Antiarrhythmic drug therapy for sustained ventricular arrhythmias complicating acute myocardial infarction.
OBJECTIVE
Few data exist to guide antiarrhythmic drug therapy for sustained ventricular tachycardia/ventricular fibrillation after acute myocardial infarction. The objective of this analysis was to describe the survival of patients with sustained ventricular tachycardia/ventricular fibrillation after myocardial infarction according to antiarrhythmic drug treatment.


METHODS
We conducted a retrospective analysis of ST-segment elevation myocardial infarction patients with sustained ventricular tachycardia/ventricular fibrillation in Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO) IIB and GUSTO III and compared all-cause death in patients receiving amiodarone, lidocaine, or no antiarrhythmic. We used Cox proportional-hazards modeling and inverse weighted estimators to adjust for baseline characteristics, β-blocker use, and propensity to receive antiarrhythmics. Due to nonproportional hazards for death in early follow-up (0-3 hrs after sustained ventricular tachycardia/ventricular fibrillation) compared with later follow-up (>3 hrs), we analyzed all-cause mortality using time-specific hazards.


METHODS
Among 19,190 acute myocardial infarction patients, 1,126 (5.9%) developed sustained ventricular tachycardia/ventricular fibrillation and met the inclusion criteria. Patients received lidocaine (n = 664, 59.0%), amiodarone (n = 50, 4.4%), both (n = 110, 9.8%), or no antiarrhythmic (n = 302, 26.8%).


RESULTS
In the first 3 hrs after ventricular tachycardia/ventricular fibrillation, amiodarone (adjusted hazard ratio 0.39, 95% confidence interval 0.21-0.71) and lidocaine (adjusted hazard ratio 0.72, 95% confidence interval 0.53-0.96) were associated with a lower hazard of death-likely evidence of survivor bias. Among patients who survived 3 hrs, amiodarone was associated with increased mortality at 30 days (adjusted hazard ratio 1.71, 95% confidence interval 1.02-2.86) and 6 months (adjusted hazard ratio 1.96, 95% confidence interval 1.21-3.16), but lidocaine was not at 30 days (adjusted hazard ratio 1.19, 95% confidence interval 0.77-1.82) or 6 months (adjusted hazard ratio 1.10, 95% confidence interval 0.73-1.66).


CONCLUSIONS
Among patients with acute myocardial infarction complicated by sustained ventricular tachycardia/ventricular fibrillation who survive 3 hrs, amiodarone, but not lidocaine, is associated with an increased risk of death, reinforcing the need for randomized trials in this population.
Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA. jonathan.piccini@duke.edu
Jonathan P
JP
Piccini
Phillip J
PJ
Schulte
Karen S
KS
Pieper
Rajendra H
RH
Mehta
Harvey D
HD
White
Frans
F
Van de Werf
Diego
D
Ardissino
Robert M
RM
Califf
Christopher B
CB
Granger
E Magnus
EM
Ohman
John H
JH
Alexander
D000368:Aged; D000638:Amiodarone / Q000008:administration & dosage / Q000009:adverse effects; D000889:Anti-Arrhythmia Agents / Q000008:administration & dosage* / Q000009:adverse effects; D015331:Cohort Studies; D016001:Confidence Intervals; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008012:Lidocaine / Q000008:administration & dosage / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications* / Q000175:diagnosis / Q000401:mortality; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis; D017180:Tachycardia, Ventricular / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality*; D016896:Treatment Outcome; D014693:Ventricular Fibrillation / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality*
D000889:Anti-Arrhythmia Agents; D008012:Lidocaine; D000638:Amiodarone