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Geri G, Passouant O, Dumas F, Bougouin W, Champigneulle B, Arnaout M, Chelly J, Chiche JD, Varenne O, Guillemet L, Pène F, Waldmann V, Mira JP, Marijon E, Cariou A. Etiological diagnoses of out-of-hospital cardiac arrest survivors admitted to the intensive care unit: Insights from a French registry. Resuscitation 2017; 117:66-72. [DOI: 10.1016/j.resuscitation.2017.06.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/01/2017] [Accepted: 06/06/2017] [Indexed: 01/17/2023]
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Safavi-Naeini P, Rasekh A, Razavi M, Saeed M, Massumi A. Sudden Cardiac Death in Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_24] [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: 11/28/2022]
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Abstract
Sudden cardiac death (SCD) is a leading cause of mortality in industrialized countries, and ventricular fibrillation and sustained ventricular tachycardia are the major causes of SCD. Although there are now effective devices and medications that can prevent such serious arrhythmias, it is crucial to have methods of identifying patients at risk. Numerous studies suggest that most patients dying of SCD have coronary artery disease or cardiomyopathy. Functional or electrophysiological measurements are effective in risk stratification. Left ventricular ejection fraction measured by echocardiography or cardiac imaging techniques is the gold standard to detect high-risk patients. Electrophysiological studies have also been used for risk stratification. Noninvasive techniques and measurements, such as T-wave alternans, signal-averaged electrocardiography, nonsustained ventricular tachycardia, heart rate variability, and heart rate turbulence, have been proposed as useful tools in identifying patients at risk for SCD. This article reviews the epidemiology, mechanisms, substrates, and current status of risk stratification of SCD.
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Affiliation(s)
- Takanori Ikeda
- Second Department of Internal Medicine, Kyorin University School of Medicine, Mitaka, Tokyo 181-8611, Japan.
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Sudden Cardiac Death. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247-346. [PMID: 16949478 DOI: 10.1016/j.jacc.2006.07.010] [Citation(s) in RCA: 863] [Impact Index Per Article: 47.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Brodsky MA, Mitchell LB, Halperin BD, Raitt MH, Hallstrom AP. Prognostic value of baseline electrophysiology studies in patients with sustained ventricular tachyarrhythmia: the Antiarrhythmics Versus Implantable Defibrillators (AVID) trial. Am Heart J 2002; 144:478-84. [PMID: 12228785 DOI: 10.1067/mhj.2002.125502] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We sought to determine the value of electrophysiology (EP) testing in patients with ventricular fibrillation (VF), ventricular tachycardia (VT) with syncope, or sustained VT in the setting of left ventricular dysfunction. BACKGROUND Traditionally, EP testing is part of the workup of patients with sustained VT or VF. Recently, some have suggested that EP testing is unnecessary in these patients, many of whom are likely to receive an implantable cardioverter-defibrillator (ICD). METHODS Within a multicenter trial (Antiarrhythmics Versus Implantable Defibrillators) designed to evaluate whether drugs or ICD resulted in a better outcome, data were analyzed regarding EP testing. Although this testing was not required, it was performed in >50% of patients. Information regarding the results of EP testing was correlated to baseline clinical characteristics and outcome. RESULTS Of 572 patients subjected to an EP test, 384 (67%) had inducible sustained VT or VF. Inducible patients were more likely to have coronary artery disease, previous infarction, and VT as their index arrhythmic event. Inducibility of VT or VF did not predict death or recurrent VT or VF. CONCLUSIONS Information derived from EP testing in this patient population, particularly those with VF, is of limited value and may not be worth the risks and costs of the procedure, particularly in those patients likely to receive an ICD.
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Affiliation(s)
- Michael A Brodsky
- Division of Cardiology, University of California Irvine Medical Center, Orange, Calif 92868-4080, USA.
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Zaim S, Zaim B, Rottman J, Mendoza I, Nasir N, Pacifico A. Characterization of spontaneous recurrent ventricular arrhythmias detected by electrogram-storing defibrillators in sudden cardiac death survivors with no inducible ventricular arrhythmias at baseline electrophysiologic testing. Am Heart J 1996; 132:274-9. [PMID: 8701887 DOI: 10.1016/s0002-8703(96)90422-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This retrospective study characterized the recurring ventricular arrhythmias with an electrogram-storing defibrillator in survivors of sudden cardiac death who had no inducible sustained ventricular arrhythmias at baseline electrophysiologic testing (EPS). The study group was composed of 24 selected patients with documented ventricular fibrillation (VF) without need of revascularization or chronic antiarrhythmic therapy. The EPS protocol usually consisted of three extrastimuli at two drive cycles at two right ventricular sites. Nonischemic cardiomyopathy was the most frequent structural abnormality (n = 11) followed by coronary artery disease (n = 7). The mean ejection fraction was 0.37 +/- 0.13. Cardiac status did not appear to change during a mean follow-up period of 16.4 +/- 12.5 months, and eight (33%) patients received appropriate shocks in that time period. On the basis of intracardiac electrograms, 7 (88%) patients experienced VF and 1 (12%) patient had ventricular tachycardia as the first recurring arrhythmia. Four patients had additional recurrences and all were VF episodes. VF was usually present from the onset of the arrhythmia. In addition, 9 (38%) patients had nonsustained ventricular arrhythmias that were solely VF in 6 (67%). In conclusion, VF of sudden onset was the most frequent recurring sustained ventricular arrhythmia in this group.
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Affiliation(s)
- S Zaim
- Hahnemann University Hospital, Philadelphia, Pa, USA
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Swerdlow CD, Chen PS, Kass RM, Allard JR, Peter CT. Discrimination of ventricular tachycardia from sinus tachycardia and atrial fibrillation in a tiered-therapy cardioverter-defibrillator. J Am Coll Cardiol 1994; 23:1342-55. [PMID: 8176092 DOI: 10.1016/0735-1097(94)90376-x] [Citation(s) in RCA: 157] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES This study was conducted to evaluate criteria for discrimination of ventricular tachycardia from atrial fibrillation and sinus tachycardia in a tiered-therapy cardioverter-defibrillator (Medtronic PCD). BACKGROUND Interval stability algorithms discriminate ventricular tachycardia from atrial fibrillation. Onset algorithms discriminate ventricular tachycardia from sinus tachycardia. Neither has been validated clinically. METHODS The stability criterion requires that a ventricular tachycardia interval not vary from any of the three previous intervals by more than the programmable stability value. The onset criterion detects initiation of ventricular tachycardia only if the ratio of an interval to the mean of four previous intervals is less than a programmed onset ratio and either the second or third preceding interval exceeds the ventricular tachycardia detection interval. We evaluated these criteria in 100 patients at electrophysiologic study and exercise testing (65 patients) and during a mean (+/- SD) follow-up of 16.2 +/- 7.9 months. The PCDs were programmed to tiered therapy in 54 patients. In the remaining 46 patients, the PCD's memory for detected ventricular tachycardia was used to study the specificity of the chosen onset criterion for rejecting sinus tachycardia. We used stored intervals preceding appropriate (n = 99) and inappropriate (n = 54) detections to test a new onset criterion that was less sensitive to a single index interval. RESULTS Programmed stability of 40 ms decreased detection of induced atrial fibrillation by 95% (20 patients), paroxysmal atrial fibrillation by 95% (6 patients) and chronic atrial fibrillation by 99% (9 patients); all episodes of spontaneous (n = 877) and induced (n = 339) ventricular tachycardia were detected. A programmed onset ratio of 87% rejected sinus acceleration (98%) but caused underdetection of 0.5% of ventricular tachycardias. The onset criterion permitted inappropriate detection of premature ventricular complexes during sinus tachycardia, but the new criterion reduced these inappropriate detections by 98%. CONCLUSIONS The PCD's onset and stability criteria reduced inappropriate detection of atrial fibrillation and sinus acceleration while detecting 99.5% of ventricular tachycardias.
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Affiliation(s)
- C D Swerdlow
- Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California
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9
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Sudden death in Cork and Kerry - results of a one year survey and a review of the literature. Ir J Med Sci 1994. [DOI: 10.1007/bf02943008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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10
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Brodsky MA, Orlov MV, Winters RJ, Allen BJ. Determinants of inducible ventricular tachycardia in patients with clinical ventricular tachyarrhythmia and no apparent structural heart disease. Am Heart J 1993; 126:1113-20. [PMID: 8237753 DOI: 10.1016/0002-8703(93)90662-s] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Thirty-seven patients with symptomatic ventricular tachyarrhythmia and no apparent structural heart disease were evaluated with multiple cardiovascular tests to establish the relationship between the results of programmed electric stimulation and other clinical and arrhythmia variables. Of 37 patients, 12 (32%) had inducible sustained ventricular tachycardia. Factors associated with the results of programmed electric stimulation included a history of ventricular tachycardia > or = 30 seconds requiring intervention for termination and global right heart abnormality documented by echocardiography. During treatment for a mean follow-up of 50 months, 29 patients did well, 6 patients had recurrences of major arrhythmia symptoms, 1 was lost to follow-up and 1 had a noncardiac death. Those patients with an adverse outcome were more likely to have inducible ventricular tachycardia. Thus certain clinical and echocardiographic data are associated with the results of programmed electric stimulation, which in turn have important prognostic value in this group of patients. Sustained ventricular tachycardia is unlikely to be induced in patients with no evidence of structural heart disease and clinical nonsustained ventricular tachycardia.
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Affiliation(s)
- M A Brodsky
- University of California, Irvine Medical Center, Orange 92668
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Callans DJ, Josephson ME. Future developments in implantable cardioverter defibrillators: the optimal device. Prog Cardiovasc Dis 1993; 36:227-44. [PMID: 8234776 DOI: 10.1016/0033-0620(93)90016-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Despite recent therapeutic advances, SCD remains the leading cause of mortality in industralized nations. The most frequent cause of SCD is ventricular tachyarrhythmias in the setting of advanced structural heart disease due to chronic coronary heart disease or idiopathic dilated cardiomyopathy. Although high-risk groups can be prospectively identified, attempts at primary prevention have been largely unsuccessful. Effective treatment strategies for SCD survivors include antiarrhythmic drug therapy guided by programmed stimulation, endocardial resection, and ICDs. Device therapy has proven extremely effective in preventing recurrent sudden death from ventricular tachyarrhythmias. Widespread application of ICD therapy, perhaps even to include members of high-risk populations that have not experienced cardiac arrest, will depend on many factors including the demonstration that device therapy improves total mortality, not just arrhythmia-related mortality, reduction in cost, and improvements in the devices themselves. Some of the important characteristics of the optimal ICD of the future are nonthoracotomy lead placement; subpectoral generator placement; multiprogrammable, tiered therapy; improved diagnostic specificity, whether based on electrogram or hemodynamic-sensing algorithms; improved integration of brady- and tachy-sensing systems; and enhanced electrogram storage capability with trans-telephonic retrieval of electrogram recordings. The creation of this ideal ICD will obviously require continued technological advances; however, given the tremendous improvements realized over the first three generations of ICD systems, optimism for the future seems warranted.
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Affiliation(s)
- D J Callans
- Clinical Electrophysiology Laboratories, Hospital of the University of Pennsylvania, Philadelphia
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Abstract
Important data have recently been added to our understanding of sustained ventricular tachyarrhythmias occurring in the absence of demonstrable heart disease. Idiopathic ventricular tachycardia (VT) is usually of monomorphic configuration and can be classified according to its site of origin as either right monomorphic (70% of all idiopathic VTs) or left monomorphic VT. Several physiopathological types of monomorphic VT can be presently individualized, according to their mode of presentation, their relationship to adrenergic stress, or their response to various drugs. The long-term prognosis is usually good. Idiopathic polymorphic VT is a much rarer type of arrhythmia with a less favorable prognosis. Idiopathic ventricular fibrillation may represent an underestimated cause of sudden cardiac death in ostensibly healty patients. A high incidence of inducibility of sustained polymorphic VT with programmed ventricular stimulation has been found by our group, but not by others. Long-term prognosis on Class IA antiarrhythmic medications that are highly effective at electrophysiologic study appears excellent.
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Affiliation(s)
- B Belhassen
- Department of Cardiology, Tel Aviv-Elias Sourasky Medical Center, Israel
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Sager PT, Perlmutter RA, Rosenfeld LE, Batsford WP. Determinants of the hemodynamic consequence to sustained ventricular arrhythmias after a single myocardial infarction. Am Heart J 1992; 124:1484-91. [PMID: 1462903 DOI: 10.1016/0002-8703(92)90061-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Patients who have sustained ventricular arrhythmias after myocardial infarction present with either a cardiac arrest or with hemodynamically stable sustained ventricular tachycardia. Recent reports have suggested a different electrophysiologic milieu in these two patient groups and a higher incidence of cardiac arrest in patients with a history of more than one myocardial infarction. No studies have examined patients with only a single previous myocardial infarction. To assess the determinants of the hemodynamic consequence of sustained ventricular arrhythmias more than 3 days after a single myocardial infarction, 82 patients who were resuscitated from arrhythmic cardiac arrest (CA group, 40 patients) or who had hemodynamically stable sustained ventricular tachycardia (No CA group, 42 patients) were examined. Patients in both groups had similar global left ventricular ejection fractions (mean +/- SD; 30% +/- 12% vs 27% +/- 12%; p = NS), proportion of patients with anterior wall infarctions as compared with the proportion of patients with inferior wall infarctions (55% vs 50%; p = NS), time from infarction to arrhythmia development, severity of coronary artery disease, and the proportion of patients with congestive heart failure or bundle branch block. Patients who presented without cardiac arrest, however, more frequently had left ventricular aneurysms (58% vs 28%; p = 0.005). Sixty-seven patients underwent baseline drug-free electrophysiologic studies. Sustained ventricular tachycardia was induced in 79% of patients in the CA group and 85% of patients in the No CA group (p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P T Sager
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn
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Sager PT, Perlmutter RA, Rosenfeld LE, Batsford WP. Antiarrhythmic drug exacerbation of ventricular tachycardia inducibility during electrophysiologic study. Am Heart J 1992; 123:926-33. [PMID: 1550002 DOI: 10.1016/0002-8703(92)90698-u] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Most studies examining antiarrhythmic drug exacerbation of ventricular arrhythmias have been performed in patients in whom clinical proarrhythmia developed. The clinical significance and predictors of antiarrhythmic drug exacerbation of inducible ventricular arrhythmias during electrophysiologic study have received less attention. Accordingly, a consecutive number of patients undergoing electrophysiologic study for evaluation of ventricular arrhythmias (but who had no history of clinical proarrhythmia) were prospectively examined. Drug-induced exacerbation was defined as no inducible ventricular tachycardia in the baseline drug-free state that increased to inducible nonsustained or sustained ventricular tachycardia, or inducible nonsustained ventricular tachycardia at baseline that increased to inducible sustained ventricular tachycardia. After administration of primarily type IA antiarrhythmic agents (procainamide and quinidine in 97% of the patients), patients were considered drug test negative (n = 80) when they had no increase in inducible ventricular tachycardia, and patients were considered drug test positive (n = 16) when they had exacerbation of inducible arrhythmias. The drug test-positive group's clinical characteristics differed markedly from those of the drug test-negative group. Compared with the drug test-negative group, the drug test-positive group had reduced (less than 40%) left ventricular ejection fractions (80% vs 39%, p = 0.005) and higher prevalences of myocardial infarctions (81% vs 35%, p = 0.027), left ventricular aneurysms (27% vs 5%, p = 0.026), and bundle branch blocks (53% vs 16%, p = 0.005). Thus exacerbation of ventricular tachycardia induction after antiarrhythmic agent administration was most common in patients with significant organic heart disease. The drug test-positive group was more frequently treated with antiarrhythmic therapy than was the drug test-negative group.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P T Sager
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn
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Abstract
Coronary artery disease is the leading cause of death in the United States. Approximately half of the deaths attributable to coronary artery disease are sudden cardiac deaths. A logical approach to prevention of sudden death is to identify those who are at risk and then to initiate effective therapy. Left ventricular dysfunction, frequent ventricular ectopic activity, nonsustained ventricular tachycardia, and late potentials have been identified as markers for increased risk of sudden cardiac death. The sensitivity and specificity of these risk factors vary, and the positive predictive power is less than satisfactory. The value of invasive electrophysiologic testing for risk stratification in the general postinfarction patient population remains unclear. In addition to these diagnostic difficulties, prevention of sudden death also has been limited by imperfect efficacy and potential lethal effects of the currently available antiarrhythmic agents. Automatic implantable defibrillators are effective for aborting sudden death; however, the potential for more general use of automatic defibrillators in asymptomatic but high-risk postinfarction patients has not been evaluated.
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MESH Headings
- Adult
- Arrhythmias, Cardiac/complications
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/therapy
- Clinical Protocols
- Coronary Disease/complications
- Coronary Disease/physiopathology
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Electrocardiography
- Humans
- Myocardial Infarction/complications
- Myocardial Infarction/physiopathology
- Risk Factors
- Stroke Volume
- Ventricular Function, Left
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Affiliation(s)
- W K Shen
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN 55905
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Abstract
A review of the literature dealing with sudden death revealed 19 articles in which ostensibly healthy patients with documented VF unrelated to any known cardiac or noncardiac etiology are reported. Fifty-four patients fulfilling the criteria for idiopathic VF, including 14 patients investigated at our institution, are described. The mean age of patients for studies that reported age data was 36 years, with a male-to-female ratio of 2.5 to 1. Over 90% of the patients required resuscitation, while syncope due to nonsustained VF occurred in the rest. Diagnosis of VF was preceded by syncope in one fourth of the patients. Holter monitoring and exercise stress tests were often unrewarding. Available electrophysiologic data revealed a 69% inducibility rate of sustained ventricular tachyarrhythmias using nonaggressive protocols of ventricular stimulation in most cases. Induced tachyarrhythmias were poorly tolerated, and were mostly of polymorphic configuration. Class IA antiarrhythmic agents were highly effective in preventing reinduction of these arrhythmias. Available figures suggest an 11% rate of sudden death within 1 year of diagnosis. Appropriate antiarrhythmic therapy appears to improve prognosis. Reviewed data suggest that idiopathic VF represents an underestimated cause of sudden cardiac death in ostensibly healthy patients. An international registry of patients with idiopathic VF is warranted.
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Affiliation(s)
- S Viskin
- Department of Medicine, Tel-Aviv Medical Center, Ichilov Hospital, Israel
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Affiliation(s)
- J P DiMarco
- Department of Medicine, University of Virginia School of Medicine, Charlottesville
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Belhassen B, Shapira I, Sheps D, Laniado S. Programmed ventricular stimulation using up to two extrastimuli and repetition of double extrastimulation for induction of ventricular tachycardia: a new highly sensitive and specific protocol. Am J Cardiol 1990; 65:615-22. [PMID: 2309631 DOI: 10.1016/0002-9149(90)91040-d] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The sensitivity and specificity of a new protocol of programmed ventricular stimulation were evaluated in 71 consecutive patients who were divided into 2 groups: group 1 included 41 patients, of whom 25 had sustained ventricular tachycardia (VT) not associated with cardiac arrest and 16 had ventricular fibrillation (VF) not precipitated by any obvious factor; group 2 included 30 patients without demonstrable heart disease and no suspected or documented sustained ventricular tachyarrhythmias. The study consisted of a standard protocol (up to 2 extrastimuli given only once for each extrastimulus prematurity, 2 right ventricular sites and 3 basic pacing cycle lengths, as well as rapid ventricular pacing) in which double extrastimulation at the shortest coupling intervals that allowed ventricular capture was repeated 10 times. A stimulus current of 3 mA was used. Sustained ventricular tachyarrhythmias were induced in 23 of 25 (92%) patients who presented with sustained VT, 14 of 16 (88%) patients who presented with VF and 2 of 30 (7%) group 2 patients. Eighteen of 25 (72%) patients with sustained VT but only 4 of 16 (25%) with VF had arrhythmias inducible at "immediate" trials of single or double extrastimulation (p less than 0.01). Repetition of double extrastimulation increased the yield of inducible sustained ventricular tachyarrhythmia to 92% in patients with sustained VT (+20%, p = 0.14) and 75% (+50%, p = 0.013) in patients with VF. Rapid right ventricular pacing added a 13% increase in the overall yield in patients with VF. This new protocol of programmed ventricular stimulation has both high sensitivity (90%) and specificity (93%) for induction of sustained VT.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- B Belhassen
- Department of Cardiology, Tel-Aviv Medical Center, Ichilov Hospital, Israel
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Greene HL. Sudden arrhythmic cardiac death--mechanisms, resuscitation and classification: the Seattle perspective. Am J Cardiol 1990; 65:4B-12B. [PMID: 2404396 DOI: 10.1016/0002-9149(90)91285-e] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Ventricular fibrillation (VF) is the first recorded arrhythmia in 75% of patients who have a sudden cardiovascular collapse. Rarely (1%) does sustained ventricular tachycardia (VT) alone cause collapse and unconsciousness. Whether all VF begins as VT is unknown. Early application of cardiopulmonary resuscitation and rapid defibrillation are essential to ensure survival and satisfactory neurologic recovery. During the last 2 years in Seattle, the initial resuscitation rate for VF was 269 of 447 patients (60%), with 114 of 447 patients (26%) surviving long-term. Survivors of VF have a high overall risk of recurrent VF, with many univariate risk factors identified: evidence of poor left ventricular function (history of congestive heart failure, prior myocardial infarction [MI] or low ejection fraction), extensive coronary artery disease, absence of a new MI (either Q wave or non-Q wave) with VF, male gender, advanced age, complex or high-frequency ventricular ectopy on Holter recording, inducibility at electrophysiologic study, exercise-induced angina or hypotension, and smoking. Classification of cardiac deaths as arrhythmic or nonarrhythmic is important in interpreting the therapeutic response. However, because many patients have chronic symptoms, timing of the onset of a new event is difficult. Furthermore, accurate timing of an event does not guarantee correct classification. Sudden death is not necessarily arrhythmic, nor is all arrhythmic death sudden. Total cardiac mortality may be a simpler and more relevant end point to measure the overall effect of antiarrhythmic therapy.
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Affiliation(s)
- H L Greene
- Department of Medicine, Harborview Medical Center, Seattle, Washington 98104
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Holmes DR, Davis K, Gersh BJ, Mock MB, Pettinger MB. Risk factor profiles of patients with sudden cardiac death and death from other cardiac causes: a report from the Coronary Artery Surgery Study (CASS). J Am Coll Cardiol 1989; 13:524-30. [PMID: 2918155 DOI: 10.1016/0735-1097(89)90587-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Identification of patients at risk of sudden death is essential if optimal preventive treatment strategies are to be developed. In the Coronary Artery Surgery Study (CASS) Registry, 19,946 patients were analyzed to characterize baseline clinical, hemodynamic and angiographic features of patients dying from sudden cardiac death and to compare them with features of patients dying from other cardiac causes, of those dying from noncardiac causes and of survivors. Of the 11,843 medically treated patients, 1,621 died during a mean follow-up period of 5.0 years: death was sudden in 557 (34%), nonsudden but cardiac in 813 (50%) and noncardiac in 251 (16%). In 8,103 surgically treated patients, 824 deaths occurred during a mean follow-up period of 5.1 years: death was sudden in 204 (25%), nonsudden but cardiac in 390 (47%) and noncardiac in 230 (28%). In general, the patients (both medically and surgically treated) who died of cardiac causes, either suddenly or nonsuddenly, were similar to each other but significantly different from patients who either survived or died of noncardiac causes. Although patients with an increased risk of any type of cardiac death could be identified, there were no measures of angiographic or hemodynamic characteristics that were significantly different between patients with sudden cardiac death and those with nonsudden cardiac death. Identification of patients at high risk for sudden cardiac death will require approaches in addition to clinical, angiographic and hemodynamic assessment, such as electrophysiologic assessment or monitoring techniques to identify triggering mechanisms.
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Affiliation(s)
- D R Holmes
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905
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Stevenson WG, Stevenson LW, Weiss J, Tillisch JH. Inducible ventricular arrhythmias and sudden death during vasodilator therapy of severe heart failure. Am Heart J 1988; 116:1447-54. [PMID: 3195428 DOI: 10.1016/0002-8703(88)90727-2] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Sudden death is common in patients with severe heart failure, but antiarrhythmic drug therapy has potential risks as well as benefits. Programmed electrical stimulation may offer a means of identifying lower risk patients who are less likely to benefit from antiarrhythmic therapy and who could potentially be spared the risk of adverse drug effects. Therefore 72 consecutive patients referred for management of severe heart failure (left ventricular ejection fraction 0.18 +/- 0.06) were studied. The mean age was 47 +/- 12 years; 45 (61%) patients had idiopathic dilated cardiomyopathy and 24 (33%) had coronary artery disease. Fifty-eight (82%) patients had nonsustained ventricular tachycardia. Following adjustment of vasodilators and diuretics, programmed stimulation was performed from the right ventricular apex with one, two, and three extrastimuli. Sustained ventricular tachycardia was initiated in nine (13%) patients and all received chronic antiarrhythmic drug therapy. During follow-up of 176 +/- 187 days, 1 of 13 patients treated for inducible ventricular tachycardia and 13 of 63 noninducible patients died suddenly (p = 0.20). The actuarial risk of sudden death in the noninducible patients was 13% at 6 weeks and 30% at 6 months. The only independent predictors of sudden death were pulmonary artery systolic pressure greater than 55% mm Hg and a pulmonary capillary wedge pressure with vasodilator therapy greater than 16 mm Hg. Of the 63 noninducible patients, 11 (17%) received long-term antiarrhythmic agents due to atrial fibrillation or referring physician preference, and antiarrhythmic therapy was not associated with a lower risk of sudden death in these patients.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- W G Stevenson
- Department of Medicine, UCLA School of Medicine 90024
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Freedman RA, Swerdlow CD, Soderholm-Difatte V, Mason JW. Clinical predictors of arrhythmia inducibility in survivors of cardiac arrest: importance of gender and prior myocardial infarction. J Am Coll Cardiol 1988; 12:973-8. [PMID: 3417994 DOI: 10.1016/0735-1097(88)90463-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Clinical characteristics that correlate with arrhythmia inducibility were determined in 150 consecutive survivors of cardiac arrest. All underwent electrophysiologic study with a uniform protocol when they were not receiving antiarrhythmic drugs. A ventricular tachyarrhythmia (sustained monomorphic ventricular tachycardia, ventricular fibrillation or nonsustained ventricular tachycardia) was induced in 113 patients (75%). The strongest correlates of inducing a tachyarrhythmia were male gender (p less than 0.0001) and a history of prior myocardial infarction (p less than 0.0001). Induction of sustained monomorphic tachycardia alone was also strongly related to gender and prior infarction; in particular, none of 26 women without prior infarction had induction of sustained monomorphic ventricular tachycardia. Among patients with induced sustained tachyarrhythmias, those with induced monomorphic ventricular tachycardia were distinguished from those with induced ventricular fibrillation in they were more likely to have coronary artery disease (p = 0.0001), healed myocardial infarction (p = 0.0002), left ventricular aneurysm (p = 0.0007) and ventricular tachycardia documented at the time of cardiac arrest (p = 0.02). Other variables showing significant correlations with arrhythmia inducibility were ejection fraction, documentation of ventricular tachycardia at the time of cardiac arrest and presence of an intraventricular conduction delay. However, stepwise logistic regression identified male gender and healed myocardial infarction as the only independent predictors of arrhythmia inducibility. On the basis of these two variables alone, arrhythmia inducibility or noninducibility could be correctly predicted in 89% of the patients in this series.
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Affiliation(s)
- R A Freedman
- Cardiology Division, University of Utah Medical Center, Salt Lake City 84132
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Affiliation(s)
- M H Schoenfeld
- Cardiac Electrophysiology and Pacer Laboratory, Hospital of Saint Raphael, New Haven, Connecticut 06511
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Sager PT, Batsford WP. Ventricular Arrhythmias: Medical Therapy, Device Treatment, and Indications for Electrophysiologic Study. Cardiol Clin 1988. [DOI: 10.1016/s0733-8651(18)30500-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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