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.
Piccini
Jonathan P
JP
Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA. jonathan.piccini@duke.edu
Schulte
Phillip J
PJ
Pieper
Karen S
KS
Mehta
Rajendra H
RH
White
Harvey D
HD
Van de Werf
Frans
F
Ardissino
Diego
D
Califf
Robert M
RM
Granger
Christopher B
CB
Ohman
E Magnus
EM
Alexander
John H
JH
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