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CLINICAL STUDIES

Long-term outcome of patients with unexplained syncope treated with an electrophysiologic-guided approach in the implantable cardioverter-defibrillator era

^a Department of Medicine, Division of Cardiology, the New York Hospital–Cornell University Medical Center, New York, New York 10021, USA

Manuscript received October 29, 1998; revised manuscript received March 19, 1999, accepted June 21, 1999.

Reprint requests and correspondence: Dr. Bruce B. Lerman, Division of Cardiology, New York Hospital–Cornell Medical Center, 525 East 68 Street, Starr 4, New York, New York 10021
blerman{at}mail.med.cornell.edu

OBJECTIVES

We evaluated the long-term outcome of patients with coronary artery disease and unexplained syncope who were treated with an electrophysiologic (EP)-guided approach.

BACKGROUND

Electrophysiologic studies are frequently performed to evaluate unexplained syncope in patients with coronary artery disease. Patients with this profile who have inducible ventricular tachycardia are considered at high risk for sudden death and increased overall mortality, and therefore are often treated with an implantable cardioverter-defibrillator (ICD). The impact of this EP-guided strategy is unknown because there are no data comparing the long-term outcome of ICD recipients with that of noninducible patients.

METHODS

We evaluated 67 consecutive patients with coronary artery disease and unexplained syncope. All patients were treated with an EP-guided approach that included ICD implantation in patients with inducible ventricular tachycardia.

RESULTS

Electrophysiologic testing suggested a plausible diagnosis in 32 (48%) of these patients. Inducible monomorphic ventricular tachycardia was the most common abnormality. Despite frequent appropriate therapy with ICDs, the total mortality for patients with inducible monomorphic ventricular tachycardia was significantly higher than for noninducible patients. The respective one- and two-year survival rates were 94% and 84% in noninducible patients and 77% and 45% in inducible patients (p = 0.02).

CONCLUSIONS

Electrophysiologic testing suggests an etiology for unexplained syncope in approximately 50% of patients and risk stratifies these patients with regard to long-term outcome. Patients who receive an ICD for the management of inducible ventricular tachycardia have a high incidence of spontaneous ventricular arrhythmias requiring ICD therapy. However, despite ICD implantation and frequent appropriate delivery of ICD therapies, patients with inducible ventricular tachycardia have a significantly worse prognosis than do those who are noninducible.

Abbreviations and Acronyms   AV = atrioventricular   CABG = coronary artery bypass grafting   ECG = electrocardiogram, electrocardiography   EP = electrophysiology, electrophysiologic   ICD = implantable cardioverter-defibrillator   IV = intravenous   LV = left ventricle, left ventricular   PTCA = percutaneous transluminal coronary angioplasty

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