Amiodarone therapy for sustained ventricular tachycardia after myocardial infarction: long-term follow-up, risk assessment and predictive value of programmed ventricular stimulation.
We determine the value of the programmed ventricular stimulation (PVS) and of clinical, angiographic and electrophysiologic variables in assessing the long-term risk of arrhythmia recurrence in a group of coronary artery diseased patients presenting with a first episode of monomorphic sustained ventricular tachycardia (VT) treated with amiodarone. Mortality and arrhythmia recurrence rates were retrospectively assessed in 55 consecutive patients with previous myocardial infarction presenting with a first VT episode. Results of left heart catheterization, echocardiography and time-domain signal-averaging were collected. Patients underwent PVS after amiodarone oral loading and were classified according to inducibility before being all discharged on amiodarone (200 mg daily). The mean follow-up was 42+/-31 months. Total and cardiac mortality rates were 29% (16 patients) and 23% (13 patients) respectively. Sudden death (SD) occurred in nine patients (16%). VT recurred in 13 patients (23%). Sustained monomorphic VT was inducible in 40 patients (72%) after amiodarone loading. Neither total mortality (10/40 vs. 6/15) nor cardiac mortality (3/40 vs. 1/15) were significantly different between inducible and non-inducible patients. Recurrent VT rate was 27% (11/40 patients) for the inducible group and 13% (2/15 patients) for the non-inducible group (NS). SD occurred in 6/40 inducible patients (15%) and in 2/15 non-inducible patients (13%) (NS). Arrhythmic events occurred in 42% (17/40) inducible patients vs. 26% (4/15) non-inducible patients (P=0.07). Parameters correlated with outcome were ejection fraction (EF) (5 SD/11 patients with EF <0.3 vs. 4/44 with EF >0.3, P=0.003), mitral insufficiency (MI) (4 SD/10 patients with MI vs. 4/44 patients without MI, P=0.004) and age (65+/-9 years for patients with VT recurrence vs. 58+/-9, P=0.02). Although the risk stratification can be improved, reliable and safe long-term prediction of recurrence of malignant ventricular arrhythmia in individual patients cannot be made. Consequently, the systematic implantation of a cardioverter-defibrillator in case of a first episode of sustained VT occurring in coronary artery disease patients should be further debated.
Maury
P
P
Division of Cardiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
Zimmermann
M
M
Metzger
J
J
Reynard
C
C
Dorsaz
P
P
Adamec
R
R
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000638:Amiodarone / Q000627:therapeutic use*; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use*; D016009:Chi-Square Distribution; D016757:Death, Sudden, Cardiac / Q000209:etiology; D004594:Electrophysiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications*; D011237:Predictive Value of Tests; D012008:Recurrence; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D017180:Tachycardia, Ventricular / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality; D016896:Treatment Outcome
D000889:Anti-Arrhythmia Agents; D000638:Amiodarone