Electrophysiology-guided defibrillator implantation early after ST-elevation myocardial infarction

Saurabh Kumar, Gopal Sivagangabalan, Sarah Zaman, Elizabeth B. West, Arun Narayan, Aravinda Thiagalingam, Pramesh Kovoor

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Abstract

Background Sudden death risk is highest early after myocardial infarction (MI). Inducible ventricular tachycardia (VT) confers increased risk of spontaneous ventricular arrhythmias. Objective The purpose of this study was to evaluate outcomes of electrophysiology (EP)-guided defibrillator implantation early after ST-elevation MI in patients with ejection fraction ≤40%. Methods EP study was performed 9 days after MI (n = 360). Predischarge defibrillator was recommended if VT with cycle length <200 ms was induced with ≤4 extrastimuli (EP-positive [EPpos], n = 142). EP-negative (EP neg) patients were discharged without a defibrillator (n = 218). Primary endpoint was either sudden death or spontaneous ventricular arrhythmia. Results Defibrillator was implanted in 71% of EPpos patients (median 21 days post-MI) and withheld in 94% of EPneg patients. At 2 years, primary endpoint was 4.3% in the EPneg group and 22% in the EP pos group (adjusted hazard ratio 0.46, P = .035, EPneg vs EPpos). Lack of a defibrillator in EPpos patients conferred a fourfold increased risk of sudden death (P = .014). EPneg patients without a defibrillator were at significantly lower risk for the primary endpoint than were EPpos patients without a defibrillator (adjusted HR 0.34, P = .011). Short inducible VT cycle length (200230 ms) and use of the fourth extrastimulus identified patients at significant arrhythmic risk. Conclusion EP study performed early after MI identified patients at significant long-term arrhythmic risk at a critical time after MI in whom defibrillator implantation was protective. A large majority of patients (EP neg; two thirds) were at significantly lower risk of arrhythmic events without a defibrillator in the long term.

Original languageEnglish
Pages (from-to)1589-1597
Number of pages9
JournalHeart Rhythm
Volume7
Issue number11
DOIs
Publication statusPublished - 1 Nov 2010
Externally publishedYes

Keywords

  • Electrophysiologic study
  • Implantable cardioverterdefibrillator
  • Myocardial infarction
  • Sudden death
  • Ventricular tachycardia

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