Risk stratification and prediction of sudden death following myocardial infarction

  • A. W. M. Turner
  • M. Malik

Summary

Accurate and reliable identification of those survivors of acute myocardial infarction who are at high risk of sudden death remain an important and challenging problem. This review summarises the current state-of-the-art of the risk stratification techniques and lists achievements in this field.

The review comments in detail on individual factors used in risk stratification. Residual ischemia may be considered as one of the main triggering factors of post-infarction arrhythmia. Depressed left ventricular ejection fraction indicates deterioration of ventricular function. Electrical instability of the myocardium reflects the potential substrate of arrhythmia. Frequent ventricular ectopic activity provides triggers of ventricular tachycardia and/or fibrillation when acting on a suitable substrate. Impaired autonomic status of the heart may lead to the loss of vagal antiarrhythmic protection.

Further, the tests used for risk stratification are discussed. Ventriculography provides estimates of left ventricular ejection fraction. Holter monitoring is used for the assessment of ventricular ectopic activity and heart rate variability. Exercise testing is used to address residual ischemia. Programmed ventricular stimulation and the analysis of signal averaged electrocardiograms estimate electrical instability of the myocardium. Baroreflex sensitivity is a measure of cardiac parasympathetic reflexes.

The design and results of different experimental and clinical studies which utilised these tests are also discussed.

Keywords

Catheter Aspirin Heparin Adenosine Cocaine 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Ahnve S, Gilpin E, Dittrich H et al. (1988) First myocardial infarction: are and ejection fraction identify a low risk group. Am Heart J 16: 925–932CrossRefGoogle Scholar
  2. 2.
    Amour J, Hageman G, Randall W (1972) Arrhythmias induced by local cardiac nerve stimulation. Am J Physiol 223: 1068Google Scholar
  3. 3.
    Benhorin J, Moss AJ, Oakes D et al. (1990) The prognostic importance of first myocardial infarction type ( Q wave versus non-Q wave) and Q wave location. J Am Coll Cardiol 15: 1201–7PubMedCrossRefGoogle Scholar
  4. 4.
    Bhandari A, Widerhorn J, Sager et al. (1992) Prognostic significance of programmed ventricular stimulation in patients surviving complicated myocardial infarction: a prospective study. Am Heart J 124: 87–96PubMedCrossRefGoogle Scholar
  5. 5.
    Bigger JT, Fliess JL, Kleiger R, Miller JP, Rolinitsky LM (1984) The relationships among ventricular arrhythmias, left ventricular dysfunction, and mortality in the 2 years after myocardial infarction. Circulation 69: 250–7PubMedCrossRefGoogle Scholar
  6. 6.
    Bigger JT Jr, Kleiger R, Fleiss J, Rolinzky L, Steinmann R, Miller J (1988) Components of heart rate variability measured during healing of acute myocardial infarction. Am J Cardiol 61: 208PubMedCrossRefGoogle Scholar
  7. 7.
    Bocker D, Shenasa M, Borggrefe M, Fetsch T, Breuthardt G (1993) Late potentials, heart rate variability, and electrocardiography. Curr Op Cardiol 8: 39–53CrossRefGoogle Scholar
  8. 8.
    Boden WE (1988) Non-Q-wave MI: prognosis and management. Am J Cardiol 62: 10CrossRefGoogle Scholar
  9. 9.
    Bourke J, Richards D, Ross D, Wallace E, McGuire M, Uther J (1991) Routine programmed electrical stimulation in survivors of acute myocardial infarction for the prediction of spontaneous ventricular tcahyarrhymias during follow-up: results, optimal stimulation protocol and cost effective screening. Am Coll Cardiol 18: 780CrossRefGoogle Scholar
  10. 10.
    Breithardt G, Cain ME, El Sherif N et al. (1991) Standards for analysis of ventricular late potentials using high-resolution or signal-averaged electrocardiography: a statement by a task force committee of the European Society of Cardiology, Amercian Heart Association and Amercian College of Cardiology. Eur Heart J 12: 473–80 and J Am Coll Cardiol 17: 999–1006Google Scholar
  11. 11.
    Brown KA, Weiss RM, Clements JP, Wackers FJ (1987) Usefulness of ischaemic myocardium within prior infarct zone for identifying patients at high risk late after acute myocardial infarction. Am J Cardiol 60: 15–9PubMedCrossRefGoogle Scholar
  12. 12.
    Cerati D, Schwartz P (1991) Single cardiac nerve fibre activity, acute myocardial ischaemia and sudden death. Circ Res 69: 1389PubMedGoogle Scholar
  13. 13.
    Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction. Results of thrombolysis in acute myocardial infarction (TIMI) Phase II trail. N Eng J Med 320: 618–27Google Scholar
  14. 14.
    Cripps T, Bennett ED, Camm AJ, Ward DE (1988) High gain signal averaged electrocardiogram combined with 24 hour monitoring patients early after mycordial infarction for bedside prediction of arrhythmic events. Br Heart J 60: 181–7PubMedCrossRefGoogle Scholar
  15. 15.
    Cripps T, Bennett ED, Camm AJ, Ward DE (1989) Inducibility of sustained monomorphic ventricular tachycardia as a prognostic indicator in survivors of recent myocardial infarction: a prospective evaluation in relation to other prognostic variables. J Am Coll Cardiol 14: 289–96PubMedCrossRefGoogle Scholar
  16. 16.
    Cripps T, Malik M, Farell T, Camm AJ (1991) Prognostic value of reduced heart rate variability after acute myocardial infarction: clinical evalution of a new analysis method. Br Heart J 65: 14PubMedCrossRefGoogle Scholar
  17. 17.
    Denniss AR, Baalens H, Cody DV et al. (1985) Value of programmed stimulation and exercise testing in predicting 1-year mortality after acute myocardial infarction. Am J Cardiol 56: 213–20PubMedCrossRefGoogle Scholar
  18. 18.
    Denniss AR, Richards DA, Cody DV et al. (1986) Prognostic significance of ventricular tachycardia and fibrillation induced at programmed stimulation and delayed potentials detected on the signal averaged electrocardiograms of survivors of acute myocardial infarction. Circulation 74: 731–45PubMedCrossRefGoogle Scholar
  19. 19.
    Dwyer EM, McMaster P, Greenberg H (1984) Nonfatal cardiac events and recurrent infarction in the year after acute myocardial infarction. J Am Coll Cardiol 4: 695–702PubMedCrossRefGoogle Scholar
  20. 20.
    Dwyer EM, Greenberg HM, Steinberg G (1989) Clinical characteristics and natural history of survivors of pulmonary congestion during acute myocardial infarction. Am J Cardiol 63: 1423–8PubMedCrossRefGoogle Scholar
  21. 21.
    Erichsen (1841) On the influence of the coronary circulation on the action of the heart. London medical gazette 2: 561Google Scholar
  22. 22.
    Ewing J, Neilson J, Travis P (1984) New method for assessing cardiac parasympathetic activity using 24 hour electrocardiograms. Br Heart J 52: 396PubMedCrossRefGoogle Scholar
  23. 23.
    Farell T, Paul V, Cripps T, Mallik M, Bennett E, Ward D, Camm AJ (1991) Baroreflex sensitivity and electrophysiological correlates and cardiovascular mortality among patients with first myocardial infarction. 83: 945Google Scholar
  24. 24.
    Farell T, Bashir Y, Cripps T et al. (1991) Risk stratification for arrhythmic events in postinfarction patients based on heart rate variability, ambulatory electrocardiographic variables and the signal averaged electrocardiogram. J Am Coll Cardiol 18: 687CrossRefGoogle Scholar
  25. 25.
    Farell T, Odemuyiwa O, Bashir Y, Cripps T, Malik M, Camm AJ (1992) Prognostic value of baroreflex sensitivity testing after acute myocardial infarction. Br Heart J 67: 129CrossRefGoogle Scholar
  26. 26.
    Fletcher PJ, Pfeffer JM, Braunwald E (1981) Left ventricular diastolic pressure-volume relations in rats with healed myocardial infarction: effects on systolic function. Circ Res 49: 618–26PubMedGoogle Scholar
  27. 27.
    Gomes JA, Winters S, Stewart D et al. (1987) A new non-invasive index to predict sustained ventricular tachycardia and sudden death in the first year after myocarial infarction: based on signal averaged electrocardiogram, radionuclide ejection fraction and Holter monitoring. J Am Coll Cardiol 10: 349–57PubMedCrossRefGoogle Scholar
  28. 28.
    Greenberg H, Gillespie J, Dwyer EM (1987) A new electrocardiographic classification for post–infarction clinical trials. The Multicenter Post–infarction Research Group. Am J Cardiol. 59: 10–57–63Google Scholar
  29. 29.
    Greene HL, Reid PR, Schaeffer A (1978) The repetitive ventricular response in man: a predictor of sudden death. N Eng J Med 299: 729–34CrossRefGoogle Scholar
  30. 30.
    Greene H, Richardson D, Barker A, Roden D, Capone R, Echt D, Friedman L, Gillespie M, Hallstrom A, Verter J, the CAPS Investigators (1989) Classification of death after myocardial infarction as arrhythmic or nonarrhythmic. Am J Cardiol 63: 1–6PubMedGoogle Scholar
  31. 31.
    Haberl R, Hilge G, Steinbigler P, Steinbeck G (1992) Spectrotemporal mapping of the surface electrocardiogram. In High-Resolution Electrocardiography. Ed El Sharif N, Turitto G. Mount Kisco, NY: Futura Publishing Co.; Mt. Kisci 635–653Google Scholar
  32. 32.
    Hakki AH, Nestico PF, Heo J, Unwala AA, Iskandrian AS (1987) Reactive prognostic usefulness of rest Thalliu-201 imaging, radionuclide ventriculography and 24 hour electrocardiographic monitoring after acute myocardial infarction. J Am Coll Cardiol 10: 25–32PubMedCrossRefGoogle Scholar
  33. 33.
    Han J (1969) Ventricular vulnerability during acute coronary occlusion. Am J Cardiol 24: 857PubMedCrossRefGoogle Scholar
  34. 34.
    Han J, de Jalon P, Moe G (1987) Adrenergic effects on ventricular vulnerability. Circ Res 16: 516Google Scholar
  35. 35.
    Hlatky MA, Califf RM, Lee KL, Pryor DB, Wagner GS, Rosati RA (1985) Prognostic significance of precordial ST-segment depression during inferior myocardial infarction. Am J Cardiol 55: 325–9PubMedCrossRefGoogle Scholar
  36. 36.
    Jaarsma W, Visser CA, Funke Kupper AJ et al. (1990) Usefulness of two-dimensional echocardiography shortly after myocardial infarction. Comparison of early exercise treadmill test and oral dipyridamole thallium-201 tomography for the identification of jeopardized myocardium in patients receiving thrombolytic therapy for acute myocardial infarction. Am J Cardiol 66: 551–5CrossRefGoogle Scholar
  37. 37.
    Jennings K, Reid DS, Hawkins T, Julian DG (1984) Role of exercise testing after myocardial infarction in identifying candidates for coronary artery surgery. Br Med J 228: 185.CrossRefGoogle Scholar
  38. 38.
    Kannel WB, Sorlie P, McNamara PM (1979) Prognosis after initial myocardial infarction: the Framingham study. Am J Cardiol 44: 53–9PubMedCrossRefGoogle Scholar
  39. 39.
    Karch S, Billingham M. (1987) Pathology of cocaine induced heart disease. Arch Pathol Lab Med 112: 225Google Scholar
  40. 40.
    Kelen GJ, Henkin R, Starr AM, Caref EB, Bloomfield D, El Sharif N. (1991) Spectral turbulance analysis of the signal averaged electrocardiogram and its predictive accuracy for inducible monomorphic tachycardia. Am J Cardiol 67: 965–75PubMedCrossRefGoogle Scholar
  41. 41.
    Kleiger R, Miller J, Bigger JT Jr, Moss A (1987) Decreased heart rate variability and its association with increased mortality after acute myocardial infarction. Am J Cardiol 59: 256PubMedCrossRefGoogle Scholar
  42. 42.
    Kostis JB, Byington R, Friedman LM, Goldstein S, Furberg C (1987) Prognostic significance of ventricular ectopic activity in survivors of acute myocardial infarction. J Am Coll Cardiol 10: 231–42PubMedCrossRefGoogle Scholar
  43. 43.
    Kotler MN, Tabatznik B, Tominga S (1973) Prognostic significance of ventricular ectopic beats with respect to sudden death in the late postinfarction period. Circulation 47: 959–66PubMedGoogle Scholar
  44. 44.
    Krone RJ, Friedman E, Thanavaro S, Miller JP, Klieger RE, Oliver GC (1983) Long-term prognosis after first Q-wave (transmural) or non-Q-wave (non-transmural) myocardial infarction: an analysis of 593 patients. Am J Cardiol 53: 234–9CrossRefGoogle Scholar
  45. 45.
    Krone RJ, Gillispie JA, Weld FM, Miller JP, Moss AJ (1984) The Multicenter Postinfarction Group. Low-level exercise testing after myocardial infarction: usefulness in enchancing clinical risk stratification. Circulation 71: 80CrossRefGoogle Scholar
  46. 46.
    Kuchar DL, Thorburn CW, Sammuel NL (1987) Prediction of serious arrhythmic events after myocardial infarction: signal-averaged electrocardiogram, Holter monitoring and radionuclide ventriculography. J Am Coll Cardiol 9: 816–24CrossRefGoogle Scholar
  47. 47.
    La Rovere M, Speechia G, Mortara A, Schwartz P (1988) Baroreflex sensitivity, clinical correlates and cardiovascular mortality among patients with first myocardial infarction circulation 78: 816Google Scholar
  48. 48.
    Larso S, Porges S (1982) The otogeny of heart period patterning in the rat. Dev Psychbiol. 15: 519CrossRefGoogle Scholar
  49. 49.
    Launberg J, Berning J, Fruergaard P, Appleyard M (1992) Sensitivity and specificity of echocardiographic identification of patients eligible for safe and early discharge after myocardial infarction. Am Heart J 124: 846–53CrossRefGoogle Scholar
  50. 50.
    Lombardi F, Sandrone G, Pernpruner S et al. (1990) Heart rate variability as an index of sympathovagal interaction acute myocardial infarction. Am J Cardiol 60: 123Google Scholar
  51. 51.
    Lombardi F, Sandrone G, Mortara A et al. (1992) Circadian variation of spectral indices of the heart rate variability after myocardial infarction. Am Heart J 123: 1521PubMedCrossRefGoogle Scholar
  52. 52.
    Malik M, Camm A (1990) Heart rate variability. Clin Cardiol 13: 570PubMedCrossRefGoogle Scholar
  53. 53.
    Malik M, Odemuyiwa O, Poloniecki J et al. (1991) Age-related normal values of signal averaged electrocardiographic variables after acute myocardial infarction. Am J Cardiol 68: 440–5PubMedCrossRefGoogle Scholar
  54. 54.
    Malik M, Odemuyiwa O, Poloniecki J et al. (1992) Late potentials after acute myocardial infarction. Performance of different criteria for the prediction of arrhythmic complications. Eur Heart J 13: 599–607PubMedGoogle Scholar
  55. 55.
    Mancia G, Mark A (1983) Arterial baroreflexes in humans in Handbook of physiology. The Cardiovascular system. Bethseda, Md, American Physiology Society Vol3: 755Google Scholar
  56. 56.
    Manning J, Cotten M (1962) Mechanisms of cardiac arrhythmias induced by dien-cephalic stimulation. 20: 1120Google Scholar
  57. 57.
    Marchlinski FE, Buxton AE, Waxman HL, Josephson ME (1983) 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 53: 1190–6CrossRefGoogle Scholar
  58. 58.
    Masaoka S, Lev-Ran A, Hill L, Vakil G, Hon E (1985) Heart rate variability in diabetes: relationship to age and duration of disease. Diabetes Care 8: 64PubMedCrossRefGoogle Scholar
  59. 59.
    McEwan T, Sima A (1987) Autonomic neoropathy in BB rat. Assessment by improved method for measuring heart rate variability. Diabetes 35: 227Google Scholar
  60. 60.
    McKee WB, Doyle WP, McNamara, Kannel WB (1971) The natural history of congestive heart failure: the Framingham study. N Eng J Med 285: 1441–6CrossRefGoogle Scholar
  61. 61.
    Middlekauf K, Stevenson W, Tillisch J (1992) Prevention of sudden death in survivors of myocardial infarction. Am Heart J 123: 475–480CrossRefGoogle Scholar
  62. 62.
    Miranda C, Lehmann K, Froelicher V (1991) Correlation between resting ST segment depression, exercise testing, coronary angiography, and long-term prognosis. Am Heart J 122: 1617–28PubMedCrossRefGoogle Scholar
  63. 63.
    Morady F, Schainman MM, Hess DS, Sung RJ, Shen E, Shapiro W (1983) Electrophysiological testing in the management of survivors of out-of-hospital cardiac arrest. Am J Cardiol 51: 85–9PubMedCrossRefGoogle Scholar
  64. 64.
    Moss AJ, Davies HT, DeCamilla J, Bayer LW (1979) Ventricular ectopic beats and their relationship to sudden and non-sudden cardiac death after myocardial infarction. Circulation 60: 998–1003PubMedGoogle Scholar
  65. 65.
    Mukarji J, Rude RE, Poole WK et al. (1984) Risk factors for sudden death after acute myocardial infarction: two year follow-up. Am J Cardiol 54: 31–5CrossRefGoogle Scholar
  66. 66.
    Multicenter Postinfarction Study Group (1982) Risk stratification and survival after myocardial infarction. N Eng J Med 309: 331–6Google Scholar
  67. 67.
    Nanji A, Filipenko J (1984) Asystole and ventricular fibrillation associated with cocaine intoxication. Chest 85: 132PubMedCrossRefGoogle Scholar
  68. 68.
    Nicod P, Gilpin E, Dittrich H et al. (1991) Short-and long-term clinical outcome after Q wave and non-Q wave myocardial infarction in a large patient population. Circulation 79: 528–36CrossRefGoogle Scholar
  69. 69.
    Odemuyiwa O, Malik M, Farrell T et al. (1991) Multifactoral prediction of arrhythmic events after myocardial infarction. Combination of heart rate variability and left ventricular ejection fraction with other variables. Pace 14: 91Google Scholar
  70. 70.
    Odemuyiwa O, Malik M, Farrell T, Bashir Y, Staunton A, Poloniecki J, Camm AJ (1991) Multifactoral prediction of arrhythmic events after myocardial infarction. Combination of heart rate variability and left ventricular ejection fraction with other variables. Pace 14: 129Google Scholar
  71. 71.
    Osculati G, Gianattasio C, Seravalle G, Valagussa F, Zanchetti, Mancia G (1990) Early alterations of the barorereceptor control of the heart rate in patients with acute myocardial infarction. Circulation 81: 939PubMedCrossRefGoogle Scholar
  72. 72.
    Pagani M, Lombardi F, Guzzetti S et al. (1986) Power spectral analysis of heart rate variabilities as a marker of sympatho-vagal interaction in man and conscious dogs. Circ res 59: 178PubMedGoogle Scholar
  73. 73.
    Pfeffer MA, Braunwald E (1990) Early remodeling after myocardial infarction: experimental observations and clinical implications. Circulation 81: 1161–72PubMedCrossRefGoogle Scholar
  74. 74.
    Pfeffer JM, Pfeffer MA, Fletcher PJ, Braunwald E (1991) Progressive ventricular remodeling in rat with myocardial infarction. Am J Physiol 260: H1406 - H414PubMedGoogle Scholar
  75. 75.
    Pfisterer M, Salamin P, Schwendener R, Burkart F (1992) Clinical risk assessment after first myocardial infarction: is additional noninvasive testing necessary? Chest 102: 1499–1506PubMedCrossRefGoogle Scholar
  76. 76.
    Piccalo G, Pirelli S, Massa D, Cipriani M, Sarullo F, De Vita C (1992) Value of negative pre-discharge exercise test in identifying patients at low risk after acute myocardial infarction treated by systemic thrombolysis. Am J Cardiol 70: 31–3PubMedCrossRefGoogle Scholar
  77. 77.
    Pomeranz, Macualy R, Caudill M et al. (1985) Assessment of autonomic function in humans by heart rate spectral analysis. Am J Physiol 248: H151Google Scholar
  78. 78.
    Ranhosky A, Kempthorne-Rawson J (1990) The safety of intravenous dipyridamole thallium myocardial perfusion imaging. The Intravenous Dipyridamole Thallium Imaging Study Group. Circulation 81: 1205–9PubMedCrossRefGoogle Scholar
  79. 79.
    Rehnqist W, Sjorgen (1977) Ventricular arrhythmias prior to discharge and one year after myocardial infarction. Eur J Cardiol 5: 425–2Google Scholar
  80. 80.
    Rogers W, Babb J, Bairn D et al. (1991) Selective versus routine coronary arteriography after therapy with recombinant tissue-type plasminogen activator, heparin and aspirin for acute myocardial infarction. J Am Coll Cardiol 71: 1007–16CrossRefGoogle Scholar
  81. 81.
    Roy D, Marchand E, Theroux P, Waters DD, Pelletier GB, Bourassa MG (1985) Programmed ventricular stimulation in survivors of acute myocardial infarction. Circulation 72: 487–94PubMedCrossRefGoogle Scholar
  82. 82.
    Ruberman W, Weinblatt E, Goldberg J, Frank CW, Shapiro S (1977) Ventricular premature beats and mortality after myocardial infarction. N Eng J Med 297: 750–7CrossRefGoogle Scholar
  83. 83.
    Saunamaki KI, Anderson JD (1987) Clinical significance of the ST segment response and other early exercise variables in uncomplicated vs complicated myocardial infarction. Eur Heart J 8: 603.PubMedGoogle Scholar
  84. 84.
    Schulz RA jr, Rouleau J, Rigo P, Bowers S, Struass HW, Pitt B (1975) Ventricular arrhythmias in the late hospital phase of acute myocardial infarction: relation of left ventricular function detected by gated cardiac blood pool scanning. Circulation 52: 1006–11.Google Scholar
  85. 85.
    Schuster EH, Bulkey BH (1981) Early post-infarction angina. Ischaemia at a distance and ischaemia in the infarct zone. N Eng J Med 305: 1110–9.CrossRefGoogle Scholar
  86. 86.
    Schwartz P, Stone H, Brown A (1976) Effects of unilateral stellate ganglion blockade on arrhythmias associated with coronary occlusion. 92: 589.Google Scholar
  87. 87.
    Schwartz P (1985) The idiopathic long QT syndrome: Progress and questions. Am Heart J 109: 399.PubMedCrossRefGoogle Scholar
  88. 88.
    Schwartz P, Vanoli E, Stramba-Bachale M, De Ferrari G, Billman G, Foreman R (1988) Autonomic mechanisms and sudden death. Circulation 78: 969.PubMedCrossRefGoogle Scholar
  89. 89.
    Schwartz P, Zaza A, Pala M, Locati E, Beria G, Zanchetti A (1988) Baroreflex sensitivity and its evolution during the first year after myocardial infarction. J Am Coll Cardiol 12: 629.PubMedGoogle Scholar
  90. 90.
    Seimens P, Hiller H, Frowein R (1989) Heart rate variability and the reaction of the heart rate to atropine in brain dead patients.Neurosurg Rev 12: 282.Google Scholar
  91. 91.
    Simson MB (1981) Use of signals in the terminal QRS complex to identify patients with ventricular tachycardia after myocardial infarction. Circulation 64: 235–42.PubMedCrossRefGoogle Scholar
  92. 92.
    Snellen HA (1984) History of Cardiology. The Netherlands: Donker AcademicGoogle Scholar
  93. 93.
    The Multicenter Postinfarction Group. Risk stratification and survival after myocardial infarction. N Eng J Med (1983) 309: 331–6.CrossRefGoogle Scholar
  94. 94.
    Theroux P, Waters DD, Halpen C, Debaisieus JC, Mizgala HF (1979) Prognostic value of exercise testing soon after myocardial infarction. N Eng J Med 301: 341–5.CrossRefGoogle Scholar
  95. 95.
    Tilkemeir PL, Guiney TE, La Raia PJ, Boucher CA (1990) Prognostic value of predischarge low-level exercise thallium testing after thrombolytic treatment of acute myocardial infarction. Am J Cardiol 66: 1203–7.CrossRefGoogle Scholar
  96. 96.
    Verani MS, Mahamarian JJ, Hixson JB, Boyce TM, Staudacher RA (1990) Diagnosis of coronary artery disease by controlled coronary vasodilation with adenosine and thallium-201 scintigraphy in patients unable to exercise. Circulation 82: 80–7.PubMedCrossRefGoogle Scholar
  97. 97.
    Verheugt FW, Brugada P (1991) Sudden death after acute myocardial infarction: the forgotten thrombotic view. Am J Cardiol 67: 1130–4PubMedCrossRefGoogle Scholar
  98. 98.
    Waldo Al, Akhtar M, Brugada P et al (1985) The minimally appropriate electrophysiologic study for the initial assessment of patients with documented sustained monomorphic ventricular tachycardia. J Am Coll Cardiol 6: 1174–7.PubMedCrossRefGoogle Scholar
  99. 99.
    Weld FM, Chu K, Bigger JT Jr, Rolnitzky L (1981) Risk stratification with low-level exercise testing 2 weeks after myocardial infarction. Circulation 64: 306.PubMedCrossRefGoogle Scholar
  100. 100.
    Wellens HJ, Brugada P, Stevenson WG (1985) Programmed electrical stimulation of the heart in patients with life-threatening ventricular arrhythmias: what is the significance of induced arrhythmias and what is the correct protocol? Circulation 72: 1–7.PubMedCrossRefGoogle Scholar
  101. 101.
    White CW (1989) Recurrent ischaemic events following successful thrombolysis in acute myocardial infarction: the Achilles’ heel of thrombolytic therapy. Circulation 801: 1482–5.CrossRefGoogle Scholar
  102. 102.
    Wiese F, Muller D, Krell D, Kielstein V, Koch R (1985) Heart rate variability in withdrawn alcoholic patients. Drug Alchohol Depend 16: 85.CrossRefGoogle Scholar
  103. 103.
    Wolf MW, Vargios G, Hunt D, Sloman J (1978) Sinus arrhythmia in acute myocardial infarction. Med J Austral 2: 52.PubMedGoogle Scholar

Copyright information

© Dr. Dietrich Steinkopff Verlag GmbH & Co. KG, Darmstadt 1994

Authors and Affiliations

  • A. W. M. Turner
    • 1
  • M. Malik
    • 2
  1. 1.Department of Cardiological SciencesSt Georges’ Hospital Medical SchoolLondonEngland
  2. 2.Department of Cardiological SciencesSt Georges’ Hospital Medical SchoolLondonEngland

Personalised recommendations