Evaluation and treatment strategies in patients at high risk of sudden death post myocardial infarction

Multimodality Imaging of Sudden Cardiac Death and Acute Complications in Acute Coronary Syndrome

Sudden cardiac death (SCD) is a potentially fatal event usually caused by a cardiac arrhythmia, which is often the result of coronary artery disease (CAD). Up to 80% of patients suffering from SCD have concomitant CAD. Arrhythmic complications may occur in patients with acute coronary syndrome (ACS) before admission, during revascularization procedures, and in hospital intensive care monitoring. In addition, about 20% of patients who survive cardiac arrest develop a transmural myocardial infarction (MI). Prevention of ACS can be evaluated in selected patients using cardiac computed tomography angiography (CCTA), while diagnosis can be depicted using electrocardiography (ECG), and complications can be evaluated with cardiac magnetic resonance (CMR) and echocardiography. CCTA can evaluate plaque, burden of disease, stenosis, and adverse plaque characteristics, in patients with chest pain. ECG and echocardiography are the first-line tests for ACS and are affordable and useful for diagnosis. CMR can evaluate function and the presence of complications after ACS, such as development of ventricular thrombus and presence of myocardial tissue characterization abnormalities that can be the substrate of ventricular arrhythmias.

Temporal variations in microvolt T-wave alternans testing after acute myocardial infarction

BACKGROUND

Microvolt T-wave alternans (TWA) have been accepted as a tool for assessing vulnerability to ventricular tachyarrhythmias. There is lack of data concerning prospective temporal variations in TWA measurements after acute myocardial infarction (AMI). We analysed the temporal patterns of TWA in post-AMI patients.

METHODS AND RESULTS

TWA tests were performed <1 month (TWA_early) and 6 months (TWA_late) after AMI in 51 consecutive patients treated with successful percutaneous coronary intervention (PCI). Twenty seven patients (53%) had anterior wall infarctions and 24 (47%) had inferior/lateral wall infarctions. TWA was measured during a treadmill manual exercise protocol and defined as positive, negative and indeterminate. Group A included patients with TWA negative in both tests and Group B included those with TWA abnormal (positive or indeterminate) at first or second determinations. TWA_early was negative, positive and indeterminate in 38 (74.6%), 8 (15.6%) and 5 (9.8%) patients, respectively, whereas TWA_late was negative, positive and indeterminate in 30 (58.9%), 14 (27.4%) and 7 (13.7%) patients, respectively. TWA_early was classified as normal in 74.6% and abnormal in 25.4% of the cases, and TWA_late was normal in 58.9% and abnormal in 41.1%. TWA tests were concordant in 36 patients (70.6%) and discordant 15 patients (29.4%). At TWA_late, 10 patients (19.6%) changed from TWA negative to TWA abnormal and 4 patients (7.8%) from TWA abnormal to TWA negative. After TWA_early+TWA_late, 45% of the patients had 1 test classified as abnormal. Left ventricular ejection fraction was <50% in 22% of Group A and 52% of Group B (P = 0.037).

CONCLUSIONS

In the era of primary PCI, temporal changes in TWA measurements may occur frequently during the first 6 months post-AMI. These findings should be considered in risk stratification strategies following AMI.

Electrical interaction of mechanosensitive fibroblasts and myocytes in the heart

Fibroblasts in the heart can respond to mechanical deformation of the plasma membrane with characteristic changes of their membrane potential. Membrane depolarization of the fibroblasts occurs during the myocardial contractions and is caused by an influx of cations, mainly of sodium ions, into the cells. Conversely, application of mechanical stretch to the cells, i.e., during diastolic relaxation of the myocardium, will hyperpolarize the membrane potential of the fibroblasts due to reduced sodium entry. Thus, cardiac fibroblasts can function as mechano-electric transducers that are possibly involved in the mechano-electric feedback mechanism of the heart. Mechano-electric feedback refers to the phenomenon, that the cardiac mechanical environment, which depends on the variable filling pressure of the ventricles, modulates the electrical function of the heart. Increased sensitivity of the cardiac fibroblasts to mechanical forces may contribute to the electrical instability and arrhythmic disposition of the heart after myocardial infarction. Novel findings indicate that these processes involve the intercellular transfer of electrical signals between fibroblasts and cardiomyocytes via gap junctions. In this article we will discuss the recent progress in the electrophysiology of cardiac fibroblasts. The main focus will be on the intercellular pathways through which fibroblasts and cardiomyocytes communicate with each other.

MnSOD antisense treatment and exercise-induced protection against arrhythmias

Exercise provides protection against ischemia-reperfusion (I-R)-induced arrhythmias, myocardial stunning, and infarction. An exercise-induced increase in myocardial manganese superoxide dismutase (MnSOD) activity has been reported to be vital for protection against infarction. However, whether MnSOD is essential for exercise-induced protection against ventricular arrhythmias is unknown. We determined the effects of preventing the exercise-induced increase in MnSOD activity on arrhythmias during I-R resulting in myocardial stunning. Male rats remained sedentary or were subjected to successive bouts of endurance exercise. During in vivo myocardial I-R, the incidence of arrhythmias was significantly lower in the exercise-trained rats than in the sedentary rats as evidenced by the arrhythmia. When exercised rats were pretreated with antisense oligonucleotides directed against MnSOD, protection from arrhythmias was attenuated. Moreover, I-R resulted in significant increases in nitro-tyrosine (NT) in the sedentary group. Exercise abolished this I-R-induced NT formation but this protection was unchanged by antisense treatment. Protein carbonyls were increased by I-R, but neither exercise nor antisense treatment impacted carbonyl formation. These data demonstrate that an exercise-induced increase in MnSOD activity is important for protection against arrhythmias. The mechanism by which MnSOD provides protection does not appear to be linked to protein nitrosylation or oxidation.

Mechanically induced potentials in atrial fibroblasts from rat hearts are sensitive to hypoxia/reoxygenation

Membrane potential changes of atrial fibroblasts in response to mechanical stress have been considered to modulate the rhythmic electrical activity of healthy hearts. Our recent findings suggest that cardiac arrhythmia after infarction is related to enhanced susceptibility of the fibroblasts to physical stretch. In this study, we analysed the effect of hypoxia/reoxygenation, which are major components of tissue ischemia/reperfusion, on the membrane potential of atrial fibroblasts. Intracellular microelectrode recordings were performed together with isometric force measurements on isometrically contracting right atrial tissue preparations from adult rats. Lowering the oxygen tension in the perfusate from 80 kPa to 3.5 kPa reduced active force development and decreased the resting membrane potential of the cardiac fibroblasts from -23+/-5 mV to -5+/-2 mV ( n=35). Application of gadolinium (40 microM) to inhibit non-selective cation channels prevented hypoxia-induced membrane depolarization of the fibroblasts. Reoxygenation of the myocardial tissue resulted in a transient increase of the resting membrane potential to maximally -60+/-8 mV. These findings indicate that transmembrane currents in atrial fibroblasts are sensitive to changes in tissue oxygenation. In conclusion, altered electro-mechanical function of the ischemic heart may possibly involve changes of the membrane potential of the cardiac fibroblasts.

Opposite effects of iv amiodarone on cardiovascular vagal and sympathetic efferent activities in rats

It is unknown whether amiodarone exerts a direct central action on the cardiovascular autonomic nervous system. This study was designed to evaluate the effects of acute amiodarone administration on vagal and sympathetic efferent nerve discharges. Experiments were carried out in 25 decerebrate unanesthetized rats. In one group, vagal activity was recorded from preganglionic fibers isolated from the cervical vagus nerve. In another group, sympathetic recordings were obtained from fibers isolated from the cervical sympathetic trunk in intact conditions or after barodenervation. Recordings were performed before and for 60 min after amiodarone (50 mg/kg iv) administration. In all groups, amiodarone induced bradycardia and hypotension. Vagal activity increased immediately, reaching a significant difference after 20 min (260 +/- 131% from 16.4 +/- 3.3 spikes/s) and was unmodified by the barodenervation. At difference, sympathetic activity after an initial and short-lasting increase (150 +/- 83% from 24.8 +/- 5.7 spikes/s) began to decrease significantly after 20 min (36 +/- 17%) throughout the experiment. The initial increase in sympathetic activity was not observed in barodenervated animals. These changes in vagal and sympathetic activity could play an important role in contributing to the antiarrhythmic action of amiodarone.

Carvedilol: molecular and cellular basis for its multifaceted therapeutic potential

Carvedilol is a unique cardiovascular drug of multifaceted therapeutic potential. Its major molecular targets recognized to date are membrane adrenoceptors (beta 1, beta 2, and alpha 1), reactive oxygen species, and ion channels (K+ and Ca2+). Carvedilol provides prominent hemodynamic benefits mainly through a balanced adrenoceptor blockade, which causes a reduction in cardiac work in association with peripheral vasodilation. This drug assures remarkable cardiovascular protection through its antiproliferative/atherogenic, antiischemic, antihypertrophic, and antiarrhythmic actions. These actions are a consequence of its potent antioxidant effects, amelioration of glucose/lipid metabolism, modulation of neurohumoral factors, and modulation of cardiac electrophysiologic properties. The usefulness of carvedilol in the treatment of hypertension, ischemic heart disease, and congestive heart failure is based on a combination of hemodynamic benefits and cardiovascular protection.

The role of EP-guided therapy in ventricular arrhythmias: beta-blockers, sotalol, and ICD's

Arrhythmic death can be reduced by antiarrhythmic drugs to a range of 24%. Electrophysiologic study by testing noninducibility of ventricular arrhythmia represents the classic method for evaluating the effectiveness of drug therapy. Several clinical studies have shown thaat sotalol suppresses VT induction and prevents arrhythmias recurrences at long term follow-up in 23% to 67% of patients. The efficacy of sotalol EP guided therapy in preventing VT/VF is not necessarily related to prevention of sudden death. In the ESVEM study the superiority of d,l-sotalol to other antiarrhythmic drugs was confirmed. The response to programmed ventricular stimulation was found to be strongly predictive for arrhythmia free state while the failure of sotalol therapy to suppress VT at the EP study was associated with an high recurrence rate (40%). However, EP study failes to predict freedom from sudden death. The beta-blocking activity of racemic sotalol may account for some of the observed survival benefit.Beta-blockers therapy reduces mortality in patients after myocardial infarction primarily by a reduction of sudden death. A reduction of death, worsening heart failure and life threatening ventricular arrhythmias was shown in a recent study on carvedilol. In the prospective study of Steinbeck the EP guided-therapy did not improve the overall outcome when compared to metoprolol. Suppression of inducible arrhythmias by antiarrhythmic drugs was associated with a better outcome. The effectiveness of defibrillator therapy in reducing overall mortality, has been uncertain since great clinical trials have been concluded. MADIT, AVID and CASH trials confirmed the superiority of ICD therapy over antiarrhythmic drugs therapy: ICD should be considered the first choice therapy in post-cardiac arrest patients. The ongoing BEST Trial will give us further responses about the interaction between EP study and metoprolol effect compared to ICD in patients post myocardial infarction also focusing on tolerability and compliance of the beta-blocking therapy in patients with low ejection fraction. In this study will be useful to optimize therapy in patients at high risk of sudden death.

Risk stratification after acute myocardial infarction in the reperfusion era

Historically, risk stratification for survivors of acute myocardial infarction (AMI) has centered on 3 principles: assessment of left ventricular function, detection of residual myocardial ischemia, and estimation of the risk for sudden cardiac death. Although these factors still have important prognostic implications for these patients, our ability to predict adverse cardiac events has significantly improved over the last several years. Recent studies have identified powerful predictors of adverse cardiac events available from the patient history, physical examination, initial electrocardiogram, and blood testing early in the evaluation of patients with AMI. Numerous studies performed in patients receiving early reperfusion therapy with either thrombolysis or primary angioplasty have emphasized the importance of a patent infarct related artery for long-term survival. The predictive value of a variety of noninvasive and invasive tests to predict myocardial electrical instability have been under active investigation in patients receiving early reperfusion therapy. The current understanding of the clinically important predictors of clinical outcomes in survivors of AMI is reviewed in this article.

Defibrillation thresholds are increased by right-sided implantation of totally transvenous implantable cardioverter defibrillators

Whether an ICD is placed via a left- or right-sided approach depends on venous access, the presence of a preexisting pacemaker, and other factors. Since the DFT is affected by lead position, which in turn is determined in part by the side of access, right-sided venous access could adversely affect DFTs. Furthermore, right-sided active can placement directs electric current toward the right hemithorax, which could further increase DFTs. This study sought to determine whether DFTs were increased by right-sided vascular access, and whether active can technology was beneficial or detrimental with right-sided ICD placement. Stepdown to failure DFTs were found in 290 patients receiving transvenous systems at the time of initial ICD implantation. Of these, 271 (93%) received left-sided systems and 19 (7%) received right-sided systems. The mean DFT in systems placed via left-sided vascular access was 11.3 +/- 5.3 J versus 17.0 +/- 4.9 J for right-sided implantation (P < 0.0001); right-sided DFTs were elevated for both active can and cold can systems. Right-sided active can devices had a lower DFT than right-sided cold can systems (15 +/- 4.1 J vs 19 +/- 4.8 J, P = 0.05). The right-sided implantation of implantable defibrillators results in significantly higher DFTs than the left-sided approach. This may be due to the less favorable distribution of the defibrillating field relative to the myocardium with the devices on the right. When right-sided implantation is clinically mandated, active can devices result in lower thresholds and should be used.

Carvedilol blocks the repolarizing K+ currents and the L-type Ca2+ current in rabbit ventricular myocytes

Carvedilol ((+/-)-1-(carbazol-4-yloxy)-3-[[2-(o-methoxyphenoxy)ethyl]am ino]-2-propanol), a beta-adrenoceptor-blocking agent with vasodilator properties, has been reported to produce dose-related improvements in left ventricular function and reduction in mortality in patients with chronic heart failure. However, its electrophysiological effects have not been elucidated. We studied ion channel and action potential modulation by carvedilol in rabbit ventricular preparations using whole-cell voltage-clamp and standard microelectrode techniques. In ventricular myocytes, carvedilol blocked the rapidly activating component of the delayed rectifier K+ current (I(Kr)) in a concentration-dependent manner (IC50 = 0.35 microM). This block was voltage- and time-independent; a prolongation of the depolarizing pulses from a holding potential of -50 mV to +10 mV within the range of 100-3000 ms did not affect the extent of I(Kr) block. Carvedilol also inhibited the L-type Ca2+ current (I(Ca)), the transient outward K+ current (I(to)) and the slowly activating component of the delayed rectifier K+ current (I(Ks)) with IC50 of 3.59, 3.34, and 12.54 microM, respectively. Carvedilol (0.3-30 microM) had no significant effects on the inward rectifier K+ current. In papillary muscles from rabbits pretreated with reserpine, action potential duration was prolonged by 7-12% with 1 microM and by 12-24% with 3 microM carvedilol at stimulation frequencies of 0.1-3.0 Hz. No further action potential duration prolongation was observed at concentrations higher than 3 microM. These results suggest that concomitant block of K+ and Ca2+ currents by carvedilol resulted in a moderate prolongation of action potential duration with minimal reverse frequency-dependence. Such electrophysiological effects of carvedilol would be beneficial in the treatment of ventricular tachyarrhythmias.

An overview of arrhythmias and antiarrhythmic approaches

Although treatment of cardiac arrhythmias has been revolutionized in the past decade, patients with atrial fibrillation (AF) still represent a major challenge. With the graying of the population, AF is increasing in prevalence and is responsible for significant morbidity, mortality, and health care expenditures. Drug therapy will be required for the majority of patients with this disorder. Patients with ventricular tachyarrhythmias represent the other major challenge to the cardiac electrophysiologist. The use of implantable cardioverter-defibrillators (ICDs) has reduced the sudden death mortality to 1% or less per year in patients at risk of dying from a ventricular tachyarrhythmia. Unfortunately, high-risk patients who receive an ICD are only a small proportion of the patients who die suddenly each year. Considering the number of at-risk patients, it is likely that drug therapy will remain the mainstay of treatment of patients with ventricular tachyarrhythmias. Therefore, the major challenge is to recognize patients at risk and treat them with antiarrhythmic drugs to prevent sudden cardiac death. Consequently, it has become clear that we have come to a crossroad with regard to antiarrhythmic drugs. Our knowledge of the molecular biology of cardiac ion channels, electrophysiology, and emerging antiarrhythmic drugs provides us an opportunity to create new pharmacologic stratagems.