Download Role of ventricular ectopic activity in sudden death

40
JACC Vol. 6, No. I
July 1985:40
Editorial Comment
Role of Ventricular Ectopic
Activity in Sudden Death*
HEIN J. J. WELLENS, MD, FACC
Maastricht, The Netherlands
One of the challenges in cardiology today is the recognition
of patients at high risk for sudden cardiac death. Although
there is agreement on the importance of the degree of impairment of left ventricular function, debate continues on
the role of ventricular ectopic activity. Recently, attention
has been given to the induction of sustained ventricular
arrhythmias by programmed electrical stimulation of the
heart as an independent marker to identify survivors of myocardial infarction at high risk for sudden cardiac death.
Currently, there is no unanimous opinion on the value of
programmed electrical stimulation in these patients (1-7).
In this issue of the Journal, Spielman et al. (8) reported on
patients who had spontaneously occurring non sustained ventricular tachycardia in the presence of abnormal left ventricular function. They found a high incidence of inducible
ventricular tachycardia or fibrillation in the presence of left
ventricular wall motion abnormalities in these patients. From
that finding they conclude that: ". . . electrophysiologic
testing may allow further substratification of risk of sudden
cardiac death in high risk patients with nonsustained ventricular tachycardia. " I believe that further study is required
before this conclusion can be accepted. One cannot exclude
that the electrical induction of a sustained ventricular tachy*Editorials published in Journal of the American College of Cardiology
reflect the views of the author and do not necessarily represent the views
of JACC or the American College of Cardiology.
From the University of Limburg, Annadal Hospital, Maastricht, The
Netherlands.
Address for reprints: Hein J. J. Wellens, MD, University of Limburg,
Annadal Hospital, St. Annadall, Postbus 1918,6201 Bx, Maastricht, The
Netherlands.
© 1985 by the American College of Cardiology
cardia is related to abnormal wall motion as such, and that
the occurrence of nonsustained ventricular tachycardia is
entirely coincidental. This is, in fact, suggested by the authors when they say that: "the goal of electrophysiologic
testing ... is simply to expose a latent abnormality, not
reproduce a clinical arrhythmia"!
What is lacking, therefore, is a control group with similar
left ventricular functional impairment, but without spontaneously occurring non sustained ventricular tachycardia. Before accepting one of the three approaches listed in the final
paragraph of their article, Spielman et al. have to give us
information on such a control group so that one can decide
not only on the ethical or practical aspects of antiarrhythmic
drug treatment in these patients but also on its true value.
References
I. Richards DA, Cody DV, Denniss AR, Russell PA, Young AA, Uther
JB. Ventricular electrical instability: a predictor of death after myocardial infarction. Am J Cardiol 1983;51:75-80.
2. Hamer A, Vohra J, Hunt D, Siowman G. Prediction of sudden death
by electrophysiologic studies in high risk patients surviving acute myocardial infarction. Am J Cardiol 1982;50:223-9.
3. Denniss AR, C()(\y DV, Ho B, et al. Prognostic significance of inducible
ventricular tachycardia after myocardial infarction (abstr). J Am Coli
Cardiol 1984;3:610.
4. Marchlinski FR, Buxton AE, Waxman HL, Josephson ME. Identifying
patients at risk of sudden death after myocardial infarction: value of
the response to programmed stimulation, degree of ventricular ectopic
activity and severity of left ventricular dysfunction. Am J Cardiol
1983;52: 1190-6.
5. Roy D, Marchand E, Theroux P, et al. Reproducibility and significance
of ventricular arrhythmias induced after an acute myocardial infarction
(abstr). Circulation 1984;70(suppl 11):11-18.
6. Gonzalez R, Arriagada D, Corbalan R, et al. Programmed electrical
stimulation of the heart does not help to identify patients at high risk
post-myocardial infarction (abstr). Circulation I 984;70(suppl 11):11-19.
7. Brugada P, Waldecker B, Wellens H11. Characteristics of induced
ventricular arrhythmias in four subgroups of patients with myocardial
infarction (abstr). Circulation 1984;70(suppl II):II-29.
8. Spielman SR, Greenspan AM, Kay HR, et al. Electrophysiologic testing
in patients at high risk for sudden cardillc death. I. Nonsustained ventricular tachycardia and abnormal ventricular function. J Am Coll Cardiol 1985;6:31-9.
0735-1097/85/$3.30