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

Cardiology Unit, Westmead Hospital, New South Wales, Australia.

Of 3,286 consecutive patients treated for acute myocardial infarction, electrophysiologic testing was performed in 1,209 survivors (37%) free of significant complications at the time of hospital discharge to determine their risk of spontaneous ventricular tachyarrhythmias during follow-up. Sustained monomorphic ventricular tachycardia was inducible by programmed electrical stimulation in 75 (6.2%). Antiarrhythmic therapy was not routinely prescribed regardless of the test results. During the 1st year of follow-up, 14 infarct survivors (19%) with inducible ventricular tachycardia experienced spontaneous ventricular tachycardia or fibrillation in the absence of new ischemia compared with 34 (2.9%) of those without inducible ventricular tachycardia (p less than 0.0005). During the extended follow-up period (median 28 months) of those with inducible ventricular tachycardia, 19 (25%) had a spontaneous electrical event; 37% of these first events were fatal. These results suggest that the most cost-effective strategy for predicting arrhythmia will be obtained by restricting electrophysiologic testing to infarct survivors whose left ventricular ejection fraction is less than 40% and using a stimulation protocol containing four extrastimuli. Electrophysiologic testing is the single best predictor of spontaneous ventricular tachyarrhythmias during follow-up in infarct survivors. The majority (94%) with a negative test benefit from the more reliable reassurance that all is well, whereas the 25% risk of electrical events in those with inducible ventricular tachycardia justifies a prospective trial of effective prophylactic antiarrhythmic interventions.

This article has been cited by other articles:

				R. J. Myerburg, V. Reddy, and A. Castellanos Indications for implantable cardioverter-defibrillators based on evidence and judgment. J. Am. Coll. Cardiol., August 25, 2009; 54(9): 747 - 763. [Abstract] [Full Text] [PDF]

				S. Zaman, G. Sivagangabalan, A. Narayan, A. Thiagalingam, D. L. Ross, and P. Kovoor Outcomes of Early Risk Stratification and Targeted Implantable Cardioverter-Defibrillator Implantation After ST-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention Circulation, July 21, 2009; 120(3): 194 - 200. [Abstract] [Full Text] [PDF]

				R. J. Myerburg Implantable Cardioverter-Defibrillators after Myocardial Infarction N. Engl. J. Med., November 20, 2008; 359(21): 2245 - 2253. [Full Text] [PDF]

				L. Ding, W. Hua, H. Niu, K. Chen, and S. Zhang Primary prevention of sudden cardiac death using implantable cardioverter defibrillators Europace, September 1, 2008; 10(9): 1034 - 1041. [Abstract] [Full Text] [PDF]

				G. M. De Ferrari, R. Rordorf, F. Frattini, B. Petracci, P. De Filippo, and M. Landolina Predictive value of programmed ventricular stimulation in patients with ischaemic cardiomyopathy: implications for the selection of candidates for an implantable defibrillator Europace, December 1, 2007; 9(12): 1151 - 1157. [Abstract] [Full Text] [PDF]

				J. P. Daubert, W. Zareba, W. J. Hall, C. Schuger, A. Corsello, A. R. Leon, M. L. Andrews, S. McNitt, D. T. Huang, A. J. Moss, et al. Predictive Value of Ventricular Arrhythmia Inducibility for Subsequent Ventricular Tachycardia or Ventricular Fibrillation in Multicenter Automatic Defibrillator Implantation Trial (MADIT) II Patients J. Am. Coll. Cardiol., January 3, 2006; 47(1): 98 - 107. [Abstract] [Full Text] [PDF]

				U. Sartipy, A. Albage, E. Straat, P. Insulander, and D. Lindblom Surgery for Ventricular Tachycardia in Patients Undergoing Left Ventricular Reconstruction by the Dor Procedure Ann. Thorac. Surg., January 1, 2006; 81(1): 65 - 71. [Abstract] [Full Text] [PDF]

				D. Bello, D. S. Fieno, R. J. Kim, F. S. Pereles, R. Passman, G. Song, A. H. Kadish, and J. J. Goldberger Infarct morphology identifies patients with substrate for sustained ventricular tachycardia J. Am. Coll. Cardiol., April 5, 2005; 45(7): 1104 - 1108. [Abstract] [Full Text] [PDF]

				A. Raviele, M. G. Bongiorni, M. Brignole, R. Cappato, A. Capucci, F. Gaita, M. Gulizia, S. Mangiameli, A. S. Montenero, R. F. E. Pedretti, et al. Early EPS/ICD strategy in survivors of acute myocardial infarction with severe left ventricular dysfunction on optimal beta-blocker treatment: The BEta-blocker STrategy plus ICD trial Europace, January 1, 2005; 7(4): 327 - 337. [Abstract] [Full Text] [PDF]

				P. Khairy, M. J. Landzberg, M. A. Gatzoulis, H. Lucron, J. Lambert, F. Marcon, M. E. Alexander, and E. P. Walsh Value of Programmed Ventricular Stimulation After Tetralogy of Fallot Repair: A Multicenter Study Circulation, April 27, 2004; 109(16): 1994 - 2000. [Abstract] [Full Text] [PDF]

				D. O'Donnell, J.P. Bourke, R. Anilkumar, E. Simeonidou, and S.S. Furniss Radiofrequency ablation for post infarction ventricular tachycardia. Report of a single centre experience of 112 cases Eur. Heart J., November 1, 2002; 23(21): 1699 - 1705. [Abstract] [Full Text] [PDF]

				J. J. Bailey, A. S. Berson, H. Handelsman, and M. Hodges Utility of current risk stratification tests for predicting major arrhythmic events after myocardial infarction J. Am. Coll. Cardiol., December 1, 2001; 38(7): 1902 - 1911. [Abstract] [Full Text] [PDF]

				M. J. Eisenberg Risk stratification for arrhythmic events: are the bangs worth the bucks? J. Am. Coll. Cardiol., December 1, 2001; 38(7): 1912 - 1915. [Full Text] [PDF]

				C. Schmitt, P. Barthel, G. Ndrepepa, J.u. Schreieck, A. Plewan, A. Schomig, and G. Schmidt Value of programmed ventricular stimulation for prophylactic internal cardioverter-defibrillator implantation in postinfarction patients preselected by noninvasive risk stratifiers J. Am. Coll. Cardiol., June 1, 2001; 37(7): 1901 - 1907. [Abstract] [Full Text] [PDF]

				A. E. Buxton, K. L. Lee, L. DiCarlo, M. R. Gold, G. S. Greer, E. N. Prystowsky, M. F. O'Toole, A. Tang, J. D. Fisher, J. Coromilas, et al. Electrophysiologic Testing to Identify Patients with Coronary Artery Disease Who Are at Risk for Sudden Death N. Engl. J. Med., June 29, 2000; 342(26): 1937 - 1945. [Abstract] [Full Text] [PDF]

				A. E. Buxton, K. L. Lee, J. D. Fisher, M. E. Josephson, E. N. Prystowsky, G. Hafley, and The Multicenter Unsustained Tachycardia Trial Inve A Randomized Study of the Prevention of Sudden Death in Patients with Coronary Artery Disease N. Engl. J. Med., December 16, 1999; 341(25): 1882 - 1890. [Abstract] [Full Text] [PDF]

				X.-J. Du, H. S. Cox, A. M. Dart, and M. D. Esler Sympathetic activation triggers ventricular arrhythmias in rat heart with chronic infarction and failure Cardiovasc Res, September 1, 1999; 43(4): 919 - 929. [Abstract] [Full Text] [PDF]

				A. E. Buxton, G. E. Hafley, M. H. Lehmann, M. Gold, M. O'Toole, A. Tang, J. Coromilas, B. Hook, N. J. Stamato, and K. L. Lee Prediction of Sustained Ventricular Tachycardia Inducible by Programmed Stimulation in Patients With Coronary Artery Disease : Utility of Clinical Variables Circulation, April 13, 1999; 99(14): 1843 - 1850. [Abstract] [Full Text] [PDF]

				D. Andresen, G. Steinbeck, T. Bruggemann, D. Muller, R. Haberl, S. Behrens, E. Hoffmann, K. Wegscheider, R.u. Dissmann, and H.-C. Ehlers Risk stratification following myocardial infarction in the thrombolytic era: a two-step strategy using noninvasive and invasive methods J. Am. Coll. Cardiol., January 1, 1999; 33(1): 131 - 138. [Abstract] [Full Text] [PDF]

				W. G. Stevenson and P. M. Ridker Should Survivors of Myocardial Infarction With Low Ejection Fraction Be Routinely Referred to Arrhythmia Specialists? JAMA, August 14, 1996; 276(6): 481 - 485. [Abstract] [PDF]

				D. M. Roden Risks and Benefits of Antiarrhythmic Therapy N. Engl. J. Med., September 22, 1994; 331(12): 785 - 791. [Full Text]