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CLINICAL STUDY

Differences in inducibility and prognosis of in-hospital versus out-of-hospital identified nonsustained ventricular tachycardia in patients with coronary artery disease: clinical and trial design implications¹

Luis A. Pires, MD, FACC^*, Michael H. Lehmann, MD, FACC, Alfred E. Buxton, MD, FACC, Gail E. Hafley, MS, Kerry L. Lee, PhD the Multicenter Unsustained Tachycardia Trial Investigators

^* St. John Hospital and Medical Center and Wayne State University School of Medicine, Detroit, Michigan, USA
Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, USA
Department of Medicine, Brown Medical School, Providence, Rhode Island, USA
Duke University Clinical Research Institute, Durham, North Carolina, USA

Manuscript received January 12, 2001; revised manuscript received May 25, 2001, accepted June 15, 2001.

Reprint requests and correspondence: Dr. Luis A. Pires, Cardiac Electrophysiology, St. John Hospital and Medical Center, 22101 Moross Road, Detroit, Michigan 48236
luis.pires{at}stjohn.org

OBJECTIVES

The goal of this study was to describe the influence of the clinical setting (in-hospital vs. out-of-hospital) in which nonsustained ventricular tachycardia (NSVT) is discovered on the rate of inducibility of sustained ventricular tachycardia (VT), arrhythmic events and survival in patients with coronary artery disease (CAD) and left ventricular (LV) dysfunction.

BACKGROUND

In-hospital presentation of sustained VT is independently associated with lower long-term overall survival. The impact of the clinical setting in which NSVT is documented is unknown.

METHODS

In the Multicenter Unsustained Tachycardia Trial (MUSTT), designed to assess the benefit of randomized antiarrhythmic therapy guided by electrophysiologic testing in patients with asymptomatic NSVT, CAD and LV dysfunction, eligible patients were enrolled irrespective of the setting in which the index arrhythmia was discovered. In this retrospective analysis, we compared the rate of VT inducibility and outcome of MUSTT-enrolled patients with in-hospital versus out-of-hospital presentation of NSVT.

RESULTS

Monomorphic sustained VT was induced in 35% and 28% of the patients whose index NSVT occurred in-hospital and out-of-hospital, respectively (adjusted p = 0.006). Cardiac arrest or death due to arrhythmia at two- and five-year follow-ups were 14% and 28% for untreated patients with in-hospital-identified NSVT and 11% and 21% for the out-of-hospital group (adjusted p = 0.10). Overall mortality rates at two- and five-year follow-ups were 24% and 48% for inpatients and 18% and 38% for outpatients (adjusted p = 0.018). In patients randomized to antiarrhythmic therapy, there was no significant interaction between patient status (in-hospital vs. out-of-hospital) and treatment impact on the rates of total mortality (p = 0.98) and arrhythmic events (p = 0.08).

CONCLUSIONS

In patients with CAD and impaired LV function, asymptomatic NSVT identified in-hospital, compared with that identified out-of-hospital, is associated with a higher rate of induction of sustained VT and overall mortality. Therefore, in similar patients, the clinical setting in which NSVT is discovered should be taken into account when formulating patient risk, treatment and clinical trial design.

Abbreviations and Acronyms   AVID = Antiarrhythmic Versus Implantable Defibrillator study   CAD = coronary artery disease   CHF = congestive heart failure   LV = left ventricle or left ventricular   MI = myocardial infarction   MUSTT = Multicenter Unsustained Tachycardia Trial   NSVT = nonsustained ventricular tachycardia   VT = ventricular tachycardia

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