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CLINICAL STUDY: ELECTROPHYSIOLOGY

Value of programmed ventricular stimulation for prophylactic internal cardioverter-defibrillator implantation in postinfarction patients preselected by noninvasive risk stratifiers

^a Deutsches Herzzentrum München, Munich, Germany
^b 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany

Manuscript received August 17, 2000; revised manuscript received December 28, 2000, accepted February 15, 2001.

Reprint requests and correspondence: Dr. Claus Schmitt, Deutsches Herzzentrum München, Lazarettstrasse 36, D-80636 München, Germany
schmitt{at}dhm.mhn.de

OBJECTIVES

The aim of this prospective study was to evaluate the role of programmed ventricular stimulation (PVS) after noninvasive risk stratification to identify a subgroup of acute myocardial infarction (AMI) survivors considered at risk for ventricular arrhythmias and whether these patients could benefit from internal cardioverter-defibrillators (ICDs).

BACKGROUND

The predictive value of noninvasive and invasive risk stratifiers after AMI has been questioned. The question of whether the group of patients 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 noninvasively by Holter monitoring, heart rate variability, ventricular late potentials, and ejection fraction. A subgroup of 248 patients (17.3%) were identified 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 applied.

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 cardiac death, symptomatic VT, cardiac arrest) was 33% with a positive electrophysiological test versus 2.6% (p < 0.0001) with a negative electrophysiological test. A subgroup of 96 high-risk patients declined electrophysiological 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 electrophysiological testing and consecutive ICD implantation.

CONCLUSIONS

After a two-step risk stratification, PVS is helpful in selecting a subgroup of AMI survivors without spontaneous ventricular arrhythmias who benefit from prophylactic ICD implantation.

Abbreviations and Acronyms   AMI = acute myocardial infarction   ECG = electrocardiogram, electrocardiographic   ICD = internal cardioverter-defibrillator   PVS = programmed ventricular stimulation   RR = relative risk   VF = ventricular fibrillation   VT = ventricular tachycardia

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