Download Ventricular Stimulation After Myocardial Infarction

ARRHYTHMIAS
|
REVIEW
Ventricular Stimulation After Myocardial Infarction
Béatrice Brembilla-Perrot
Department of Cardiology, University Hospital of Brabois, Vandoeuvre, France
Received 5/7/2011, Reviewed 13/7/2011, Accepted 18/7/2011
Key words: myocardial infarction, ventricular stimulation
DOI:10.5083/ejcm.20424884.51
SUMMARY
CORRESPONDENCE
Ventricular stimulation after myocardial infarction (MI) is still recommended (class IB) in patients
with syncope and left ventricular ejection fraction (LVEF) more than 30-35%, in asymptomatic
patients with a LVEF between 30-40% and with non sustained ventricular tachycardia (VT) patients
at Holter monitoring. It can also identify patients at high risk of arrhythmic events in the early postMI period. Combined with imaging methods PVS could be widely used again during VT ablation.
B. Brembilla-Perrot
From 1982 to 1995, programmed ventricular stimulation (PVS) was a major technique of screening
patients at risk for ventricular tachycardia (VT) and
VT–related sudden death (1-3). During this time PVS
was not considered advantageous for risk stratification in coronary heart disease since implantable cardioverter defibrillators (ICD): a number of landmark
trials have shown a benefit of prophylactic ICD implantation in patients with only low left ventricular
ejection fraction (LVEF) (4,5). Now, the guidelines
recommend the systematic implantation of ICD in
patients with history of myocardial infarction (MI)
(more than 6 weeks) and LVEF lower than 30% (6).
However, proarrhythmic effect of ICD and other
complications were reported (7-9). More, inducible
VT remains an important and independent factor of
cardiac mortality (10).
Yet, often PVS is still used after the implantation of
ICD mainly for VT ablation. PVS remains a reliable
method of screening the risk of sudden death in
ischemic heart disease with LVEF more than 30%.
1) What are we awaiting from PVS?
PVS is used to induce a monomorphic VT indicating the possible presence of a reentrant circuit and
a risk of VT.
There are two indications of PVS:
- The main benefit is the diagnosis and the evaluation of the mechanism of a wide QRS tachycardia
or the diagnosis of symptoms of tachycardia. The
method remains always essential (11).
- The second benefit which is actually debated is the
risk stratification of patients with MI: the method
is useful to predict a risk of VT (1-3), but is not considered to be beneficial to predict a risk of sudden
death; sudden death has multiple origins as VT degenerating into ventricular fibrillation (VF) (20 to
30%), asystole associated or not to a complete atrioventricular block (25%) or primary VF.
34
2) The protocol is well-codified:
Complete electrophysiological study is recommended, including a right atrial pacing. Then
stimulation of right ventricle with 1 and 2 extrastimulus is performed at two cycles in right
ventricular apex and then in the infundibulum. If
VT is not induced a third extrastimulus is added
in both sites. The increasing number of extrastimuli increases the sensitivity, but decreases
the specificity with a risk of induction of a nonspecific arrhythmia as VF.
Cardiology –
University Hospital of Brabois,
54500 Vandoeuvre
Les Nancy
Tel: 00 333 83 15 32 56
Fax: 00 333 83 15 42 26
E-mail : b.brembilla-perrot@
chu-nancy.fr
A short coupling lower than 200 ms is also associated with a risk of VF induction.
PVS should be repeated after isoproterenol infusion in the case of stress of exercise-related syncope or tachycardia.
3) The results are well-known after MI:
The sensitivity of PVS in patients with spontaneous VT is excellent (90%) (11).
In asymptomatic patients, the induction of a
monomorphic sustained VT is always pathological and associated with a risk of VT-related sudden death and spontaneous VT (1-3); only ICD
implantation decreases the risk of sudden death
in these patients (4). The interest of the method
was debated after the Multicenter Automatic
Defibrillator Implantation Trial II (MADIT) (8),
where low LVEF, less than 30 % was only used for
the indication of ICD with a significant decrease
of sudden deaths.
ISSN 2042-4884
EUROPEAN JOURNAL OF CARDIOVASCULAR MEDICINE
VOL I ISSUE IV
VENTRICULAR STIMULATION AFTER MYOCARDIAL INFARCTION
The induction of a ventricular flutter (monomorphic VT with a rate
higher than 270 bpm) occurring in 10 % of asymptomatic patients
with MI is more controversial and is considered as pathological only
in MADIT I study (4).
The induction of a polymorphic VT (VF) is without significance except after resuscitated sudden death (1-3).
Several studies have reported the good prognosis of patients with
negative PVS (1-3, 10) except in a sub study of MADIT II study: patients with negative study had more VF than those with inducible
VF (12).
In conclusion, although PVS is now less frequently indicated after
MI than 10 years ago, it is still recommended (IB) in patients with
syncope and LVEF more than 30-35% or in asymptomatic patients
with a LVEF between 30-40% and with non sustained VT at Holter
monitoring. Combined with imaging methods, PVS could be widely
used again during VT ablation. Patients could benefit from PVS to
better risk-identify patients who may be at high risk of VT or arrhythmic events in the early post-MI period.
REFERENCES
1
Breithardt G, Borggrefe M, Hierten K. Ventricular late potentials and
inducible ventricular tachyarrhythmias as a marker for ventricular
tachycardia after myocardial infarction. Eur Heart J 1986; 7 (suppl A)
127-134
2
Denniss AR, Richards DA, Cody DV et al. Prognostic significance of
ventricular tachycardia and fibrillation induced at programmed
stimulation and delayed potentials detected on the signal-averaged
electrocardiogram of survivors of acute myocardial infarction.
Circulation 1986; 1074: 737-45
3
Brembilla-Perrot B, Terrier de la Chaise A, Briancon S et al.
Programmed ventricular stimulation in survivors of acute infarction:
long term follow-up. Int J Cardiol 1995; 49: 55-65
4
Moss AJ, Hall J, Cannom DS et al for the Multicenter autonomic
fibrillation trial investigators. Improved survival with an implanted
defibrillator in patients with coronary disease at high risk for
ventricular arrhythmia. New Engl J Med 1996; 335: 1933-4
5
Moss AJ, Zareba W, Hall J et al for the Multicenter Automatic
Defibrillator Implantation. Trial II Investigators. Prophylactic
implantation of a defibrillator in patients with myocardial infarction
and reduced ejection fraction. N Engl J Med 2002; 346: 877-83
6
Furthermore, PVS performed soon after MI (day 9) identify individuals at risk or not (17, 18). The same group reported recently the role
of PVS to identify the high–risk patients for ICD implantation, where
PVS was used post-MI. The patient group had a LVEF less than 40%
early post MI and underwent primary percutaneous coronary intervention for ST elevation MI. The prospective study of early ICD
implantation 6 to 40 days post-MI (Defibrillator in Acute Myocardial
Infarction Trial, DINAMIT) (19) and a retrospective analysis of data
from the MADIT II trial (12) failed to show a survival benefit for patients with ICD implantation in the early post-MI period. The recent
studies suggest that patients may benefit from an ICD if they have
an inducible ventricular tachyarrhythmia in the early post MI period. A large majority (two thirds) of patients with a negative PVS
were at significantly lower risk of arrhythmic events without a defibrillator in the long term.
Zipes DP, A. Camm, J, Borggrefe M et al. 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) Developed in collaboration
with the European Heart Rhythm Association and the Heart Rhythm
Society. Eur Heart J 2006; 27: 2099-140
7
Arya A, Haghjoo M, Dehghani R et al. Prevalence and predictors
of electrical storm in patients with implantable cardioverterdefibrillator. Am J Cardiol 2006; 97: 389-92
8
Reynolds MR, Cohen DJ, Kugelmass AD et al. The frequency and
incremental cost of major complications among medicare
beneficiaries receiving implantable cardioverter-defibrillators. J Am
Coll Cardiol 2006; 47: 2493-7
9
At least PVS is indicated before VT ablation and the latter indication is now raising either in patients with spontaneous VT and LVEF
more than 35/40 % or in patients with VT and before ICD implantation (VTACH) to reduce the recurrences (20). PVS is combined with
imaging methods.
Germano JJ, Reynolds M, Essebag V, Josephson ME. Frequency and
causes of implantable cardioverter-defibrillator therapies: is device
therapy proarrhythmic? Am J Cardiol 2006; 97: 1255-61
10
Buxton A E, Lee KL, Hafley GE et al for the MUSTT investigators.
Relation of ejection fraction and inducible ventricular tachycardia to
mode of death in patients with coronary artery disease. An analysis
of patients enrolled in the Multicenter Unsustained Tachycardia Trial.
Circulation 2002; 106: 2466-72
4) Actual and future indications of PVS after MI:
The assessment of cardiac syncope occurring in a patient with LVEF
higher than 30/35% is a class IB recommendation (13) even when a
possible aetiology is suspected: this cause may hide another. Complete electrophysiological study might be indicated in patient with
MI, syncope and LVEF lower than 30% when ICD implantation can
be discussed in the case of advanced age or poor general condition
to find another cause of syncope as supraventricular tachycardia or
conduction disorder.
PVS is used for the risk stratification after MI in the case of LVEF between 40% and 30/35 % when nonsustained VT is noted at Holter
monitoring (MADIT I) (IB recommendation) (6).
We have to remember the limits of the prognostic value of LVEF (14, 15)
with a higher risk of sudden death in patients with LVEF higher than
30% and another risk factor than in patients with only a LVEF lower
than 30 % and no other risk factor.
The sub analysis of the Multicenter Unsustained Tachycardia Trial
(MUSTT) (10) and MADIT 2 studies (12) reports more VT in patients
with inducible VT. The prognosis is worse in patients studied in the
first 6 months and inducible VT in MUSTT study (16).
EUROPEAN JOURNAL OF CARDIOVASCULAR MEDICINE
VOL I ISSUE IV
35
HEALTHCARE BULLETIN
|
ARRHYTHMIAS
REFERENCES (Continued)
11
Livelli FD, Bigger J Th, Reifel JA et al. Response to programmed
ventricular stimulation: sensitivity, specificity and relation to heart
disease. Am J Cardiol 1982; 50: 452-458
12
Daubert JP, Zareba W, Hall WJ et al. MADIT II Study Investigators.
Predictive value of ventricular arrhythmia inducibility for subsequent
ventricular tachycardia or ventricular fibrillation in Multicenter
Automatic Defibrillator Implantation Trial (MADIT) II patients.
J Am Coll Cardiol 2006; 47: 108-11
13
Moya A, Sutton R, Ammirati F et al; Developed in collaboration with,
European Heart Rhythm Association (EHRA); Heart Failure Association
(HFA); and Heart Rhythm Society (HRS); Guidelines for the diagnosis
and management of syncope (version 2009): The Task Force for the
Diagnosis and Management of Syncope of the European Society of
Cardiology (ESC). Eur Heart J. 2009; 30: 2631-71
14
Buxton A E, Lee KL, Hafley GE, Pires LA et al. Limitations of ejection
fraction for prediction of sudden death risk in patients with coronary
artery disease. J Am Coll Cardiol 2007; 50: 1150-7
15
Tung R, Zimmerbaum P, Josephson M. A critical appraisal of
implantable cardioverter-defibrillator therapy for the prevention of
sudden cardiac death. J Am Coll Cardiol 2008; 52: 1111-21
16
Al-Khatib SM, Hafley G, Lee KL, Buxton AE. Relation between time
from myocardial infarction to enrolment and patient outcomes in the
Multicenter UnSustained Tachycardia Trial. Europace 2010;12: 1112-8.
17
Zaman S, Sivagangabalan G, Narayan A, Thiagalingam A, Ross DL,
Kovoor P. Outcomes of early risk stratification and targeted
implantable cardioverter-defibrillator implantation after ST-elevation
myocardial infarction treated with primary percutaneous coronary
intervention. Circulation 2009; 120: 194-200.
18
Kumar S, Sivagangabalan G, Zaman S et al. Electrophysiologyguided defibrillator implantation early after ST-elevation myocardial
infarction. Heart Rhythm 2011; 7: 1589-97.
19
Dorian P, Hohnloser SH, Thorpe KE et al. Mechanisms underlying
the lack of effect of implantable cardioverter-defibrillator therapy
on mortality in high-risk patients with recent myocardial infarction:
insights from the Defibrillation in Acute Myocardial Infarction Trial
(DINAMIT). Circulation 2010; 122: 2645-52.
20
Kuck KH, Schaumann A, Eckardt L et al; VTACH study group.
Catheter ablation of stable ventricular tachycardia before defibrillator
implantation in patients with coronary heart disease (VTACH):
a multicentre randomised controlled trial. Lancet 2010; 375: 31-40.
36
EUROPEAN JOURNAL OF CARDIOVASCULAR MEDICINE
VOL I ISSUE IV