Outcomes of Early Risk Stratification and Targeted Implantable Cardioverter-Defibrillator Implantation After ST-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

Zaman, Sarah; Sivagangabalan, Gopal; Narayan, Arun; Thiagalingam, Aravinda; Ross, David L.; Kovoor, Pramesh

doi:10.1161/circulationaha.108.836791

Cited by 73 publications

(61 citation statements)

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“…According to hospital protocol, patients with LVEF ≤40% were eligible for EPS as a risk-stratification test to identify patients at risk of SCD. Previous research conducted at our institution analyzing the predictive value of EPS after STEMI had prospectively recruited patients from 1999 to 2008, 17,18 with ≈40% of these patients included in the present study. In the present study, patients were included if they had an EPS performed with LVEF ≤30% (irrespective of the presence of HF) or an EPS performed with LVEF 31% to 35% (only if HF New York Heart Association class II or III was also present).…”

Section: Methodsmentioning

confidence: 99%

“…The predictive value of this approach has been discussed in detail previously. [17][18][19][20][21][22] Predischarge ICD implantation was recommended for EPS-positive patients. EPS-negative patients were discharged without an ICD and according to study protocol did not undergo ICD implantation >40 days after MI irrespective of persistent LV dysfunction.…”

Section: Electrophysiological Studymentioning

confidence: 99%

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Long-Term Arrhythmia-Free Survival in Patients With Severe Left Ventricular Dysfunction and No Inducible Ventricular Tachycardia After Myocardial Infarction

et al. 2014

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I mpaired left ventricular ejection fraction (LVEF) is one of the strongest predictors of death or arrhythmia postmyocardial infarction (MI). Randomized trials have demonstrated that post-MI patients with impaired LVEF derive a mortality benefit with implantation of a prophylactic implantable cardioverter-defibrillator (ICD) for prevention of sudden cardiac death (SCD).1,2 This mortality benefit is seen only in the chronic stage, with no randomized trial yet showing a benefit of early post-MI (within 40 days) ICD implantation.3,4 Current guidelines therefore limit prophylactic ICDs to patients who are >40 days post-MI with either LVEF ≤30% or LVEF ≤35% in the presence of New York Heart Association class II/III heart failure (HF).5 However, this risk-stratification method for prevention of SCD is limited by the poor specificity of impaired LVEF for arrhythmic versus nonarrhythmic cardiac death. 6 In addition, although the rate of SCD has declined in the era of early revascularization for MI, it remains concerningly elevated in the first 40 days.7-9 Inducible ventricular tachycardia (VT) at electrophysiological study (EPS) demonstrates the presence of a substrate for reentrant tachyarrhythmia and consistently predicts arrhythmia in observational and randomized studies. [10][11][12][13][14][15][16] The potential utility of EPS to guide early ICD implantation after MI has been demonstrated. 17,18Background-A negative electrophysiology study (EPS) may delineate a subgroup of patients with severely impaired left ventricular ejection fraction (LVEF) whose care can be safely managed long-term without an implantable cardioverter-defibrillator. Methods and Results-Consecutive patients treated with primary percutaneous coronary intervention for ST-segmentelevation myocardial infarction underwent early (median 4 days) LVEF assessment. Patients with LVEF ≤40% underwent EPS. A prophylactic implantable cardioverter-defibrillator was implanted for a positive (inducible monomorphic ventricular tachycardia) but not a negative (no inducible ventricular tachycardia or inducible ventricular fibrillation/ flutter) EPS result. Patients who would have become eligible for a late primary prevention implantable cardioverterdefibrillator with LVEF ≤30% or ≤35% with New York Heart Association class II/III heart failure were included and analyzed according to EPS result. Patients with LVEF >40%, ineligible for EPS, were followed up as control subjects (n=1286). The primary end point was survival free of death or arrhythmia (resuscitated cardiac arrest or sustained ventricular tachycardia/ventricular fibrillation). EPS performed in 128 patients with LVEF ≤30% or with LVEF ≤35% and heart failure was negative in 63% (n=80) and positive in 37% (n=48). Implantable-cardioverter defibrillators were implanted in <0.1%, 4%, and 90% of control, EPS-negative, and EPS-positive patients, respectively. The distribution of time to death or arrhythmia was comparable in control patients and EPS-negative patients with LVEF ≤30% or with LVEF ≤35% and heart fai...

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Section: Methodsmentioning

confidence: 99%

Section: Electrophysiological Studymentioning

confidence: 99%

Long-Term Arrhythmia-Free Survival in Patients With Severe Left Ventricular Dysfunction and No Inducible Ventricular Tachycardia After Myocardial Infarction

et al. 2014

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“…15 EPS has also been assessed in 2 large, multicenter, contemporary studies, both performed within the subacute time after MI. The Alternans Before Cardioverter Defibrillator (ABCD) trial enrolled patients with ischemic cardiomyopathy and demonstrated that EPS significantly predicted the arrhythmic Randomized ICD trials: survival benefit in patients with LVEF ≤30% (5.6% absolute mortality reduction) 16 Electrophysiology study Randomized ICD trial: nonsignificant survival benefit 27 Observational ICD studies: positive EPS predicts arrhythmia; 28,29 negative EPS predicts survival without an ICD 29 Randomized ICD trials: survival benefit in EPS-positive patients (combined with LVEF; 23% and 31% absolute mortality reduction) 14,15 Microvolt T-wave alternans No randomized trials Observational study: nonpredictive of arrhythmic death 48 No randomized trials Observational studies: predictive of arrhythmic death [48][49][50] Autonomic dysfunction: HRV or resting tachycardia Randomized ICD trials: no survival benefit (combined with LVEF) 12,17 Observational studies: predictive of arrhythmic death 51 No randomized trials Observational studies: predictive of arrhythmic death [51][52][53][54] Signal-averaged ECG No randomized trials Observational study: nonpredictive of arrhythmic death 55 Randomized ICD trial: no survival benefit (combined with LVEF) 56 …”

Section: Electrophysiology Studymentioning

confidence: 99%

“…53 The utility of EPS to guide early ICD implantation has been assessed in 2 single-center observational studies. Zaman et al 29 and Kumar et al 28 recruited >1000 STEMI patients with EPS performed at a median of 9 days after MI in patients with LVEF ≤40%. Both studies demonstrated that patients with inducible VT at EPS had a high rate of spontaneous ventricular tachyarrhythmia, with a high proportion occurring within the first 40 days.…”

Section: Cmrmentioning

confidence: 99%

“…Randomizovaná studie s ICD: statisticky Randomizované studie s ICD: přínos z hlediska přežití nevýznamný přínos z hlediska přežití 27 u pacientů s pozitivní EPS (v kombinaci s EFLK; 23% a 31% Observační studie s ICD: pozitivní EPS predikuje absolutní snížení mortality) 14,15 arytmie; 28,29 negativní EPS predikuje přežití bez ICD 29 Alternans vlny T na úrovni Žádné randomizované studie Žádné randomizované studie mikrovoltů Observační studie: nepredikuje úmrtí na arytmie 48 Observační studie: predikuje úmrtí na arytmie [48][49][50] Autonomní dysfunkce: HRV Randomizované studie s ICD: žádný přínos z hlediska Žádné randomizované studie nebo klidová tachykardie přežití (v kombinaci EFLK) 12,17 Observační studie: predikuje úmrtí na arytmie [51][52][53][54] Observační studie: predikuje úmrtí na arytmie 51 Zprůměrovaný EKG Žádné randomizované studie Randomizovaná studie s ICD: bez přínosu z hlediska Observační studie: nepredikuje úmrtí na arytmie 55 přežití (v kombinaci s EFLK) 56 Šířka komplexu QRS Žádné randomizované studie Žádné randomizované studie Observační studie: nepredikuje úmrtí na arytmie 48 Observační studie: predikuje 57,58 a nepredikuje 59 úmrtí na arytmie Nesetrvalá KT Randomizované studie s ICD: bez přínosu z hlediska přežití Randomizované studie s ICD: přínos z hlediska přežití (v kombinaci s EFLK) 17 (v kombinaci s EFLK a pozitivní EPS) 15 Observační studie: predikuje úmrtí na arytmie 60 …”

Section: Metody Stratifi Kace Rizika V čAsné Primární Prevenci Nssunclassified

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Sudden Cardiac Death Early After Myocardial Infarction

2014

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The issue of SCD primary prevention early after MI remains unresolved. The focus is now firmly centered on the elucidation of risk stratification tests that effectively select patients at high risk of SCD who benefit from early ICD implantation. Zaman and Kovoor Primary Prevention of SCD Early After MI 2429A summary of major risk stratification tests currently used to identify patients at high risk of SCD is given in Table 2. LV DysfunctionImpaired LVEF, one of the most powerful predictors of survival, 64 has been shown to identify patients who derive a mortality benefit from an ICD when implanted predominantly in the remote period after MI. 16,65 However, there are major concerns with the use of LVEF alone as a risk stratifier to guide ICD implantation. One such concern is the low specificity of LVEF for selecting patients who experience arrhythmic versus nonarrhythmic death. In the MADIT II trial, the use of LVEF ≤30% alone to stratify patients for an ICD resulted in relatively small absolute improvement in mortality with low therapeutic efficiency (15-17 defibrillators per life saved). 66 Another concern is the sensitivity of LVEF, given that a large proportion of SCDs still occur in patients with preserved LV function. VALIANT demonstrated that, although the risk of SCD is greatest in patients with severe dysfunction (LVEF ≤30%), almost half of all sudden deaths occur in patients with a higher ejection fraction (LVEF, 31%-40%). 5 The use of LVEF as a risk stratification tool has been tested in the early post-MI stage in the DINAMIT and IRIS trials, which selected patients with LVEF ≤35% and ≤40%, respectively, and failed to show a benefit of early ICD implantation. 12,17 The major limitation with the use of an early LVEF cutoff is the phenomenon of myocardial stunning with variable and unpredictable recovery of LV function after MI. This is especially relevant in the contemporary era of primary PCI for STEMI. Of STEMI patients with LVEF ≤40% at day 3, 24% will improve to have an LVEF >40% at 6 months with a mean 6% relative improvement. 67 Hence, although LV function will invariably be incorporated into risk stratification models for the prevention of SCD, it is clear that other tests are required to adequately select high-risk patients early after MI. RV DysfunctionAlthough impaired LV function has been studied extensively as a predictor of mortality and arrhythmic death, RV dysfunction has been largely overlooked. We know from the VALIANT study that almost 50% of arrhythmic deaths occur in patients with a preserved LVEF.5 RV involvement in inferior MI has been shown to be a predictor of morbidity and mortality, with a higher rate of serious arrhythmias in patients with inferior MI and RV dysfunction. 68,69 In addition, RV dysfunction has been correlated with increased inducibility of VT at EPS. 70 Although there is no current evidence to support the role of early RV assessment to guide ICD implantation, these findings highlight the inadequacy of LVEF alone as a risk stratification tool for the prevention...

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European Heart Rhythm Association/Heart Failure Association joint consensus document on arrhythmias in heart failure, endorsed by the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society

Lip¹,

Heinzel²,

Gaïta³

et al. 2015

European J of Heart Fail

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Outcomes of Early Risk Stratification and Targeted Implantable Cardioverter-Defibrillator Implantation After ST-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

Abstract: Early ICD implantation limited to patients with inducible ventricular tachycardia enables a low overall mortality in patients with impaired LVEF after primary percutaneous coronary intervention for ST-elevation myocardial infarction.

Cited by 73 publications

References 43 publications

Long-Term Arrhythmia-Free Survival in Patients With Severe Left Ventricular Dysfunction and No Inducible Ventricular Tachycardia After Myocardial Infarction

Long-Term Arrhythmia-Free Survival in Patients With Severe Left Ventricular Dysfunction and No Inducible Ventricular Tachycardia After Myocardial Infarction

Sudden Cardiac Death Early After Myocardial Infarction

European Heart Rhythm Association/Heart Failure Association joint consensus document on arrhythmias in heart failure, endorsed by the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society

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