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Triantafyllou K, Fragakis N, Gatzoulis KA, Antoniadis A, Giannopoulos G, Arsenos P, Tsiachris D, Antoniou C, Trachanas K, Tsimos K, Vassilikos V. Risk assessment of post-myocardial infarction patients with preserved ejection fraction using 45-min short resting Holter electrocardiographic recordings. Ann Noninvasive Electrocardiol 2023; 28:e13087. [PMID: 37700553 PMCID: PMC10646375 DOI: 10.1111/anec.13087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/04/2023] [Accepted: 08/17/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Risk stratification for sudden cardiac death in post-myocardial infarction (post-MI) patients remains a challenging task. Several electrocardiographic noninvasive risk factors (NIRFs) have been associated with adverse outcomes and were used to refine risk assessment. This study aimed to evaluate the performance of NIRFs extracted from 45-min short resting Holter ECG recordings (SHR), in predicting ventricular tachycardia inducibility with programmed ventricular stimulation (PVS) in post-MI patients with preserved left ventricular ejection fraction (LVEF). METHODS We studied 99 post-MI ischemia-free patients (mean age: 60.5 ± 9.5 years, 86.9% men) with LVEF ≥40%, at least 40 days after revascularization. All the patients underwent PVS and a high-resolution SHR. The following parameters were evaluated: mean heart rate, ventricular arrhythmias (premature ventricular complexes, couplets, tachycardias), QTc duration, heart rate variability (HRV), deceleration capacity, heart rate turbulence, late potentials, and T-wave alternans. RESULTS PVS was positive in 24 patients (24.2%). HRV, assessed by the standard deviation of normal-to-normal R-R intervals (SDNN), was significantly decreased in the positive PVS group (42 ms vs. 51 ms, p = .039). SDNN values <50 ms were also associated with PVS inducibility (OR 3.081, p = .032 in univariate analysis, and 4.588, p = .013 in multivariate analysis). No significant differences were identified for the other NIRFs. The presence of diabetes, history of ST-elevation MI (STEMI) and LVEF <50% were also important predictors of positive PVS. CONCLUSIONS HRV assessed from SHR, combined with other noninvasive clinical and echocardiographic variables (diabetes, STEMI history, LVEF), can provide an initial, practical, and rapid screening tool for arrhythmic risk assessment in post-MI patients with preserved LVEF.
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Affiliation(s)
- Konstantinos Triantafyllou
- Third Cardiology Department, Hippokration HospitalAristotle University of ThessalonikiThessalonikiGreece
| | - Nikolaos Fragakis
- Third Cardiology Department, Hippokration HospitalAristotle University of ThessalonikiThessalonikiGreece
| | - Konstantinos A. Gatzoulis
- First Department of Cardiology, Hippokration General HospitalNational and Kapodistrian University of Athens School of MedicineAthensGreece
| | - Antonios Antoniadis
- Third Cardiology Department, Hippokration HospitalAristotle University of ThessalonikiThessalonikiGreece
| | - Georgios Giannopoulos
- Third Cardiology Department, Hippokration HospitalAristotle University of ThessalonikiThessalonikiGreece
| | - Petros Arsenos
- First Department of Cardiology, Hippokration General HospitalNational and Kapodistrian University of Athens School of MedicineAthensGreece
| | - Dimitrios Tsiachris
- First Department of Cardiology, Hippokration General HospitalNational and Kapodistrian University of Athens School of MedicineAthensGreece
| | - Christos‐Konstantinos Antoniou
- First Department of Cardiology, Hippokration General HospitalNational and Kapodistrian University of Athens School of MedicineAthensGreece
| | | | - Konstantinos Tsimos
- Department of Cardiology, Faculty of MedicineUniversity of IoanninaIoanninaGreece
| | - Vassilios Vassilikos
- Third Cardiology Department, Hippokration HospitalAristotle University of ThessalonikiThessalonikiGreece
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2
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Park EH, Kim JM, Seong E, Lee E, Chang K, Choi Y. Effects of Mesenchymal Stem Cell Injection into Healed Myocardial Infarction Scar Border Zone on the Risk of Ventricular Tachycardia. Biomedicines 2023; 11:2141. [PMID: 37626638 PMCID: PMC10452743 DOI: 10.3390/biomedicines11082141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/27/2023] Open
Abstract
The scar border zone is a main source of reentry responsible for ischemic ventricular tachycardia (VT). We evaluated the effects of mesenchymal stem cell (MSC) injection into the scar border zone on arrhythmic risks in a post-myocardial infarction (MI) animal model. Rabbit MI models were generated by left descending coronary artery ligation. Surviving rabbits after 4 weeks underwent left thoracotomy and autologous MSCs or phosphate-buffered saline (PBS) was administered to scar border zones in two rabbits in each group. Another rabbit without MI underwent a sham procedure (control). An implantable loop recorder (ILR) was implanted in the left chest wall in all animals. Four weeks after cell injections, ventricular fibrillation was induced in 1/2 rabbit in the PBS group by electrophysiologic study, and no ventricular arrhythmia was induced in the MSC group or control. Spontaneous VT was not detected during ILR analysis in any animal for 4 weeks. Histologic examination showed restoration of connexin 43 (Cx43) expression in the MSC group, which was higher than in the PBS group and comparable to the control. In conclusion, MSC injections into the MI scar border zone did not increase the risk of VT and were associated with favorable Cx43 expression and arrangement.
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Affiliation(s)
- Eun-Hye Park
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-H.P.); (J.-M.K.); (E.S.); (E.L.); (K.C.)
| | - Jin-Moo Kim
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-H.P.); (J.-M.K.); (E.S.); (E.L.); (K.C.)
| | - EunHwa Seong
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-H.P.); (J.-M.K.); (E.S.); (E.L.); (K.C.)
| | - Eunmi Lee
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-H.P.); (J.-M.K.); (E.S.); (E.L.); (K.C.)
| | - Kiyuk Chang
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-H.P.); (J.-M.K.); (E.S.); (E.L.); (K.C.)
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Young Choi
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-H.P.); (J.-M.K.); (E.S.); (E.L.); (K.C.)
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
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3
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Bhaskaran A, De Silva K, Kumar S. Contemporary updates on ventricular arrhythmias: from mechanisms to management. Intern Med J 2023; 53:892-906. [PMID: 36369893 PMCID: PMC10947276 DOI: 10.1111/imj.15976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/09/2022] [Indexed: 03/20/2024]
Abstract
Ventricular arrhythmias (VAs) are a group of heart rhythm disorders that can be life-threatening and cause significant morbidity. VA in the presence of structural heart disease (SHD) has distinct prognostic implications and requires a comprehensive and multifaceted approach for investigation and management. Early specialist referral should be considered for all patients with VA. Particular urgency is recommended in patients with syncope, nonsustained/sustained VA on Holter monitor and SHD on cardiac imaging because of the heightened risk of sudden cardiac death. Comprehensive phenotyping is recommended for most patients with VA, encompassing noninvasive cardiac functional testing, multimodality imaging and genetic testing in select circumstances. Management of idiopathic VA is guided heavily by symptom burden and the presence of ventricular systolic impairment. In SHD, guideline-directed heart failure therapy and device implantation are critical considerations. Whilst commonly used and well-established, antiarrhythmic drugs can be hampered by toxicity and failure of adequate arrhythmia control. Catheter ablation is increasingly being considered a feasible first-line alternative to medical therapy, where outcomes are influenced by disease aetiology and scar burden in SHD. Catheter ablation is associated with reduced arrhythmia recurrence and burden and improved quality of life at follow-up.
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Affiliation(s)
- Ashwin Bhaskaran
- Department of CardiologyWestmead HospitalSydneyNew South WalesAustralia
- Westmead Applied Research CentreUniversity of SydneySydneyNew South WalesAustralia
| | - Kasun De Silva
- Department of CardiologyWestmead HospitalSydneyNew South WalesAustralia
- Westmead Applied Research CentreUniversity of SydneySydneyNew South WalesAustralia
| | - Saurabh Kumar
- Department of CardiologyWestmead HospitalSydneyNew South WalesAustralia
- Westmead Applied Research CentreUniversity of SydneySydneyNew South WalesAustralia
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4
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QT interval extracted from 30-minute short resting Holter ECG recordings predicts mortality in heart failure. J Electrocardiol 2022; 72:109-114. [DOI: 10.1016/j.jelectrocard.2022.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 03/07/2022] [Accepted: 03/30/2022] [Indexed: 01/08/2023]
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5
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Arsenos P, Gatzoulis KA, Tsiachris D, Dilaveris P, Sideris S, Sotiropoulos I, Archontakis S, Antoniou CK, Kordalis A, Skiadas I, Toutouzas K, Vlachopoulos C, Tousoulis D, Tsioufis K. Arrhythmic risk stratification in ischemic, non-ischemic and hypertrophic cardiomyopathy: A two-step multifactorial, electrophysiology study inclusive approach. World J Cardiol 2022; 14:139-151. [PMID: 35432775 PMCID: PMC8968455 DOI: 10.4330/wjc.v14.i3.139] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 10/28/2021] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
Annual arrhythmic sudden cardiac death ranges from 0.6% to 4% in ischemic cardiomyopathy (ICM), 1% to 2% in non-ischemic cardiomyopathy (NICM), and 1% in hypertrophic cardiomyopathy (HCM). Towards a more effective arrhythmic risk stratification (ARS) we hereby present a two-step ARS with the usage of seven non-invasive risk factors: Late potentials presence (≥ 2/3 positive criteria), premature ventricular contractions (≥ 30/h), non-sustained ventricular tachycardia (≥ 1episode/24 h), abnormal heart rate turbulence (onset ≥ 0% and slope ≤ 2.5 ms) and reduced deceleration capacity (≤ 4.5 ms), abnormal T wave alternans (≥ 65μV), decreased heart rate variability (SDNN < 70ms), and prolonged QTc interval (> 440 ms in males and > 450 ms in females) which reflect the arrhythmogenic mechanisms for the selection of the intermediate arrhythmic risk patients in the first step. In the second step, these intermediate-risk patients undergo a programmed ventricular stimulation (PVS) for the detection of inducible, truly high-risk ICM and NICM patients, who will benefit from an implantable cardioverter defibrillator. For HCM patients, we also suggest the incorporation of the PVS either for the low HCM Risk-score patients or for the patients with one traditional risk factor in order to improve the inadequate sensitivity of the former and the low specificity of the latter.
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Affiliation(s)
- Petros Arsenos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Konstantinos A Gatzoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | | | - Polychronis Dilaveris
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Skevos Sideris
- Department of Cardiology, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Ilias Sotiropoulos
- Department of Cardiology, Hippokration Hospital, Athens 11527, Attika, Greece
| | | | | | - Athanasios Kordalis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Ioannis Skiadas
- Fifth Department of Cardiology, Hygeia Hospital, Marousi 15123, Attika, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Charalambos Vlachopoulos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
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6
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Deshmukh T, Zaman S, Narayan A, Kovoor P. Duration of Inducible Ventricular Tachycardia Early After ST-Segment-Elevation Myocardial Infarction and Its Impact on Mortality and Ventricular Tachycardia Recurrence. J Am Heart Assoc 2020; 9:e015204. [PMID: 32573328 PMCID: PMC7670508 DOI: 10.1161/jaha.119.015204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The clinical significance of the duration of inducible ventricular tachycardia (VT) at electrophysiology study (EPS) in patients soon after ST‐segment–elevation myocardial infarction and its predictive utility for VT recurrence are not known. Methods and Results Consecutive ST‐segment–elevation myocardial infarction patients with day 3 to 5 left ventricular ejection fraction ≤40% underwent EPS. A positive EPS was defined as sustained monomorphic VT with cycle length ≥200 ms. The induced VT was terminated by overdrive pacing or direct current shock at 30 s or earlier if hemodynamic decompensation occurred. Patients with inducible VT duration 2 to 10 s were compared with patients with inducible VT >10 s. The primary end point was survival free of VT or cardiac mortality. From 384 consecutive ST‐segment–elevation myocardial infarction patients who underwent EPS, 29% had inducible VT (n=112, 87% men). After mean follow‐up of 5.9±3.9 years, primary end point occurred in 35% of patients with induced VT 2 to 10 s duration (n=68) and in 22% of patients with induced VT >10 s (n=41) (P=0.61). This was significantly different from the noninducible VT group, in which primary end point occurred in 3% of patients (n=272) (P=0.001). Conclusions This study is the first to show that in patients who undergo EPS early after myocardial infarction, inducible VT of short duration (2–10 s) has similar predictive utility for ventricular tachyarrhythmia as longer duration (>10 s) inducible VT, which was significantly different to those without inducible VT. It is possible that immediate cardioversion of rapid VT might have contributed to some of the short durations of inducible VT.
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Affiliation(s)
- Tejas Deshmukh
- Department of Cardiology Westmead Hospital Sydney Australia.,University of Sydney Australia
| | - Sarah Zaman
- Monash University Melbourne Australia.,Monash Cardiovascular Research Centre Monash Heart Melbourne Australia
| | - Arun Narayan
- Department of Cardiology Westmead Hospital Sydney Australia
| | - Pramesh Kovoor
- Department of Cardiology Westmead Hospital Sydney Australia.,University of Sydney Australia
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7
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Abstract
Sudden cardiac death (SCD) accounts for ∼50% of mortality after myocardial infarction (MI). Most SCDs result from ventricular tachyarrhythmias, and the tachycardias that precipitate cardiac arrest result from multiple mechanisms. As a result, it is highly unlikely that any single test will identify all patients at risk for SCD. Current guidelines for use of implantable cardioverter-defibrillators (ICDs) to prevent SCD are based primarily on measurement of left ventricular ejection fraction (LVEF). Although reduced LVEF is associated with increased total cardiac mortality after MI, the focus of current guidelines on LVEF omits ∼50% of patients who die suddenly. In addition, there is no evidence of a mechanistic link between reduced LVEF and arrhythmias. Thus, LVEF is neither sensitive nor specific as a tool for post-MI risk stratification. Newer tests to screen for predisposition to ventricular arrhythmias and SCD examine abnormalities of ventricular repolarization, autonomic nervous system function, and electrical heterogeneity. These tests, as well as older methods such as programmed stimulation, the signal-averaged electrocardiogram, and spontaneous ventricular ectopy, do not perform well in patients with LVEF ≤30%. Recent observational studies suggest, however, that these tests may have greater utility in patients with LVEF >30%. Because SCD results from multiple mechanisms, it is likely that combinations of risk factors will prove more precise for risk stratification. Prospective trials that evaluate the performance of risk stratification schema to determine ICD use are necessary for cost-effective reduction of the incidence of SCD after MI.
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Affiliation(s)
- Jonathan W Waks
- Department of Medicine, Harvard Medical School, Boston, Massachusetts 02115.,Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215; ;
| | - Alfred E Buxton
- Department of Medicine, Harvard Medical School, Boston, Massachusetts 02115.,Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215; ;
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8
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Katritsis DG, Zografos T, Hindricks G. Electrophysiology testing for risk stratification of patients with ischaemic cardiomyopathy: a call for action. Europace 2018; 20:f148-f152. [PMID: 29236981 DOI: 10.1093/europace/eux305] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 12/05/2017] [Indexed: 01/05/2023] Open
Abstract
Current guidelines recommendations, based on the results of primary sudden cardiac death prevention trials, use the left ventricular ejection fraction (LVEF) as a sole criterion for the indication of implantable cardioverter defibrillator therapy for primary prevention purposes. In this article, we review the sensitivity and specificity of LVEF for predicting arrhythmic vs. non-arrhythmic cardiac death and examine existing evidence on the use of electrophysiology testing for risk stratification of ischaemic patients with reduced left ventricular function.
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Affiliation(s)
| | - Theodoros Zografos
- Department of Cardiology, Athens Euroclinic, 9 Athanassiadou Street, Athens, Greece
| | - Gerhard Hindricks
- Department of Electrophysiology, University Leipzig-Heart Center, Strümpellstr. Leipzig, Germany
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9
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Disertori M, Masè M, Rigoni M, Nollo G, Ravelli F. Ventricular tachycardia-inducibility predicts arrhythmic events in post-myocardial infarction patients with low ejection fraction. A systematic review and meta-analysis. IJC HEART & VASCULATURE 2018; 20:7-13. [PMID: 29942854 PMCID: PMC6011046 DOI: 10.1016/j.ijcha.2018.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/24/2018] [Accepted: 06/06/2018] [Indexed: 01/17/2023]
Abstract
Background Inducibility of ventricular arrhythmias at electrophysiological study (EPS) has long been suggested as predictive for subsequent arrhythmic events. Nevertheless, the usefulness of EPS in the clinical practice is still unclear. We performed a systematic review and meta-analysis to assess the predictive power of EPS in primary prevention of ventricular arrhythmias in post-myocardial infarction (MI) patients with left ventricular dysfunction. Methods MEDLINE and the Cochrane Library databases were systematically searched to identify studies, which analyzed EPS predictive value in post-MI patients with mean EF < 40% for the composite arrhythmic endpoint defined by: sudden cardiac death (SCD), aborted SCD, ventricular tachycardia (VT), ventricular fibrillation (VF), appropriate implantable cardioverter-defibrillator (ICD) interventions. Results Nine studies, evaluating 3959 patients with 647 arrhythmic events, were included in the meta-analyses. EPS showed a strong predictive power for the arrhythmic endpoint with a pooled odds ratio (OR) of 4.00 (95% confidence interval [CI]: 2.30–6.96) in the whole set of studies, albeit a high level of heterogeneity among studies. EPS predictive power was higher in studies where VT-inducibility was tested (OR 6.52; 95% CI: 2.30–18.44; sensitivity 0.65, specificity 0.78, and negative predictive value 0.94), versus those assessing VT/VF-inducibility (OR 2.09; 95% CI: 1.34–3.26). VT-inducibility was predictive even when assessed within one month after MI (OR 7.85; 95% CI: 3.67–16.80). Conclusions Inducibility of ventricular arrhythmias at EPS is a strong predictor of the arrhythmic endpoint in post-MI patients with impaired EF, particularly when VT-inducibility is tested. EPS could help selecting the patients who can mostly benefit from ICD therapy.
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Affiliation(s)
- Marcello Disertori
- Healthcare Research and Innovation Program, PAT-FBK, Trento, Italy.,Department of Cardiology, Santa Chiara Hospital, Trento, Italy
| | - Michela Masè
- Department of Physics, University of Trento, Povo, Trento, Italy
| | - Marta Rigoni
- Healthcare Research and Innovation Program, PAT-FBK, Trento, Italy
| | - Giandomenico Nollo
- Healthcare Research and Innovation Program, PAT-FBK, Trento, Italy.,Department of Industrial Engineering, University of Trento, Povo, Trento, Italy
| | - Flavia Ravelli
- Department of Physics, University of Trento, Povo, Trento, Italy
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10
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Bui AH, Waks JW. Risk Stratification of Sudden Cardiac Death After Acute Myocardial Infarction. J Innov Card Rhythm Manag 2018; 9:3035-3049. [PMID: 32477797 PMCID: PMC7252689 DOI: 10.19102/icrm.2018.090201] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/02/2017] [Indexed: 01/20/2023] Open
Abstract
Despite advances in the diagnosis and treatment of acute coronary syndromes and an overall improvement in outcomes, mortality after myocardial infarction (MI) remains high. Sudden death, which is most frequently due to ventricular tachycardia or ventricular fibrillation, is the cause of death in 25% to 50% of patients with prior MI, and therefore represents an important public health problem. Use of the implantable cardioverter-defibrillator (ICD), which is the primary method of reducing the chance of arrhythmic sudden death after MI, is costly to the medical system and is associated with procedural and long-term risks. Additionally, assessment of left ventricular ejection fraction (LVEF), which is the primary method of assessing a patient’s post-MI sudden death risk and appropriateness for ICD implantation, lacks both sensitivity and specificity for sudden death, and may not be the optimal way to select the subgroup of post-MI patients who are most likely to benefit from ICD implantation. To optimally utilize ICDs, it is therefore critical to develop and prospectively validate sudden death risk stratification methods beyond measuring LVEF. A variety of tests that assess left ventricular systolic function/morphology, potential triggers for ventricular arrhythmias, ventricular conduction/repolarization, and autonomic tone have been proposed as sudden death risk stratification tools. Multivariable models have also been developed to assess the competing risks of arrhythmic and non-arrhythmic death so that ICDs can be utilized more effectively. This manuscript will review the epidemiology of sudden death after MI, and will discuss the current state of sudden death risk stratification in this population.
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Affiliation(s)
- An H Bui
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jonathan W Waks
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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11
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Gatzoulis KA, Sideris A, Kanoupakis E, Sideris S, Nikolaou N, Antoniou CK, Kolettis TM. Arrhythmic risk stratification in heart failure: Time for the next step? Ann Noninvasive Electrocardiol 2017; 22. [PMID: 28252256 DOI: 10.1111/anec.12430] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 01/10/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Primary prevention of sudden cardiac death by means of implantable cardioverter-defibrillators constitutes the holy grail of arrhythmology. However, current risk stratification algorithms lead to suboptimal outcomes, by both allocating ICDs to patients not deriving any meaningful survival benefit and withholding them from those erroneously considered as low-risk for arrhythmic mortality. METHODS In the present review article we will attempt to present shortcomings of contemporary guidelines regarding sudden death prevention in ischemic and dilated cardiomyopathy patients and present available data suggesting encouraging results following implementation of multifactorial approaches, by using multiple modalities, both noninvasive and invasive. Invasive electrophysiological testing, namely programmed ventricular stimulation, will be discussed in greater length to highlight both its potential usefulness and currently ongoing multicenter studies aiming to provide evidence necessary to make the next step in sudden death risk stratification. RESULTS Promising findings have been reported by multiple study groups regarding novel strategies for both negative selection of low and positive selection of relatively preserved ejection fraction patients as candidates for ICD implantation. CONCLUSIONS The era of ejection fraction as the sole risk stratifier for arrhythmic risk in heart failure appears to be drawing to an end, especially if current underway large studies validate previous findings.
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Affiliation(s)
- Konstantinos A Gatzoulis
- Electrophysiology Laboratory, First Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Sideris
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Emmanuel Kanoupakis
- Department of Cardiology, University General Hospital of Heraklion, Heraklion, Greece
| | - Skevos Sideris
- State Department of Cardiology, "Hippokration" General Hospital, Athens, Greece
| | - Nikolaos Nikolaou
- Department of Cardiology, "Konstantopouleio" General Hospital, Athens, Greece
| | - Christos-Konstantinos Antoniou
- Electrophysiology Laboratory, First Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Theofilos M Kolettis
- Department of Cardiology, University General Hospital of Ioannina, Ioannina, Greece
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12
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Disertori M, Gulizia MM, Casolo G, Delise P, Di Lenarda A, Di Tano G, Lunati M, Mestroni L, Salerno-Uriarte J, Tavazzi L. Improving the appropriateness of sudden arrhythmic death primary prevention by implantable cardioverter-defibrillator therapy in patients with low left ventricular ejection fraction. Point of view. J Cardiovasc Med (Hagerstown) 2016; 17:245-55. [PMID: 26895401 PMCID: PMC4768631 DOI: 10.2459/jcm.0000000000000368] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 01/10/2016] [Accepted: 01/22/2016] [Indexed: 12/12/2022]
Abstract
It is generally accepted that the current guidelines for the primary prevention of sudden arrhythmic death, which are based on ejection fraction, do not allow the optimal selection of patients with low left ventricular ejection fraction of ischemic and nonischemic etiology for implantation of a cardioverter-defibrillator. Ejection fraction alone is limited in both sensitivity and specificity. An analysis of the risk of sudden arrhythmic death with a combination of multiple tests (ejection fraction associated with one or more arrhythmic risk markers) could partially compensate for these limitations. We propose a polyparametric approach for defining the risk of sudden arrhythmic death using ejection fraction in combination with other clinical and arrhythmic risk markers (i.e. late gadolinium enhancement cardiac magnetic resonance, T-wave alternans, programmed ventricular stimulation, autonomic tone, and genetic testing) that have been validated in nonrandomized trials. In this article, we examine these approaches to identify three subsets of patients who cannot be comprehensively assessed by the current guidelines: patients with ejection fraction of 35% or less and a relatively low risk of sudden arrhythmic death despite the ejection fraction value; patients with ejection fraction of 35% or less and high competitive risk of death due to evolution of heart failure or noncardiac causes; and patients with ejection fraction between 35 and 45% with relatively high risk of sudden arrhythmic death despite the ejection fraction value.
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MESH Headings
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/mortality
- Arrhythmias, Cardiac/physiopathology
- Arrhythmias, Cardiac/prevention & control
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Humans
- Primary Prevention/methods
- Stroke Volume/physiology
- Ventricular Dysfunction, Left/complications
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Left/therapy
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Affiliation(s)
- Marcello Disertori
- Cardiology Department, S. Chiara Hospital – Healthcare Research and Innovation Program, PAT-FBK, Trento
| | | | | | - Pietro Delise
- Division of Cardiology, Pederzoli Hospital, Peschiera del Garda (VR)
| | - Andrea Di Lenarda
- Cardiovascular Center, Azienda Servizi Sanitari N.1 – University of Trieste, Trieste
| | | | - Maurizio Lunati
- Cardiology Department, Niguarda Ca’ Granda Hospital, Milano, Italy
| | - Luisa Mestroni
- Cardiovascular Institute, University of Colorado Denver AMC, Aurora, Colorado, USA
| | - Jorge Salerno-Uriarte
- Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese
| | - Luigi Tavazzi
- GVM, Maria Cecilia Hospital, Care and Research – ES Health Science Foundation, Cotignola (RA), Italy
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13
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De Ferrari GM, Rordorf R, Landolina ME. Letter by Ferrari et al regarding article, "Long-term arrhythmia-free survival in patients with severe left ventricular dysfunction and no inducible ventricular tachycardia after myocardial infarction". Circulation 2014; 130:e178. [PMID: 25385943 DOI: 10.1161/circulationaha.114.009676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gaetano M De Ferrari
- Department of Cardiology and Cardiovascular Clinical Research Center, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Roberto Rordorf
- Department of Cardiology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Maurizio E Landolina
- Department of Cardiology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
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14
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Rijnierse MT, de Haan S, Harms HJ, Robbers LF, Wu L, Danad I, Beek AM, Heymans MW, van Rossum AC, Lammertsma AA, Allaart CP, Knaapen P. Impaired Hyperemic Myocardial Blood Flow Is Associated With Inducibility of Ventricular Arrhythmia in Ischemic Cardiomyopathy. Circ Cardiovasc Imaging 2014; 7:20-30. [DOI: 10.1161/circimaging.113.001158] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background—
Risk stratification for ventricular arrhythmias (VAs) is important to refine selection criteria for primary prevention implantable cardioverter defibrillator therapy. Impaired hyperemic myocardial blood flow (MBF) is associated with increased mortality rate in ischemic and nonischemic cardiomyopathy, which may be attributed to electric instability inducing VAs. The aim of this pilot study was to assess whether hyperemic MBF impairment may be related with VA inducibility in patients with ischemic cardiomyopathy.
Methods and Results—
Thirty patients with ischemic cardiomyopathy referred for primary prevention implantable cardioverter defibrillator implantation were prospectively included (26 men; 65±8 years old; left ventricular ejection fraction, 29±6%). [
15
O]H
2
O positron-emission tomography was performed to quantify resting MBF, hyperemic MBF, and coronary flow reserve. Left ventricular dimensions, function, and scar burden were assessed with cardiovascular magnetic resonance imaging. An electrophysiological study was performed to test VA inducibility. Positive electrophysiological study patients (n=12) showed reduced hyperemic MBF (1.25±0.30 versus 1.66±0.38 mL·min
−1
·g
−1
;
P
<0.01) and coronary flow reserve (1.59±0.49 versus 2.12±0.48;
P
<0.01) compared with electrophysiological study negative patients (n=18). In electrophysiological study positive patients, the number of scar segments >75% transmurality was higher (
P
<0.05), although scar size and border zone did not differ. Receiver-operating characteristic curve analysis indicated that impaired hyperemic MBF (area under the curve, 0.84; 95% confidence intervals [0.69–0.99]) and coronary flow reserve (area under the curve, 0.77; 95% confidence intervals [0.57–0.96]) were associated with VA inducibility.
Conclusions—
In this pilot study, impaired hyperemic MBF and coronary flow reserve were associated with VA inducibility in patients with ischemic cardiomyopathy. These results are hypothesis generating for a potential role of quantitative positron-emission tomography perfusion imaging in risk stratification for VAs.
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Affiliation(s)
- Mischa T. Rijnierse
- From the Department of Cardiology and Institute for Cardiovascular Research (M.T.R., S.d.H., L.F.R., L.N.W., I.D., A.M.B., A.C.v.R., C.P.A., P.K.), Departments of Radiology and Nuclear Medicine (H.J.H., A.A.L.), Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands
| | - Stefan de Haan
- From the Department of Cardiology and Institute for Cardiovascular Research (M.T.R., S.d.H., L.F.R., L.N.W., I.D., A.M.B., A.C.v.R., C.P.A., P.K.), Departments of Radiology and Nuclear Medicine (H.J.H., A.A.L.), Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands
| | - Hendrik J. Harms
- From the Department of Cardiology and Institute for Cardiovascular Research (M.T.R., S.d.H., L.F.R., L.N.W., I.D., A.M.B., A.C.v.R., C.P.A., P.K.), Departments of Radiology and Nuclear Medicine (H.J.H., A.A.L.), Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands
| | - Lourens F. Robbers
- From the Department of Cardiology and Institute for Cardiovascular Research (M.T.R., S.d.H., L.F.R., L.N.W., I.D., A.M.B., A.C.v.R., C.P.A., P.K.), Departments of Radiology and Nuclear Medicine (H.J.H., A.A.L.), Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands
| | - LiNa Wu
- From the Department of Cardiology and Institute for Cardiovascular Research (M.T.R., S.d.H., L.F.R., L.N.W., I.D., A.M.B., A.C.v.R., C.P.A., P.K.), Departments of Radiology and Nuclear Medicine (H.J.H., A.A.L.), Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands
| | - Ibrahim Danad
- From the Department of Cardiology and Institute for Cardiovascular Research (M.T.R., S.d.H., L.F.R., L.N.W., I.D., A.M.B., A.C.v.R., C.P.A., P.K.), Departments of Radiology and Nuclear Medicine (H.J.H., A.A.L.), Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands
| | - Aernout M. Beek
- From the Department of Cardiology and Institute for Cardiovascular Research (M.T.R., S.d.H., L.F.R., L.N.W., I.D., A.M.B., A.C.v.R., C.P.A., P.K.), Departments of Radiology and Nuclear Medicine (H.J.H., A.A.L.), Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands
| | - Martijn W. Heymans
- From the Department of Cardiology and Institute for Cardiovascular Research (M.T.R., S.d.H., L.F.R., L.N.W., I.D., A.M.B., A.C.v.R., C.P.A., P.K.), Departments of Radiology and Nuclear Medicine (H.J.H., A.A.L.), Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands
| | - Albert C. van Rossum
- From the Department of Cardiology and Institute for Cardiovascular Research (M.T.R., S.d.H., L.F.R., L.N.W., I.D., A.M.B., A.C.v.R., C.P.A., P.K.), Departments of Radiology and Nuclear Medicine (H.J.H., A.A.L.), Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands
| | - Adriaan A. Lammertsma
- From the Department of Cardiology and Institute for Cardiovascular Research (M.T.R., S.d.H., L.F.R., L.N.W., I.D., A.M.B., A.C.v.R., C.P.A., P.K.), Departments of Radiology and Nuclear Medicine (H.J.H., A.A.L.), Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands
| | - Cornelis P. Allaart
- From the Department of Cardiology and Institute for Cardiovascular Research (M.T.R., S.d.H., L.F.R., L.N.W., I.D., A.M.B., A.C.v.R., C.P.A., P.K.), Departments of Radiology and Nuclear Medicine (H.J.H., A.A.L.), Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands
| | - Paul Knaapen
- From the Department of Cardiology and Institute for Cardiovascular Research (M.T.R., S.d.H., L.F.R., L.N.W., I.D., A.M.B., A.C.v.R., C.P.A., P.K.), Departments of Radiology and Nuclear Medicine (H.J.H., A.A.L.), Epidemiology and Biostatistics (M.W.H.), VU University Medical Center, Amsterdam, The Netherlands
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15
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Hayashi T, Fukamizu S, Hojo R, Komiyama K, Tanabe Y, Tejima T, Nishizaki M, Hiraoka M, Ako J, Momomura SI, Sakurada H. Fragmented QRS Predicts Cardiovascular Death of Patients With Structural Heart Disease and Inducible Ventricular Tachyarrhythmia. Circ J 2013; 77:2889-97. [DOI: 10.1253/circj.cj-13-0335] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Seiji Fukamizu
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital
| | - Rintaro Hojo
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital
| | - Kota Komiyama
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital
| | | | - Tamotsu Tejima
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital
| | | | | | - Junya Ako
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Shin-ichi Momomura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Harumizu Sakurada
- Tokyo Metropolitan Health and Medical Treatment Corporation Ohkubo Hospital
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16
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T-wave alternans in risk stratification of patients with nonischemic dilated cardiomyopathy: Can it help to better select candidates for ICD implantation? Heart Rhythm 2009; 6:S29-35. [DOI: 10.1016/j.hrthm.2008.10.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Indexed: 11/13/2022]
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17
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Sartipy U, Löfving A, Albåge A, Lindblom D. Surgery for ventricular tachycardia and left ventricular aneurysm provides arrhythmia control. SCAND CARDIOVASC J 2008; 42:226-32. [PMID: 18569956 DOI: 10.1080/14017430802005240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Report long-term freedom from ventricular tachycardia (VT), survival, and causes of death in patients with left ventricular aneurysm and VT, who underwent a combined procedure for VT and surgical ventricular restoration (SVR). DESIGN The primary outcome measures VT, survival, and cause of death, were ascertained by review of patients' records, interrogation of implanted cardioverter-defibrillators and use of national registers. RESULTS Mean follow-up was 5.2 years. Overall survival was 62% at 5 years and 51% at 9 years. Freedom from spontaneous VT was 89%. In 32 patients who were non-inducible at postoperative testing, there was no occurrence of VT during a mean follow-up of 6.0 years. Causes of death were cardiac in 17 patients, and non-cardiac in 6 patients. No patient died from ventricular arrhythmia. CONCLUSIONS Direct surgery for VT combined with SVR resulted in a very low risk of late recurrence of VT and good long-term survival. Implantation of a cardioverter-defibrillator can safely be withheld in patients who are non-inducible on postoperative programmed electrical stimulation.
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Affiliation(s)
- Ulrik Sartipy
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden.
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18
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Salerno-Uriarte JA, De Ferrari GM, Klersy C, Pedretti RFE, Tritto M, Sallusti L, Libero L, Pettinati G, Molon G, Curnis A, Occhetta E, Morandi F, Ferrero P, Accardi F. Prognostic value of T-wave alternans in patients with heart failure due to nonischemic cardiomyopathy: results of the ALPHA Study. J Am Coll Cardiol 2007; 50:1896-904. [PMID: 17980258 DOI: 10.1016/j.jacc.2007.09.004] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Revised: 08/09/2007] [Accepted: 09/07/2007] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The aim of this study was to assess the prognostic value of T-wave alternans (TWA) in New York Heart Association (NYHA) functional class II/III patients with nonischemic cardiomyopathy and left ventricular ejection fraction (LVEF) < or =40%. BACKGROUND There is a strong need to identify reliable risk stratifiers among heart failure candidates for implantable cardioverter-defibrillator (ICD) prophylaxis. T-wave alternans may identify low-risk subjects among post-myocardial infarction patients with depressed LVEF, but its predictive role in nonischemic cardiomyopathy is unclear. METHODS Four hundred forty-six patients were enrolled and followed up for 18 to 24 months. The primary end point was the combination of cardiac death + life-threatening arrhythmias; secondary end points were total mortality and the combination of arrhythmic death + life-threatening arrhythmias. RESULTS Patients with abnormal TWA (65%) compared with normal TWA (35%) tests were older (60 +/- 13 years vs. 57 +/- 12 years), were more frequently in NYHA functional class III (22% vs. 19%), and had a modestly lower LVEF (29 +/- 7% vs. 31 +/- 7%). Primary end point rates in patients with abnormal and normal TWA tests were 6.5% (95% confidence interval [CI] 4.5% to 9.4%) and 1.6% (95% CI 0.6% to 4.4%), respectively. Unadjusted and adjusted hazard ratios were 4.0 (95% CI 1.4% to 11.4%; p = 0.002) and 3.2 (95% CI 1.1% to 9.2%; p = 0.013), respectively. Hazard ratios for total mortality and for arrhythmic death + life-threatening arrhythmias were 4.6 (p = 0.002) and 5.5 (p = 0.004), respectively; 18-month negative predictive values for the 3 end points ranged between 97.3% and 98.6%. CONCLUSIONS Among NYHA functional class II/III nonischemic cardiomyopathy patients, an abnormal TWA test is associated with a 4-fold higher risk of cardiac death and life-threatening arrhythmias. Patients with normal TWA tests have a very good prognosis and are likely to benefit little from ICD therapy.
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Affiliation(s)
- Jorge A Salerno-Uriarte
- Dipartimento di Scienze Cardiovascolari, Università degli Studi dell'Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
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