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Ventricular tachycardia and sudden death after primary PCI-reperfusion therapy

Impact on primary prevention of sudden cardiac death

Ventrikuläre Tachykardie und plötzlicher Herztod nach primärer PCI-Reperfusionstherapie

Einfluss auf die Primärprävention des plötzlichen Herztods

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Abstract

Background

Current approaches to coronary artery disease (CAD) and acute myocardial infarction (MI) may not be well represented in most primary prevention trials of sudden cardiac death (SCD).

Methods

The contemporary and ongoing registry of the Rostock infarction network (Drip & Ship) represents a well-defined cohort of patients subjected to percutaneous coronary intervention (PCI) for ST-elevation infarction (STEMI) and served as the database for both candidates for an ICD for primary prevention of SCD and for sudden death (SCD) or ventricular tachycardia (VT) during follow-up.

Results

A total of 855 consecutive patients were treated with PCI for STEMI or NSTEMI in the region of Rostock (Germany) between 2001 and 2004. While all cause mortality was still 17.2%, the SCD rate was low at 1.3% during 728 ± 366 days of follow-up. Within that time 85 patients (9.9%) developed an indication for ICD therapy due to an impaired LV function (LVEF ≤ 35%) and heart failure. Univariate predictors of an ICD indication were delayed reperfusion (p = 0.001), a high creatine kinase (CK) max (p = 0.009), a persistent wide QRS complex (p = 0.001), previous cerebrovascular events (p = 0.033), and chronic renal failure (p = 0. 001). However, only 16.5% of these patients qualifying for an ICD actually received an ICD; nevertheless, the actual SCD rate was only 3.5%, while 5.4% (46 patients) suffered VTs or ventricular fibrillation (VF). The SCD/VT rate in the entire infarct population was associated with time to reperfusion (0.032), left bundle-branch block (0.002), a longer history of CAD (0.032), and VT during follow-up.

Conclusion

While mortality in patients with STEMI is still alarming even with PCI, the risk of SCD may be considerably decreased even in patients with an LVEF below 35%. With the current approach to primary prevention of sudden cardiac death, approximately 10% of postinfarction patients qualify for ICD therapy; however this may only reach a quarter of patients prone to SCD.

Zusammenfassung

Hintergrund

Aktuelle Ansätze bei koronarer Herzkrankheit (KHK) und akutem Myokardinfarkt (MI) werden möglicherweise in den meisten Studien zur Primärprävention des plötzlichen Herztods (PHT) nicht angemessen berücksichtigt.

Methoden

Das heutige, fortlaufende Register des Rostocker Infarktnetzwerks Drip & Ship (District of Rostock Infarct Project & Shipping Patients) stellt eine gut definierte Kohorte von Patienten mit Zustand nach perkutaner Koronarintervention (PCI) wegen eines ST-Hebungs-Infarkts (STEMI) dar und diente als Datenbank sowohl von Kandidaten für einen implantierbaren Kardioverter/Defibrillator (ICD) zur Primärprävention des PHT als auch für PHT oder ventrikuläre Tachykardie (VT) während der Nachbeobachtungsphase.

Ergebnisse

Zwischen 2001 und 2004 wurden in der Region um Rostock 855 aufeinander folgende Patienten mit STEMI oder NSTEMI mit einer PCI behandelt. Während die Mortalität aus sämtlichen Ursachen 17,2% betrug, lag die Rate des PHT im Lauf der Nachbeobachtungsphase von 728 ± 366 Tagen nur bei 1,3%. In dieser Zeit ergab sich bei 85 Patienten (9,9%) die Indikation zur ICD-Therapie aufgrund beeinträchtigter linksventrikulärer Funktion (linksventrikuläre Ejektionsfraktion, LV-EF  ≤ 35%) und Herzinsuffizienz. Univariate Prädiktoren einer ICD-Indikation waren eine verzögerte Reperfusion (p = 0,001), hoher CK-Maximalwert (p = 0,009), persistierender breiter QRS-Komplex (p = 0,001), frühere zerebrovaskuläre Ereignisse (p = 0,033) und chronische Niereninsuffizienz (p = 0,001). Aber nur 16,5% dieser Patienten erhielten tatsächlich einen ICD; dennoch betrug die Rate des PHT nur 3,5%, während bei 5,4% (46 Patienten) eine VT oder Kammerflimmern (KF) auftrat. Die Rate für PHT/KF in der gesamten Infarktpopulation stand in Zusammenhang mit der Zeit bis zur Reperfusion (0,032), Linksschenkelblock (0,002), längerer KHK-Anamnese (0,032) und KF während der Nachbeobachtungsphase.

Fazit

Während die Mortalität bei Patienten mit STEMI selbst nach PCI immer noch alarmierend hoch ist, kann das Risiko des PHT selbst bei Patienten mit einer LVEF unter 35% beträchtlich gesenkt werden. Bei dem derzeitigen Ansatz zur Primärprävention des PHT sind etwa 10% der Postinfarktpatienten ICD-Kandidaten. Damit wird möglicherweise nur 1/4 der Patienten erreicht, die anfällig für PHT sind.

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Abbreviations

CK:

Creatine kinase

ICD:

Implantable cardioverter defibrillator

LBBB:

Left bundle-branch block

LVEF:

Left ventricular ejection fraction

MI:

Myocardial infarction

NYHA:

New York Heart Association

PTCA:

Percutaneous transluminal coronary angioplasty

SCD:

Sudden cardiac death

STEMI:

ST-elevation myocardial infarction

VT:

Ventricular tachycardia

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Conflict of interest

The corresponding author states the following: grants were received from Biotronik, Medtronic, Boston, and St. Jude Medical for clinical trials.

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Authors and Affiliations

  1. Heart Center Rostock, University Hospital of Rostock, Schillingallee 35, 18055, Rostock, Germany

    L. Paranskaya MD, I. Akin MD, T. Chatterjee MD, A. Ritz MD, P. Paranski MD, T. Rehders MD, H. Ince MD, PhD, H. Schneider MD, C.A. Nienaber MD, PHD & D. Bänsch MD, PhD

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  1. L. Paranskaya MD
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  2. I. Akin MD
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  3. T. Chatterjee MD
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  4. A. Ritz MD
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  5. P. Paranski MD
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  6. T. Rehders MD
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  7. H. Ince MD, PhD
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  8. H. Schneider MD
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  9. C.A. Nienaber MD, PHD
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  10. D. Bänsch MD, PhD
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Corresponding author

Correspondence to D. Bänsch MD, PhD.

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Paranskaya, L., Akin, I., Chatterjee, T. et al. Ventricular tachycardia and sudden death after primary PCI-reperfusion therapy . Herzschr. Elektrophys. 22, 243–248 (2011). https://doi.org/10.1007/s00399-011-0160-z

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  • DOI: https://doi.org/10.1007/s00399-011-0160-z

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