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CLINICAL STUDY: ELECTROPHYSIOLOGY

Recurrence of symptomatic ventricular arrhythmias in patients with implantable cardioverter defibrillator after the first device therapy

Implications for antiarrhythmic therapy and driving restrictions

^a The Care Group, Indianapolis, Indiana, USA
^b Nahum A. Freedberg’s current address: Cardiology Department, Ha’Emek Medical Center, Afula 18101, Israel

Manuscript received June 5, 2000; revised manuscript received January 23, 2001, accepted February 6, 2001.

Reprint requests and correspondence: Dr. Eric N. Prystowsky, The Care Group, 8333 Naab Road, Suite 200, Indianapolis, Indiana 46260
eprystow{at}thecaregroup.com

OBJECTIVES

The purpose of this study was to investigate whether clinical or electrophysiologic characteristics could predict initial and subsequent implantable cardioverter defibrillator (ICD) therapy.

BACKGROUND

Identification of markers to predict subsequent ICD therapy and symptoms after the first event could affect patient management.

METHODS

We analyzed baseline and follow-up data on 125 ICD patients followed for 408 ± 321 days. Medications and ICD programming were not changed after first ICD therapy.

RESULTS

Implantable cardioverter defibrillator therapy occurred in 58 patients (46%). Clinical features were as follows: mean left ventricular ejection fraction (LVEF) 29% ± 15%; coronary artery disease 84%; presenting arrhythmia with sustained monomorphic ventricular tachycardia (SMVT) in 68%. In a multivariate analysis the relative risk for ICD therapy in patients presenting with SMVT versus cardiac arrest (CA) was 2.57 (range, 1.32 to 5.01), and for patients with LVEF 25%, 1.95 (1.11 to 3.45), respectively (p < 0.05). Implantable cardioverter defibrillator therapy was not predicted by any other variable. Forty-six patients had second ICD therapy. Mean time to second ICD therapy was only 66 ± 93 days compared with 138 ± 168 days for first ICD therapy (p < 0.05). No predictor for second ICD therapy was found. Regarding symptoms, impaired consciousness during initial ICD therapy was predicted only by SMVT cycle length <250 ms at electrophysiologic testing. In contrast, symptoms were similar between first and second ICD therapy (p = 0.0001). Of note, ventricular tachycardia cycle length preceding first and second ICD therapy was similar (r = 0.76, p = 0.001).

CONCLUSIONS

First ICD therapy tends to occur in patients presenting with SMVT and LVEF 25%. Subsequent therapy occurs sooner and is unpredictable, suggesting that antiarrhythmic drug therapy should be considered after the first symptomatic ICD therapy. Symptoms during first ICD therapy predict subsequent symptoms, and patients presenting with SMVT and asymptomatic first ICD therapy are at very low risk for future syncopal ICD therapy.

Abbreviations and Acronyms   AAD = antiarrhythmic drug   AF = atrial fibrillation   CA = cardiac arrest   EPS = electrophysiologic study   ICD = implantable cardioverter defibrillator   LVEF = left ventricular ejection fraction   SMVT = sustained monomorphic ventricular tachycardia   VT = ventricular tachycardia

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