Distinction between arrhythmic and nonarrhythmic death after acute myocardial infarction based on heart rate variability, signal-averaged electrocardiogram, ventricular arrhythmias and left ventricular ejection fraction

Department of Cardiological Sciences, St. George's Hospital, Medical School, London, England, United Kingdom.

OBJECTIVES: We investigated whether heart rate variability, the signal-averaged electrocardiogram (ECG), ventricular arrhythmias and left ventricular ejection fraction predict the mechanism of cardiac death after myocardial infarction. BACKGROUND: Postinfarction risk stratification studies have almost exclusively focused on predicting the risk of arrhythmic death. The factors that identify and distinguish persons at risk for arrhythmic and nonarrhythmic death are poorly known. METHODS: Heart rate variability, the signal-averaged ECG, ventricular arrhythmias and left ventricular ejection fraction were assessed in 575 survivors of acute myocardial infarction. The patients were followed up for 2 years; arrhythmic and nonarrhythmic cardiac deaths were used as clinical end points. During the follow-up period, 47 cardiac deaths occurred, 29 (62%) arrhythmic and 18 (38%) nonarrhythmic. RESULTS: All risk factors were associated with cardiac mortality in univariate analysis. With the exception of left ventricular ejection fraction, they were also predictors of arrhythmic death. Depressed heart rate variability (p < 0.001), ventricular ectopic beats (p < 0.001) and low ejection fraction (p < 0.001) were related to nonarrhythmic death. In multivariate analysis, depressed heart rate variability (p < 0.001) and runs of ventricular tachycardia (p < 0.05) predicted arrhythmic death. Nonarrhythmic death was associated with depressed heart rate variability (p < 0.001), ventricular ectopic beats (p < 0.001) and low ejection fraction (p < 0.01). By selecting patients with depressed heart rate variability, long filtered QRS duration or ventricular arrhythmias and excluding patients with the lowest ejection fraction, we identified a group in which 75% of deaths were arrhythmic. Similarly, by selecting patients with a low ejection fraction and excluding patients with the lowest heart rate variability, we identified a group in which 75% of deaths were nonarrhythmic. CONCLUSIONS: Arrhythmic death was associated predominantly with depressed heart rate variability and ventricular tachycardia runs, and nonarrhythmic death with low ejection fraction, ventricular ectopic beats and depressed heart rate variability. A combination of risk factors identified patient groups in which a majority of deaths were either arrhythmic or nonarrhythmic.

This article has been cited by other articles:

				J. J. Goldberger, M. E. Cain, S. H. Hohnloser, A. H. Kadish, B. P. Knight, M. S. Lauer, B. J. Maron, R. L. Page, R. S. Passman, D. Siscovick, et al. American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society Scientific Statement on Noninvasive Risk Stratification Techniques for Identifying Patients at Risk for Sudden Cardiac Death: A Scientific Statement From the American Heart Association Council on Clinical Cardiology Committee on Electrocardiography and Arrhythmias and Council on Epidemiology and Prevention J. Am. Coll. Cardiol., September 30, 2008; 52(14): 1179 - 1199. [Full Text] [PDF]

				J. J. Goldberger, M. E. Cain, S. H. Hohnloser, A. H. Kadish, B. P. Knight, M. S. Lauer, B. J. Maron, R. L. Page, R. S. Passman, D. Siscovick, et al. American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society Scientific Statement on Noninvasive Risk Stratification Techniques for Identifying Patients at Risk for Sudden Cardiac Death: A Scientific Statement From the American Heart Association Council on Clinical Cardiology Committee on Electrocardiography and Arrhythmias and Council on Epidemiology and Prevention Circulation, September 30, 2008; 118(14): 1497 - 1518. [Full Text] [PDF]

				J. Borgel and A. Mugge Central Sleep Apnea Induces Ventricular Bigeminus: Conclusions From a Single Polygraphy Circulation, September 23, 2008; 118(13): 1398 - 1401. [Full Text] [PDF]

				M. Christ, J. Sharkova, S. Bayrakcioglu, I. Herzum, C. Mueller, and W. Grimm B-type natriuretic peptide levels predict event-free survival in patients with implantable cardioverter defibrillators Eur J Heart Fail, March 1, 2007; 9(3): 272 - 279. [Abstract] [Full Text] [PDF]

				G A Lanza, D Cianflone, A G Rebuzzi, G Angeloni, A Sestito, G Ciriello, G La Torre, F Crea, A Maseri, and for the Stratificazione Prognostica dell'Angina In Prognostic value of ventricular arrhythmias and heart rate variability in patients with unstable angina Heart, August 1, 2006; 92(8): 1055 - 1063. [Abstract] [Full Text] [PDF]

				I. Romieu, M. M. Tellez-Rojo, M. Lazo, A. Manzano-Patino, M. Cortez-Lugo, P. Julien, M. C. Belanger, M. Hernandez-Avila, and F. Holguin Omega-3 Fatty Acid Prevents Heart Rate Variability Reductions Associated with Particulate Matter Am. J. Respir. Crit. Care Med., December 15, 2005; 172(12): 1534 - 1540. [Abstract] [Full Text] [PDF]

				P. Pascale, P. Taffe, C. Regamey, L. Kappenberger, and M. Fromer Reduced Ejection Fraction After Myocardial Infarction: Is It Sufficient To Justify Implantation of a Defibrillator? Chest, October 1, 2005; 128(4): 2626 - 2632. [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]

				A. M. Makikallio, T. H. Makikallio, J. T. Korpelainen, K. A. Sotaniemi, H. V. Huikuri, and V. V. Myllyla Heart rate dynamics predict poststroke mortality Neurology, May 25, 2004; 62(10): 1822 - 1826. [Abstract] [Full Text] [PDF]

				A. L. T. Uusitalo, T. Laitinen, S. B. Vaisanen, E. Lansimies, and R. Rauramaa Physical training and heart rate and blood pressure variability: a 5-yr randomized trial Am J Physiol Heart Circ Physiol, May 1, 2004; 286(5): H1821 - H1826. [Abstract] [Full Text] [PDF]

				A. J. Camm, C. M. Pratt, P. J. Schwartz, H. R. Al-Khalidi, M. J. Spyt, M. J. Holroyde, R. Karam, E. H. Sonnenblick, J. M.G. Brum, and on Behalf of the AzimiLide post Infarct surVival E Mortality in Patients After a Recent Myocardial Infarction: A Randomized, Placebo-Controlled Trial of Azimilide Using Heart Rate Variability for Risk Stratification Circulation, March 2, 2004; 109(8): 990 - 996. [Abstract] [Full Text] [PDF]

				L Bode-Schnurbus, D Bocker, M Block, R Gradaus, A Heinecke, G Breithardt, and M Borggrefe QRS duration: a simple marker for predicting cardiac mortality in ICD patients with heart failure Heart, October 1, 2003; 89(10): 1157 - 1162. [Abstract] [Full Text] [PDF]

				H. V. Huikuri, J. M. Tapanainen, K. Lindgren, P. Raatikainen, T. H. Makikallio, K. E. Juhani Airaksinen, and R. J. Myerburg Prediction of sudden cardiac death after myocardial infarction in the beta-blocking era J. Am. Coll. Cardiol., August 20, 2003; 42(4): 652 - 658. [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]

				H. V. Huikuri, A. Castellanos, and R. J. Myerburg Sudden Death Due to Cardiac Arrhythmias N. Engl. J. Med., November 15, 2001; 345(20): 1473 - 1482. [Full Text] [PDF]

				L Jordaens, R Tavernier, and MIRRACLE Investigators Determinants of sudden death after discharge from hospital for myocardial infarction in the thrombolytic era Eur. Heart J., July 2, 2001; 22(14): 1214 - 1225. [Abstract] [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]

				F. Lombardi, T. H Makikallio, R. J Myerburg, and H. V Huikuri Sudden cardiac death: role of heart rate variability to identify patients at risk Cardiovasc Res, May 1, 2001; 50(2): 210 - 217. [Full Text] [PDF]

				M. Kornitzer Predictive value of electrocardiographic markers for autonomic nervous system dysfunction in healthy populations: more studies needed Eur. Heart J., January 2, 2001; 22(2): 109 - 112. [PDF]

				M. Malik, A. J. Camm, M. J. Janse, D. G. Julian, G. A. Frangin, P. J. Schwartz, and on behalf of the EMIAT Investigators Depressed heart rate variability identifies postinfarction patients who might benefit from prophylactic treatment with amiodarone: A substudy of EMIAT (the European Myocardial Infarct Amiodarone Trial) J. Am. Coll. Cardiol., April 1, 2000; 35(5): 1263 - 1275. [Abstract] [Full Text] [PDF]

				H. V. Huikuri, T. Makikallio, K. E. J. Airaksinen, R. Mitrani, A. Castellanos, and R. J. Myerburg Measurement of heart rate variability: a clinical tool or a research toy? J. Am. Coll. Cardiol., December 1, 1999; 34(7): 1878 - 1883. [Abstract] [Full Text] [PDF]

				J. H. Christensen, M. S. Christensen, J. Dyerberg, and E. B. Schmidt Heart rate variability and fatty acid content of blood cell membranes: a dose-response study with n-3 fatty acids Am. J. Clinical Nutrition, September 1, 1999; 70(3): 331 - 337. [Abstract] [Full Text] [PDF]

				H. V. Huikuri, V. Jokinen, M. Syvanne, M. S. Nieminen, K. E. J. Airaksinen, M. J. Ikaheimo, J. M. Koistinen, H. Kauma, A. Y. Kesaniemi, S. Majahalme, et al. Heart Rate Variability and Progression of Coronary Atherosclerosis Arterioscler Thromb Vasc Biol, August 1, 1999; 19(8): 1979 - 1985. [Abstract] [Full Text] [PDF]

				F. Weber, H. Schneider, T. von Arnim, and W. Urbaszek Heart rate variability and ischaemia in patients with coronary heart disease and stable angina pectoris: Influence of drug therapy and prognostic value Eur. Heart J., January 1, 1999; 20(1): 38 - 50. [Abstract] [PDF]

				C. M. Albert, C. H. Hennekens, C. J. O'Donnell, U. A. Ajani, V. J. Carey, W. C. Willett, J. N. Ruskin, and J. E. Manson Fish Consumption and Risk of Sudden Cardiac Death JAMA, January 7, 1998; 279(1): 23 - 28. [Abstract] [Full Text] [PDF]

				P. S. Barie Advances in Critical Care Monitoring Arch Surg, July 1, 1997; 132(7): 734 - 739. [Abstract] [PDF]