Programmed ventricular stimulation in survivors of acute myocardial infarction: long-term follow-up

doi:10.1016/0167-5273(95)02273-Y

International Journal of Cardiology

Volume 49, Issue 1, 24 March 1995, Pages 55-65

https://doi.org/10.1016/0167-5273(95)02273-Y Get rights and content

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) (VF1), 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 VF1 (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 VF1), we recommend the indication of programmed stimulation in only the patients with one abnormal non-invasive investigation.

References (18)

JP Bourke et al.
Routine programmed electrical stimulation in survivors of acute myocardial infarction for prediction of spontaneous ventricular tachyarrhythmias during follow-up: results, optimal stimulation protocol and cost-effective screening
J Am Coll Cardiol
(1991)
LE Waspe et al.
Prediction of sudden death and spontaneous ventricular tachycardia in survivors of complicated myocardial infarction: value of the response to programmed stimulation using a maximum of three ventricular extrastimuli
J Am Coll Cardiol
(1985)
A Hamer et al.
Prediction of sudden death by electrophysiologic studies in high risk patients surviving acute myocardial infarction
Am J Cardiol
(1982)
FE Marchlinski et al.
Identifying patients at risk of sudden death after myocardial infarction: value of the response to programmed stimulation, degree of ventricular ectopic activity and severity of left ventricular dysfunction
Am J Cardiol
(1983)
P Santarelli et al.
Ventricular arrhythmia induced by programmed ventricular stimulation after acute myocardial infarction
Am J Cardiol
(1985)
AK Bhandari et al.
Frequency and significance of induced ventricular tachycardia or fibrillation 2 weeks after acute myocardial infarction
Am J Cardiol
(1985)
DE Mann et al.
Induction of clinical ventricular tachycardia using programmed stimulation: value of third and fourth extrastimuli
Am J Cardiol
(1983)
P Brugada et al.
Results of a ventricular stimulation protocol using a maximum of four premature stimuli in patients without documented or suspected ventricular arrhythmias
Am J Cardiol
(1983)
G Breithardt et al.
Ventricular late potentials and inducible ventricular tachyarrhythmias as a marker for ventricular tachycardia after myocardial infarction
Eur Heart J
(1986)

There are more references available in the full text version of this article.

Cited by (25)

What is the utility of electrophysiological study in elderly patients with syncope and heart disease?
2015, Indian Pacing and Electrophysiology Journal
Citation Excerpt :
Interruption of the induced VT was initially attempted with different protocols of anti-tachycardia pacing, followed by cardioversion. If the study remained negative, the protocol was repeated after isoproterenol infusion : a dose of 2 to 4 µg /min was administered to decrease the sinus cycle length by at least 15% and the infusion was continued until the completion of atrial and ventricular stimulation for 15 to 25 minutes. [13,14] Arterial blood pressure was continuously monitored by an external sphygmomanometer (Baxter, Japan).
Syncope in elderly patients with heart disease is a growing problem. Its aetiological diagnosis is often difficult. We intended to investigate the value of the electrophysiological study (EPS) in old patients with syncope and heart disease.
EPS was performed in 182 consecutive patients with syncope and heart disease, among whom 62 patients were ≥75 years old and 120 patients <75.
Left ventricular ejection fraction was 43.9±11.7% in patients ≥75 and 41.1±12.6% in patients <75. During EPS, induced sustained ventricular arrhythmias were as frequent in both groups (27.4% in patients ≥75 versus 27.5% in patients <75, p=0.99) whereas AV conduction abnormalities were more frequent in older patients (37.1% in patients ≥75 versus 18.3% in patients<75, p<0.005). Syncope remained unexplained in 35.5% of patients ≥75 and in 51.7% of patients <75 (p<0.04). ICD was more likely to be implanted in younger patients than in patients ≥75 years (37.5% vs 21% respectively, p<0.009). During a mean follow-up period of 3.3±3 years, the 4-year-survival rate was 66.9±6.8 % in patients ≥75 and 75.9±6.2 % in patients <75 years. The main cause of death was heart failure in both groups. The factors related to a worse outcome in a multivariate analysis were low LVEF and higher age.
Complete EPS allows the identification of treatable causes in a high proportion of elderly patients with syncope and heart disease. Yet, the prognosis of these patients is mainly related to LVEF and age.
Sudden Cardiac Death Risk Stratification in Patients with Heart Failure
2011, Heart Failure Clinics
Complete electrophysiological study remains necessary in symptomatic advanced cardiomyopathy
2010, Annales de Cardiologie et d'Angeiologie
Une tachycardie peut avoir différentes origines quelle que soit la cardiopathie sous jacente. Établir sa nature est surtout important en cas de cardiopathie évoluée du fait des conséquences thérapeutiques. L’étude électrophysiologique complète reste l’instrument privilégié de diagnostic. Nous rapportons ainsi le cas d’un homme de 39 ans ayant une cardiomyopathie dilatée connue depuis l’âge de 25 ans et qui s’est plaint de tachycardies. L’étude électrophysiologique a permis de montrer que les symptômes étaient liés à une tachycardie par réentrée intranodale qui a fait l’objet d’un traitement spécifique.
Multiple mechanisms can explain a tachycardia associated or not with a heart disease. It is important to establish its origin, particularly if advanced heart disease is present, for the treatment. Complete electrophysiological study remains an important means of diagnosis. We report the case of a 39-year old man, who had a dilated cardiomyopathy since the age of 25 years and who complained of tachycardia. These symptoms were shown to be related to atrioventricular nodal re-entrant tachycardia at electrophysiological study and a specific treatment was indicated.
Differences in mechanisms and outcomes of syncope in patients with coronary disease or idiopathic left ventricular dysfunction as assessed by electrophysiologic testing
2004, Journal of the American College of Cardiology
Citation Excerpt :
The following noninvasive studies were performed: 24-h Holter monitoring (Elatec, France), two-dimensional echocardiography, thallium exercise scintigraphy in patients with ischemic heart disease and no recent coronary angiography (n = 10) or with significant coronary artery stenosis on coronary angiography (n = 16), and head-up tilt testing without provocative drugs in 30 patients with a negative EPS or inducible ventricular flutter or ventricular fibrillation (VF). The following invasive studies were performed: right and left angiography, coronary angiography, and a complete EPS study according to a protocol previously reported (11,12). The protocol included assessment of sinoatrial function, AV conduction using measurement of the AH and HV intervals and intra-atrial conduction time, and atrial pacing at progressively faster rates until AV block occurred.
This study evaluated the causes of syncope and the significance and differences in left ventricular (LV) dysfunction, coronary disease, and idiopathic dilated cardiomyopathy (DCM).
Risk stratification of and indications for an automated defibrillator could differ according to the cause of LV dysfunction.
Electrophysiologic study, including atrial and ventricular programmed stimulation, was performed in 119 patients with coronary disease (group I) and 61 patients with DCM (group II) with an left ventricular ejection fraction (LVEF) <40% and syncope. Patients were followed from one to six years (mean 4 ± 2 years).
Sustained monomorphic ventricular tachycardia (VT) was induced in 44 group I patients (37%) and 13 group II patients (21%); ventricular flutter (>270 beats/min) or ventricular fibrillation (VF) was induced in 24 group I patients (19%) and 9 group II patients (15%); and various other arrhythmias were identified. Syncope remained unexplained in 34 group I patients (30%) and 16 group II patients (27%). Prognosis depended on the heart disease: VT or VF induction was a predictive factor of mortality in coronary disease and identified a group with high cardiac mortality (46%), compared with patients with a negative study, who had a lower mortality (6%; p < 0.001) than in other studies. Cardiac mortality was only correlated with LVEF in DCM.
Various causes could explain syncope in 70% of patients with coronary disease and DCM, but differences were noted: VT was frequent in coronary disease with a bad prognosis, and ischemia could explain syncope; in DCM, different causes such as atrial tachycardia could be responsible for syncope, but the prognosis only depended on LVEF.
Long-term prognosis of inducible ventricular flutter: Not an innocent finding
2004, American Heart Journal
Citation Excerpt :
Both VFL and SMVT were predictive of arrhythmic events during the first year after infarction, although the event rate in patients with inducible SMVT was higher than that in patients with inducible VFL (21% vs 12%). Inducible VFL may have different prognostic implications in different settings, which is further supported by the findings of Brembilla-Perrot et al.18 They found an excellent outcome in patients with inducible VFL and normal results on Holter monitoring, but a high risk of VT and cardiac death in similar patients with previous documentation of nonsustained VT. In this study, 60% of patients with inducible VFL had either sustained or nonsustained ventricular arrhythmias documented before PES, and another 36% of patients had a history of unexplained syncope.
The prognostic significance of ventricular flutter (VFL) induced during programmed electrical stimulation (PES) is currently unknown.
This study examined patients who had PES-induced VFL and assessed their long-term prognosis compared with patients who had inducible sustained monomorphic ventricular tachycardia (SMVT).
Of 3414 patients undergoing PES, 74 (2%) had sustained VFL. They were compared with a group of 71 patients undergoing PES in the same time frame who had inducible SMVT. Patients with inducible VFL had a higher ejection fraction than patients with SMVT (0.39 vs 0.33; P = .05). More aggressive pacing was required for arrhythmia induction in patients with VFL, with more stimuli (2.7 ± 0.5 vs 2.2 ± 0.6; P <.01) and tighter S₂, S₃, and S₄ intervals. After a mean follow-up of 30 ± 31 months, the mortality rate was 34% in patients with VFL and 30% in patients with SMVT (P = .41). No difference in the 2 groups in overall survival or a combined end point of sudden death or appropriate implantable cardioverter defibrillator shock was revealed with Kaplan-Meier analysis.
The long-term prognosis of patients with inducible VFL is similar to that of patients with inducible SMVT, even when VFL is induced with a relatively aggressive protocol.
Does syncope change the results of programmed ventricular stimulation in patients with previous myocardial infarction?
2004, Annales de Cardiologie et d'Angeiologie
L’induction d’une tachycardie ventriculaire (TV) après un infarctus du myocarde est considérée comme un signe de risque de TV et de mort subite chez les patients asymptomatiques. Le but de cette étude a été de savoir si la survenue d’une syncope modifie les résultats généraux de la stimulation ventriculaire programmée (SVP) après l’infarctus et le pronostic de ces patients.
Méthode. – La population de l’étude a concerné 1057 patients qui avaient une histoire d’infarctus de plus d’un mois et qui n’avaient pas de TV spontanée documentée. Huit cent trente-six d’entre eux (groupe I) étaient asymptomatiques et 228 (groupe II) avaient présenté au moins une syncope. La SVP a utilisé jusqu’à trois extrastimuli délivrés sur trois cycles et dans deux sites du ventricule droit. Les patients ont été suivis entre six mois et cinq ans ou jusqu’à la transplantation cardiaque.
Résultats. – une TV monomorphe inférieure à 280/minute a été induite chez 238 patients du groupe I (28 %) et 62 du groupe II (27 %). Un flutter ou une fibrillation ventriculaire a été induite chez 245 patients du groupe I (29 %) et 42 du groupe II (18 %) (p < 0,05). La SVP est restée négative chez 353 patients du groupe I (42 %) et 124 du groupe II (55 %) (NS).
Les patients ont différé par leur pronostic. La mortalité cardiaque (par insuffisance cardiaque et mort subite) a été de 13 % chez les patients du groupe I et 34 % chez ceux du groupe II qui avaient des TV inductibles (p < 0,01), 4 % du groupe I et 13 % du groupe II chez ceux qui avaient des flutters ou fibrillations ventriculaires inductibles (p < 0,05), 5 % des patients du groupe I et 7 % des patients du groupe II avec stimulation négative.
Conclusion. – Le risque d’induction d’une TV monomorphe inférieure à 280/minute a été similaire chez les patients asymptomatiques et ceux qui avaient présenté une syncope après un infarctus du myocarde. En revanche, la notion de syncope a augmenté significativement la mortalité cardiaque des patients avec TV inductible et aussi celle de ceux qui avaient un flutter ou une fibrillation ventriculaire inductible.
The induction of a ventricular tachycardia (VT) after myocardial infarction (MI) is associated with a high risk of VT and sudden death (SD) in asymptomatic patients; the purpose of the study was to know if syncope modifies the results of programmed ventricular stimulation (PVS) and the clinical consequences.
Methods. – PVS using two and three extra stimuli delivered in two sites of right ventricle was performed in 1057 patients without spontaneous VT or resuscitated SD at least 1 month after an acute MI; 836 patients (group I) were asymptomatic and were studied for a low ejection fraction or nonsustained VT on Holter monitoring or late potentials; 228 patients (group II) were studied for unexplained syncope. The patients were followed up to 5 years or heart transplantation.
Results. – Sustained monomorphic VT (<280 b/min) was induced in 238 group I patients (28%) and 62 group II patients (29%); ventricular flutter (VT > 270 b/min) or ventricular fibrillation (VF) was induced in 245 group I patients (29%) and 42 group II patients (18%) (P < 0.05); PVS was negative in 353 group I patients (42%) and 124 (55%) group II patients (NS). The patients differ by their prognosis; cardiac mortality was 13% in group I patients and 34% in group II patients with inducible VT < 280 b/min (P < 0.01), 4% in group I patients and 13% in group II patients with inducible VF (P < 0.05), 5% in group I patients and 7% in group II patients with negative study (NS). In conclusion, syncope did not change the results of programmed ventricular stimulation after myocardial infarction. However, syncope increased significantly cardiac mortality of patients with inducible ventricular tachycardia, flutter or fibrillation.

View all citing articles on Scopus

View full text

Original studyProgrammed ventricular stimulation in survivors of acute myocardial infarction: long-term follow-up

Abstract

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Ventricular late potentials and inducible ventricular tachyarrhythmias as a marker for ventricular tachycardia after myocardial infarction

Eur Heart J

Original study
Programmed ventricular stimulation in survivors of acute myocardial infarction: long-term follow-up