Value of programmed ventricular stimulation for prophylactic internal cardioverter-defibrillator implantation in postinfarction patients preselected by noninvasive risk stratifiers
C. Schmitt et al., Value of programmed ventricular stimulation for prophylactic internal cardioverter-defibrillator implantation in postinfarction patients preselected by noninvasive risk stratifiers, J AM COL C, 37(7), 2001, pp. 1901-1907
Citations number
38
Categorie Soggetti
Cardiovascular & Respiratory Systems","Cardiovascular & Hematology Research
OBJECTIVES The aim of this prospective study was to evaluate the role of pr
ogrammed ventricular stimulation (PVS) after noninvasive risk stratificatio
n to identify a subgroup of acute myocardial infarction (AMI) survivors con
sidered at risk for ventricular arrhythmias and whether these patients coul
d benefit from internal cardioverter-defibrillators (ICDs).
BACKGROUND The predictive value of noninvasive and invasive risk stratifier
s after AMI has been questioned. The question of whether the group of patie
nts with inducible monomorphic ventricular tachycardia (VT) after AMI could
profit from ICD implantation is unanswered.
METHODS A consecutive series of 1,436 AMI survivors was screened noninvasiv
ely by Holter monitoring, heart rate variability, ventricular late potentia
ls, and ejection fraction. A subgroup of 248 patients (17.3%) were identifi
ed as high-risk patients and scheduled for PVS. Due to the study design, 54
patients >75 years were excluded; thus, 194 patients were eligible for PVS
. Triple extrastimuli at two paced cycle lengths (600 ms and 400 ms) were a
pplied.
RESULTS In a subgroup of 98 (51%) high-risk patients, PVS was performed; 21
patients had an abnormal response, and in 20 patients an ICD was implanted
. During a mean follow-up of 607 days the arrhythmic event rate (sudden car
diac death, symptomatic VT, cardiac arrest) was 33% with a positive electro
physiological test versus 2.6% (p < 0.0001) with a negative electrophysiolo
gical test. A subgroup of 96 high-risk patients declined electrophysiologic
al study. In this nonconsent group, cardiac mortality (combined sudden and
nonsudden) was significantly higher (log-rank chi-square 9.38, p = 0.0022,
relative risk 4.7, 1.6 to 13.9) compared to the group guided by electrophys
iological testing and consecutive ICD implantation.
CONCLUSIONS After a two-step risk stratification, PVS is helpful in selecti
ng a subgroup of AMI survivors without spontaneous ventricular arrhythmias
who benefit from prophylactic ICD implantation. (J Am Coll Cardiol 2001;37:
1901-7) (C) 2001 by the American College of Cardiology.