricular arrhythmias were recorded. Eighteen arrhythmic events occurred during a mean follow-up period of 57 ± 18 months. Three independent factors were associated with a higher risk of arrhythmic events: (1) left ventricular ejection fraction (odds ratio 1.9/0.10 decrease), (2) terminal low-amplitude signal duration (odds ratio 1.5/5 ms increase), and (3) absence of thrombolytic therapy (odds ratio 3.9). Low-amplitude signal duration sensitivity for sudden cardiac death was low (30%). Left ventricular ejection fraction had the highest positive predictive value for sudden cardiac death (10%). Thus, thrombolysis decreases both the incidence of ventricular tachycardia and sudden cardiac death with a higher reopening rate of the infarct-related vessel. Signal averaging predicts the occurrence of ventricular tachycardia and an impaired left ventricular ejection fraction predicts the occurrence of sudden cardiac death.
Approach to evidence-based medicine in cardiovascular diseases
2017, Fudan University Journal of Medical Sciences

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Clinical investigationPrediction of cardiac death in patients with a very low ejection fraction after myocardial infarction: A Cardiac Arrhythmia Suppression Trial (CAST) study

Abstract

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Mayo Clin Proc

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Ejection fraction, peak exercise oxygen consumption, cardiothoracic ratio, ventricular arrhythmias, and plasma norepinephrine as determinants of prognosis in heart failure

Circulation

Effects of beta blockers on ventricular dysfunction after myocardial infarction: tolerability and survival effects

Am J Cardiol

Clinical investigation
Prediction of cardiac death in patients with a very low ejection fraction after myocardial infarction: A Cardiac Arrhythmia Suppression Trial (CAST) study