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Zaman S, Kumar S, Narayan A, Sivagangabalan G, Thiagalingam A, Ross DL, Thomas SP, Kovoor P. Induction of ventricular tachycardia with the fourth extrastimulus and its relationship to risk of arrhythmic events in patients with post-myocardial infarct left ventricular dysfunction. Europace 2012; 14:1771-7. [DOI: 10.1093/europace/eus199] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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53
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Jentzer JC, Jentzer JH. Cardiac Resynchronization Therapy With and Without Defibrillator in a Commercial Truck Driver with Ischemic Cardiomyopathy and New York Heart Association Class III Heart Failure. Card Electrophysiol Clin 2012; 4:169-180. [PMID: 26939814 DOI: 10.1016/j.ccep.2012.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Commercial drivers warrant tighter restrictions to their driving privileges than private drivers. Patients with cardiac disease who are at risk of consciousness-impairing arrhythmias are not allowed to drive commercially. Patients with left ventricular systolic dysfunction and/or heart failure symptoms are permanently disqualified from commercial driving. A biventricular pacemaker without defibrillator can improve symptoms and mortality in selected patients with heart failure. Biventricular pacing may have antiarrhythmic effects that may reduce the added benefit of a defibrillator. Motor vehicle collisions resulting from arrhythmic events are infrequent. The interests of public safety must outweigh individual liberties when driving safety is in question.
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Affiliation(s)
- Jacob C Jentzer
- Heart and Vascular Institute, Department of Cardiology, University of Pittsburgh Medical Center, Scaife Hall, Suite B-571.3, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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54
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Grothusen C, Hagemann A, Attmann T, Braesen J, Broch O, Cremer J, Schoettler J. Impact of an interleukin-1 receptor antagonist and erythropoietin on experimental myocardial ischemia/reperfusion injury. ScientificWorldJournal 2012; 2012:737585. [PMID: 22649318 PMCID: PMC3354588 DOI: 10.1100/2012/737585] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 12/27/2011] [Indexed: 01/13/2023] Open
Abstract
Background. Revascularization of infarcted myocardium results in release of inflammatory cytokines mediating myocardial reperfusion injury and heart failure. Blockage of inflammatory pathways dampens myocardial injury and reduces infarct size. We compared the impact of the interleukin-1 receptor antagonist Anakinra and erythropoietin on myocardial ischemia/reperfusion injury. In contrast to others, we hypothesized that drug administration prior to reperfusion reduces myocardial damage. Methods and Results. 12–15 week-old Lewis rats were subjected to myocardial ischemia by a 1 hr occlusion of the left anterior descending coronary artery. After 15 min of ischemia, a single shot of Anakinra (2 mg/kg body weight (bw)) or erythropoietin (5000 IE/kg bw) was administered intravenously. In contrast to erythropoietin, Anakinra decreased infarct size (P < 0.05, N = 4/group) and troponin T levels (P < 0.05, N = 4/group). Conclusion. One-time intravenous administration of Anakinra prior to myocardial reperfusion reduces infarct size in experimental ischemia/reperfusion injury. Thus, Anakinra may represent a treatment option in myocardial infarction prior to revascularization.
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Affiliation(s)
- Christina Grothusen
- Department of Cardiovascular Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 18, 24105 Kiel, Germany.
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55
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Biasucci LM, Bellocci F, Landolina M, Rordorf R, Vado A, Menardi E, Giubilato G, Orazi S, Sassara M, Castro A, Massa R, Kheir A, Zaccone G, Klersy C, Accardi F, Crea F. Risk stratification of ischaemic patients with implantable cardioverter defibrillators by C-reactive protein and a multi-markers strategy: results of the CAMI-GUIDE study. Eur Heart J 2012; 33:1344-50. [DOI: 10.1093/eurheartj/ehr487] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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56
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Fam JM, Ching CK. Review on Non-Invasive Risk Stratification of Sudden Cardiac Death. PROCEEDINGS OF SINGAPORE HEALTHCARE 2011. [DOI: 10.1177/201010581102000404] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Sudden cardiac death (SCD) is one of the most significant and challenging problems facing modern medicine today given its unpredictable nature. The evaluation of the patient at risk for sudden cardiac death still remains a complex task. The use of ICDs (implantable cardioverter defibrillators) remains the mainstay of primary prevention of sudden cardiac death. However, much remains to be determined on how best to identify patients at high risk of sudden cardiac death who would most benefit from ICD implantations. This paper will review the current issues in the risk assessment of sudden cardiac death and non-invasive markers of sudden death.
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Affiliation(s)
- Jiang Ming Fam
- Department of Cardiovascular Medicine, National Heart Centre, Singapore
| | - Chi Keong Ching
- Department of Cardiovascular Medicine, National Heart Centre, Singapore
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57
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Bastiaenen R, Batchvarov V, Gallagher MM. Ventricular automaticity as a predictor of sudden death in ischaemic heart disease. Europace 2011; 14:795-803. [DOI: 10.1093/europace/eur342] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lopera G, Curtis AB. Risk stratification for sudden cardiac death: current approaches and predictive value. Curr Cardiol Rev 2011; 5:56-64. [PMID: 20066150 PMCID: PMC2803290 DOI: 10.2174/157340309787048130] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Revised: 07/05/2008] [Accepted: 07/05/2008] [Indexed: 11/22/2022] Open
Abstract
Sudden cardiac death (SCD) is a serious public health problem; the annual incidence of out-of-hospital cardiac arrest in North America is approximately 166,200. Identifying patients at risk is a difficult proposition. At the present time, left ventricular ejection fraction (LVEF) remains the single most important marker for risk stratification. According to current guidelines, most patients with LVEF <35% could benefit from prophylactic ICD implantation, particularly in the setting of symptomatic heart failure. Current risk stratification strategies fail to identify patients at risk of SCD in larger population groups encompassing a greater number of potential SCD victims. However, the best approach to identifying patients and the value of various risk stratification tools is not entirely clear. The goal of this review is to discuss the problem of SCD and the value of the different risk stratification markers and their potential clinical use either alone or in combination with other risk stratification markers.
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Affiliation(s)
- Gustavo Lopera
- Division of Cardiology, University of Miami/Miller School of Medicine, Miami, FL, USA
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60
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Goldberger JJ, Buxton AE, Cain M, Costantini O, Exner DV, Knight BP, Lloyd-Jones D, Kadish AH, Lee B, Moss A, Myerburg R, Olgin J, Passman R, Rosenbaum D, Stevenson W, Zareba W, Zipes DP. Risk Stratification for Arrhythmic Sudden Cardiac Death. Circulation 2011; 123:2423-30. [DOI: 10.1161/circulationaha.110.959734] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Jeffrey J. Goldberger
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - Alfred E. Buxton
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - Michael Cain
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - Otto Costantini
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - Derek V. Exner
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - Bradley P. Knight
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - Donald Lloyd-Jones
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - Alan H. Kadish
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - Byron Lee
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - Arthur Moss
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - Robert Myerburg
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - Jeffrey Olgin
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - Rod Passman
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - David Rosenbaum
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - William Stevenson
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - Wojciech Zareba
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
| | - Douglas P. Zipes
- From the Path to Improved Risk Stratification/Northwestern University, Chicago, IL (J.J.G.); Brown University, Providence, RI (A.E.B.); State University of New York at Buffalo (M.C.); MetroHealth Campus, Case Western Reserve University, Cleveland, OH (O.C., D.R.); Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (D.V.E.); Northwestern University, Chicago, IL (B.P.K., D.L.-J., A.H.K., R.P.); University of California at San Francisco (B.L., J.O.); University
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Abstract
UNLABELLED Many studies have demonstrated that low heart rate variability (HRV) is a risk for high mortality and morbidity in patients with cardiovascular diseases. The primary purpose of the study was to evaluate whether pregabalin improves HRV in patients with diabetes and painful peripheral neuropathy. Resting heart rates were collected by using the LifeShirt System, developed by VivoMetrics (Ventura, Calif), at baseline and at the end of a 4-week intervention of pregabalin or placebo in patients with painful diabetic peripheral neuropathy. Heart rate variability analysis was performed on the collected R-R intervals using the Vivo- VMLA-036-00 3 Logic of the LifeShirt system. Of the 40 patients enrolled in the study, 70% completed the end of 4-week assessments (n = 15 in pregabalin and n = 14 in placebo). Compared with placebo, pregabalin treatment resulted in significant improvement in HRV measured by frequency domain analysis, that is, a reduction in low frequency-high frequency ratio (-1.30 ± 2.89 vs 0.37 ± 0.33, P = 0.03) and power of normalized low frequency (-0.049 ± 0.092 vs 0.0066 ± 0.023, P = 0.02), as well as an increase in power of normalized high frequency (0.039 ± 0.094 vs -0.038 ± 0.066, P = 0.02). Furthermore, pregabalin resulted in greater reduction of pain and symptoms of anxiety and greater improvement of quality of life. The improvement of HRV measures were not correlated with change of those measures. In conclusion, 4-week pregabalin treatment improved HRV in patients with painful diabetic peripheral neuropathy. TRIAL REGISTRATION NCT00573261 (clinicaltrials.gov).
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62
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Fishman GI, Chugh SS, Dimarco JP, Albert CM, Anderson ME, Bonow RO, Buxton AE, Chen PS, Estes M, Jouven X, Kwong R, Lathrop DA, Mascette AM, Nerbonne JM, O'Rourke B, Page RL, Roden DM, Rosenbaum DS, Sotoodehnia N, Trayanova NA, Zheng ZJ. Sudden cardiac death prediction and prevention: report from a National Heart, Lung, and Blood Institute and Heart Rhythm Society Workshop. Circulation 2011; 122:2335-48. [PMID: 21147730 DOI: 10.1161/circulationaha.110.976092] [Citation(s) in RCA: 443] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Glenn I Fishman
- NYU School of Medicine, Division of Cardiology, 522 First Avenue, Smilow 801, New York, NY 10016, USA.
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63
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Lauer MS. Risk Stratification for Sudden Cardiac Death. J Am Coll Cardiol 2010; 56:1484-5. [DOI: 10.1016/j.jacc.2010.05.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 05/04/2010] [Indexed: 11/26/2022]
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64
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Goldberger JJ. The coin toss: implications for risk stratification for sudden cardiac death. Am Heart J 2010; 160:3-7. [PMID: 20598965 DOI: 10.1016/j.ahj.2010.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Accepted: 04/05/2010] [Indexed: 11/25/2022]
Abstract
A number of risk stratification techniques have been used to identify groups of patients at risk for sudden cardiac death. These tests applied in populations do not necessarily provide adequate differentiation of high versus low risk for an individual patient. For the individual patient, the physician must act on the observed results; hence, the positive and negative predictive values of the test become a major driver of its utility for the individual patient. The positive and negative predictive values of multiple tests from 2 trials are compared with the positive and negative predictive values of a "coin toss" to illustrate the limited ability of individual tests to adequately risk stratify. Alternative approaches to achieve better risk stratification are highlighted.
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65
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Left Ventricular Ejection Fraction for Sudden Death Risk Stratification and Guiding Implantable Cardioverter-defibrillators Implantation. J Cardiovasc Pharmacol 2010. [DOI: 10.1097/fjc.0b013e3181d9f49c] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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66
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Management of sudden cardiac death risk in the very early postmyocardial infarction period. Curr Opin Cardiol 2010. [DOI: 10.1097/hco.0b013e3283387a51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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67
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de Haan S, Knaapen P, Beek AM, de Cock CC, Lammertsma AA, van Rossum AC, Allaart CP. Risk stratification for ventricular arrhythmias in ischaemic cardiomyopathy: the value of non-invasive imaging. Europace 2010; 12:468-74. [DOI: 10.1093/europace/euq064] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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68
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Gopinath D, Costantini O. Risk Stratification for Sudden Cardiac Death: The Need to Go Beyond the Left Ventricular Ejection Fraction. Card Electrophysiol Clin 2009; 1:51-59. [PMID: 28770788 DOI: 10.1016/j.ccep.2009.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Sudden cardiac death (SCD) accounts for as many as 450,000 deaths yearly in the United States. Over the last 15 years, many clinical trials have established the effectiveness of an implantable cardioverter-defibrillator (ICD) in reducing sudden and total mortality in patients with structural heart disease. However, controversy remains about exactly how to identify the patients most likely to benefit from an ICD, as well as those who may safely do without an ICD implant. The first primary prevention ICD trials used an abnormal electrophysiological study in addition to a low left ventricular ejection fraction (LVEF) as high-risk markers for SCD. More recent ICD trials selected patients based on the presence of a low LVEF alone. Ideally, noninvasive electrophysiological markers that more directly reflect arrhythmia substrates may better identify patients for prophylactic ICD implant. Several of these markers have been associated with the risk of SCD, but all have yielded contradictory outcome results or have not been tested prospectively. This review focuses on the most promising tests to date, their clinical significance, and their possible use to improve efficacy and efficiency of risk stratification for SCD.
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Affiliation(s)
- Devi Gopinath
- Heart and Vascular Center, MetroHealth Campus, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH 44109-1998, USA
| | - Otto Costantini
- Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH 44109-1998, USA
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69
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Mountantonakis S, Hutchinson MD. Who should receive an implantable cardioverter-defibrillator after myocardial infarction? Curr Heart Fail Rep 2009; 6:236-44. [DOI: 10.1007/s11897-009-0033-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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70
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Grenzen und Möglichkeiten der nichtinvasiven Risikostratifikation für den plötzlichen Herztod. Herz 2009; 34:506-16. [DOI: 10.1007/s00059-009-3290-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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71
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Scott PA, Barry J, Roberts PR, Morgan JM. Brain natriuretic peptide for the prediction of sudden cardiac death and ventricular arrhythmias: a meta-analysis. Eur J Heart Fail 2009; 11:958-66. [DOI: 10.1093/eurjhf/hfp123] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Paul A. Scott
- Wessex Cardiothoracic Unit; Southampton University Hospitals NHS Trust; Tremona Road Southampton SO16 6YD UK
| | - James Barry
- Wessex Cardiothoracic Unit; Southampton University Hospitals NHS Trust; Tremona Road Southampton SO16 6YD UK
| | - Paul R. Roberts
- Wessex Cardiothoracic Unit; Southampton University Hospitals NHS Trust; Tremona Road Southampton SO16 6YD UK
- University of Southampton; Southampton UK
| | - John M. Morgan
- Wessex Cardiothoracic Unit; Southampton University Hospitals NHS Trust; Tremona Road Southampton SO16 6YD UK
- University of Southampton; Southampton UK
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72
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Zaman S, Sivagangabalan G, Narayan A, Thiagalingam A, Ross DL, Kovoor P. Outcomes of Early Risk Stratification and Targeted Implantable Cardioverter-Defibrillator Implantation After ST-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention. Circulation 2009; 120:194-200. [DOI: 10.1161/circulationaha.108.836791] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background—
Methods to identify high-risk patients and timing of implantable cardioverter-defibrillator (ICD) therapy after ST-elevation myocardial infarction need further optimization.
Methods and Results—
We evaluated outcomes of early ICD implantation in patients with inducible ventricular tachycardia. Consecutive patients treated with primary percutaneous coronary intervention for acute ST-elevation myocardial infarction underwent early left ventricular ejection fraction (LVEF) assessment. Patients with LVEF >40% were discharged (group 1); patients with LVEF ≤40% underwent risk stratification with electrophysiological study. If no ventricular tachycardia was induced, patients were discharged without an ICD (group 2). If sustained monomorphic ventricular tachycardia (≥200-ms cycle length) was induced, an ICD was implanted before discharge (group 3). Follow-up was obtained up to 30 months in all patients and up to 48 months in a subgroup of patients with LVEF ≤30% without an ICD. The primary end point was total mortality. Group 1 (n=574) had a mean LVEF of 54±8%; group 2 (n=83), 32±6%; and group 3 (n=32), 29±7%. At a median follow-up of 12 months, there was no significant difference in survival between the 3 groups (
P
=0.879), with mortality rates of 3%, 3%, and 6% for groups 1 through 3, respectively. In the subgroup of group 2 patients with LVEF ≤30% and no ICD (n=25), there was 9% mortality at a median follow-up of 25 months. In group 3, 19% had spontaneous ICD activation resulting from ventricular tachycardia.
Conclusions—
Early ICD implantation limited to patients with inducible ventricular tachycardia enables a low overall mortality in patients with impaired LVEF after primary percutaneous coronary intervention for ST-elevation myocardial infarction.
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Affiliation(s)
- Sarah Zaman
- From the Cardiology Department, Westmead Hospital, Sydney, Australia
| | | | - Arun Narayan
- From the Cardiology Department, Westmead Hospital, Sydney, Australia
| | | | - David L. Ross
- From the Cardiology Department, Westmead Hospital, Sydney, Australia
| | - Pramesh Kovoor
- From the Cardiology Department, Westmead Hospital, Sydney, Australia
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73
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Goldberger JJ. Evidence-based analysis of risk factors for sudden cardiac death. Heart Rhythm 2009; 6:S2-7. [DOI: 10.1016/j.hrthm.2008.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Indexed: 11/28/2022]
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74
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YOKOKAWA MIKI, TADA HIROSHI, KOYAMA KEIKO, INO TOSHIHIKO, HIRAMATSU SHIGEKI, KASENO KENICHI, NAITO SHIGETO, OSHIMA SHIGERU, TANIGUCHI KOICHI. The Characteristics and Distribution of the Scar Tissue Predict Ventricular Tachycardia in Patients with Advanced Heart Failure. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:314-22. [DOI: 10.1111/j.1540-8159.2008.02238.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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75
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Risk stratification for sudden death in patients with coronary artery disease. Heart Rhythm 2009; 6:836-47. [PMID: 19467514 DOI: 10.1016/j.hrthm.2009.02.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2008] [Accepted: 02/06/2009] [Indexed: 01/10/2023]
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76
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Goldberger JJ, Cain ME, Hohnloser SH, Kadish AH, Knight BP, Lauer MS, Maron BJ, Page RL, Passman RS, Siscovick D, Stevenson WG, Zipes DP. American Heart Association/american College of Cardiology Foundation/heart Rhythm Society scientific statement on noninvasive risk stratification techniques for identifying patients at risk for sudden cardiac death: a scientific statement from the American Heart Association Council on Clinical Cardiology Committee on Electrocardiography and Arrhythmias and Council on Epidemiology and Prevention. Heart Rhythm 2009; 5:e1-21. [PMID: 18929319 DOI: 10.1016/j.hrthm.2008.05.031] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Indexed: 11/18/2022]
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77
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Predictors of long-term mortality in Multicenter Automatic Defibrillator Implantation Trial II (MADIT II) patients with implantable cardioverter-defibrillators. Heart Rhythm 2008; 6:468-73. [PMID: 19324304 DOI: 10.1016/j.hrthm.2008.12.023] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Accepted: 12/15/2008] [Indexed: 11/21/2022]
Abstract
BACKGROUND Data on long-term follow-up and factors influencing mortality in implantable cardioverter-defibrillator (ICD) recipients are limited. OBJECTIVE The aim of this study was to evaluate mortality during long-term follow-up and the predictive value of several risk markers in the Multicenter Automatic Defibrillator Implantation Trial II (MADIT II) patients with implanted cardioverter-defibrillators (ICDs). METHODS The study involved U.S. patients from the MADIT II trial randomized to and receiving ICD treatment. Data regarding long-term mortality were retrieved from the National Death Registry. Several clinical, biochemical, and electrocardiogram variables were tested in a multivariate Cox model for predicting long-term mortality, and a score identifying high-, medium-, and lower risk patients was developed. RESULTS The study population consisted of 655 patients, mean age 64 +/- 10 years. During a follow-up of up to 9 years, averaging 63 months, 294 deaths occurred. The 6-year cumulative probability of death was 40%, with evidence of a constant risk of about 8.5% per year among survivors. Median survival was estimated at 8 years. Multivariate analysis identified age >65 years, New York Heart Association class 3-4, diabetes, non-sinus rhythm, and increased levels of blood urea nitrogen as independent risk predictors of mortality. Patients with three or more of these risk factors were characterized by a 6-year mortality rate of 68%, compared with 43% in those with one to two risk factors and 19% in patients with no risk factors. CONCLUSION A combination of a few readily available clinical variables indicating advanced disease and comorbid conditions identifies ICD patients at high risk of mortality during long-term follow-up.
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78
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Kadish AH, Reiffel JA, Naccarelli GV, DiMarco JP. Device therapies in the post-myocardial infarction patient with left ventricular dysfunction. Am J Cardiol 2008; 102:29G-37G. [PMID: 18722189 DOI: 10.1016/j.amjcard.2008.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The post-myocardial infarction (MI) patient with left ventricular dysfunction (LVD) is at risk for ventricular arrhythmias resulting in sudden cardiac death. In high-risk post-MI patients with a depressed left ventricular ejection fraction, prophylactic implantable cardioverter defibrillators (ICDs) may significantly improve survival. These benefits are in addition to those of optimal pharmacologic therapy, and ICD therapy should be considered the standard of care in these patients. Recent device trials have demonstrated the benefits of prophylactic ICD placement in patients who have been selected based on post-MI left ventricular systolic dysfunction alone. In addition, cardiac resynchronization therapy can improve the quality of life beyond that achievable with drug therapy alone and should be considered in patients with symptomatic heart failure with QRS prolongation. Further risk stratification studies of post-MI LVD patients will allow ICD therapy to be applied in a more cost-effective manner.
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Affiliation(s)
- Alan H Kadish
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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79
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Goldberger JJ, Cain ME, Hohnloser SH, Kadish AH, Knight BP, Lauer MS, Maron BJ, Page RL, Passman RS, Siscovick D, Stevenson WG, Zipes DP. American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society Scientific Statement on Noninvasive Risk Stratification Techniques for Identifying Patients at Risk for Sudden Cardiac Death. J Am Coll Cardiol 2008; 52:1179-99. [DOI: 10.1016/j.jacc.2008.05.003] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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80
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Somers VK, White DP, Amin R, Abraham WT, Costa F, Culebras A, Daniels S, Floras JS, Hunt CE, Olson LJ, Pickering TG, Russell R, Woo M, Young T. Sleep apnea and cardiovascular disease: an American Heart Association/american College Of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council On Cardiovascular Nursing. In collaboration with the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). Circulation 2008; 118:1080-111. [PMID: 18725495 DOI: 10.1161/circulationaha.107.189375] [Citation(s) in RCA: 639] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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81
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de Sousa MR, Morillo CA, Rabelo FT, Nogueira Filho AM, Ribeiro ALP. Non-sustained ventricular tachycardia as a predictor of sudden cardiac death in patients with left ventricular dysfunction: a meta-analysis. Eur J Heart Fail 2008; 10:1007-14. [PMID: 18692437 DOI: 10.1016/j.ejheart.2008.07.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Accepted: 07/01/2008] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Identifying patients at risk of sudden cardiac death (SCD) remains a challenge. AIM To evaluate the performance of non-sustained ventricular tachycardia (NSVT) from 24 hour ambulatory electrocardiography as a predictor of SCD in patients with heart failure or non-ischaemic dilated cardiomyopathy with left ventricular systolic dysfunction (LVSD). METHODS AND RESULTS Study search and selection were performed by independent reviewers using a validated strategy. Eleven prognostic studies with >100 patients with good quality data and multivariate analysis of predictors of SCD were included. Publication bias was evaluated by funnel plot with Kendall's tau b test. A summary ROC (sROC) curve was built to evaluate predictive performance of NSVT. There was threshold effect (Spearman's correlation between sensitivity and specificity=-0.818, p<0.01) which indicates that combining sensitivity and specificity was not appropriate. The area of 0.68+/-0.02 under the sROC curve indicates a statistically significant contribution of NSVT in the prediction of SCD. The true negative rate varied from 89 to 97%. Multivariate analysis and meta-regression suggested that the contribution of NSVT to risk stratification is independent of ejection fraction. CONCLUSIONS Absence of NSVT indicated a low probability of SCD in patients with LVSD. A risk score including NSVT should be evaluated in prospective studies.
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Affiliation(s)
- Marcos R de Sousa
- Post-Graduate Program in Internal Medicine, Universidade Federal de Minas Gerais, Brazil.
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82
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Effects of drug, biobehavioral and exercise therapies on heart rate variability in coronary artery disease: a systematic review. ACTA ACUST UNITED AC 2008; 15:386-96. [DOI: 10.1097/hjr.0b013e3283030a97] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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83
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Hohnloser SH. Risk factor assessment: defining populations and individuals at risk. Cardiol Clin 2008; 26:355-66, v-vi. [PMID: 18538184 DOI: 10.1016/j.ccl.2008.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This article summarizes the current knowledge on risk stratification in patients who have structural heart disease, notably coronary artery disease and nonischemic cardiomyopathy. Although other types of structural heart disease and inherited ion channel abnormalities are also associated with a risk of SCD, the risk stratification strategies and data in these entities are diverse and beyond the scope of this article.
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Affiliation(s)
- Stefan H Hohnloser
- Department of Medicine, J.W. Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany.
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84
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Schoenenberger AW, Erne P, Ammann S, Gillmann G, Kobza R, Stuck AE. Prediction of arrhythmic events after myocardial infarction based on signal-averaged electrocardiogram and ejection fraction. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:221-8. [PMID: 18233976 DOI: 10.1111/j.1540-8159.2007.00972.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Trials on implantable cardioverter-defibrillators (ICD) for patients after acute myocardial infarction (AMI) have highlighted the need for risk assessment of arrhythmic events (AE). The aim of this study was to evaluate risk predictors based on a novel approach of interpreting signal-averaged electrocardiogram (SAECG) and ejection fraction (EF). METHODS SAECG, interpreted with a new index, and EF were prospectively evaluated to predict AE in 144 patients with AMI. RESULTS During the mean follow-up period of 4.1 years, 19 AE occurred. The new SAECG index showed a sensitivity of 84%, a specificity of 62%, a positive predictive value (PPV) of 25%, and a negative predictive value (NPV) of 96%. A combination of a normal new SAECG index and an EF >35% resulted in a sensitivity of 100%, a specificity of 47%, a PPV of 22%, and a NPV of 100%; this corresponded to an AE incidence rate of 0%. When both tests were abnormal, the AE incidence rate was 21.3%. CONCLUSIONS This is the first contemporary study reporting predictive values based on a combination of SAECG and EF. If confirmed in an appropriately designed and powered trial, this novel approach might be used to identify both patients at very low risk for AE not requiring further risk assessment and patients at high risk in whom ICD implantation can be considered without further risk assessment.
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Affiliation(s)
- Andreas W Schoenenberger
- Department of General Internal Medicine, Inselspital University of Bern Hospital, Bern, Switzerland
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85
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Association of impaired thrombolysis in myocardial infarction myocardial perfusion grade with ventricular tachycardia and ventricular fibrillation following fibrinolytic therapy for ST-segment elevation myocardial infarction. J Am Coll Cardiol 2008; 51:546-51. [PMID: 18237683 DOI: 10.1016/j.jacc.2007.08.061] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Revised: 08/24/2007] [Accepted: 08/27/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The goal of this analysis was to evaluate the association of impaired Thrombolysis In Myocardial Infarction myocardial perfusion grade (TMPG) with sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). BACKGROUND Impaired TMPG after successful restoration of epicardial flow among patients treated with fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI) has been associated with adverse clinical outcomes, but its relationship to VT/VF has not been evaluated. METHODS In the CLARITY-TIMI 28 (Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis In Myocardial Infarction 28) study, 3,491 patients underwent angiography a median of 3.5 days after fibrinolytic administration for STEMI; TMPG was assessed, and its association with VT/VF was evaluated. RESULTS We observed VT/VF in 4.8% of patients. Impaired myocardial perfusion (TMPG 0/1/2) was associated with an increased incidence of VT/VF (7.1% vs. 2.6% with TMPG 3; log-rank p < 0.001). Among patients with restoration of normal epicardial flow (Thrombolysis In Myocardial Infarction flow grade 3), the incidence of VT/VF was increased among patients with impaired TMPG (4.7% vs. 2.7%; p = 0.02). Among patients with left ventricular ejection fraction >or=30%, impaired TMPG remained associated with an increased incidence of VT/VF (4.7% vs. 2.5%; p = 0.03). We found that VT/VF was associated with increased mortality (25.2% vs. 3.5%; p < 0.0001). Furthermore, among patients with VT/VF, impaired TMPG was associated with increased mortality (17.1% vs. 2.3%; p = 0.02). All but 1 death among patients who had VT/VF were among patients with impaired myocardial perfusion. CONCLUSIONS Despite restoration of normal epicardial flow or a left ventricular ejection fraction >or=30%, impaired myocardial perfusion on angiography 3.5 days after fibrinolytic administration for STEMI is associated with an increased incidence of VT/VF.
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86
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Goldberger JJ, Greenstein E. Fragmented QRS for risk prediction: picking up the pieces. Heart Rhythm 2007; 4:1393-4. [PMID: 17954397 DOI: 10.1016/j.hrthm.2007.08.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Indexed: 11/24/2022]
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87
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Amit G, Costantini O. SCD in patients with cardiomyopathy: use of microvolt T-wave alternans and other noninvasive tests for risk stratification and prevention of SCD. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2007; 9:345-55. [PMID: 17897563 DOI: 10.1007/s11936-007-0054-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Based on current guidelines, most electrophysiologists today are implanting cardioverter-defibrillators (ICDs) using a low left ventricular ejection fraction alone as the sole stratifier for the risk of sudden cardiac death. However, left ventricular ejection fraction is a better marker of total mortality than sudden death. As a result, this strategy is flawed because it exposes many patients to the risk and cost of ICD therapy without its benefits. Primary prevention trials based on this strategy show that the rate of appropriate ICD shocks is only 5% to 10% per year. We believe that the effectiveness of ICD therapy can be improved by the use, in addition to ejection fraction, of one or more of the noninvasive tests, which are reviewed in this article. Such tests are more adequate to evaluate the arrhythmogenic substrate of the patient than the left ventricular ejection fraction alone. Whether any of these tests can help us identify the patients at the lowest risk of sudden death, who could safely avoid ICD implant, remains to be determined.
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Affiliation(s)
- Guy Amit
- Arrhythmia Prevention Center, MetroHealth Campus, Case Western Reserve University, 2500 MetroHealth Drive, Hamman 334, Cleveland, OH 44109-1998, USA
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88
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Bunch TJ, Hohnloser SH, Gersh BJ. Mechanisms of sudden cardiac death in myocardial infarction survivors: insights from the randomized trials of implantable cardioverter-defibrillators. Circulation 2007; 115:2451-7. [PMID: 17485594 DOI: 10.1161/circulationaha.106.683235] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- T Jared Bunch
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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89
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Bellocci F, Biasucci LM, Gensini GF, Padeletti L, Raviele A, Santini M, Giubilato G, Landolina M, Biondi-Zoccai G, Raciti G, Sassara M, Castro A, Kheir A, Crea F. Prognostic role of post-infarction C-reactive protein in patients undergoing implantation of cardioverter-defibrillators: design of the C-reactive protein Assessment after Myocardial Infarction to GUide Implantation of DEfibrillator (CAMI GUIDE) study. J Cardiovasc Med (Hagerstown) 2007; 8:293-9. [PMID: 17413310 DOI: 10.2459/01.jcm.0000263496.52656.95] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients at risk of sudden cardiac death (SCD) after myocardial infarction (MI) can currently be offered effective means of prevention, such as implantable cardioverter-defibrillators (ICD). However, predictors of SCD able to identify those patients who are at higher risk are still lacking. Whether C-reactive protein (CRP), a serum inflammatory marker with established prognostic accuracy after MI, can also be a predictor of SCD is unclear. METHODS The CAMI GUIDE study is designed to evaluate the prognostic role of CRP in patients undergoing ICD implantation after MI according to MADIT II criteria (i.e. left ventricular ejection fraction<or=30%). CAMI GUIDE is a prospective observational study aimed at assessing the role of CRP in the risk-stratification of SCD after MI. CRP will be measured on the basis of a pre-specified cut-off value of 3 mg/l, before and 1 month after ICD implantation; clinical follow-up will last 24 months. The primary endpoint is the combined rate of SCD or fast ventricular tachycardia/ventricular fibrillation. Secondary endpoints will be total mortality, death due to acute coronary syndromes, death from pump failure, non-fatal MI, coronary revascularization, hospitalization for congestive heart failure or unstable angina and inappropriate ICD shocks. Twenty-four Italian centers will participate in enrollment of the 290 patients planned according to power analysis. CONCLUSIONS The CAMI GUIDE study will assess the predictive role of CRP in SCD in patients with previous MI undergoing ICD implantation. Its results will improve risk stratification, thereby enabling better-tailored and more cost-effective therapies to be undertaken in those patients whose need is greatest.
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MESH Headings
- Biomarkers/blood
- C-Reactive Protein/metabolism
- Cohort Studies
- Data Interpretation, Statistical
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Follow-Up Studies
- Humans
- Italy/epidemiology
- Myocardial Infarction/blood
- Myocardial Infarction/complications
- Myocardial Infarction/mortality
- Myocardial Infarction/therapy
- Patient Selection
- Predictive Value of Tests
- Prognosis
- Prospective Studies
- Research Design
- Risk Assessment
- Risk Factors
- Sample Size
- Tachycardia, Ventricular/blood
- Tachycardia, Ventricular/prevention & control
- Treatment Outcome
- Ventricular Fibrillation/blood
- Ventricular Fibrillation/prevention & control
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Affiliation(s)
- Fulvio Bellocci
- Institute of Cardiology, Catholic University, A. Gemelli Hospital, Rome, Italy
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90
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Iravanian S, Arshad A, Steinberg JS. Role of Electrophysiologic Studies, Signal‐Averaged Electrocardiography, Heart Rate Variability, T‐Wave Alternans, and Loop Recorders for Risk Stratification of Ventricular Arrhythmias. ACTA ACUST UNITED AC 2007; 14:16-9. [PMID: 15654148 DOI: 10.1111/j.1076-7460.2005.03354.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ventricular tachycardia and fibrillation are major causes of morbidity and mortality after myocardial infarction. Frequently, sudden cardiac death is the first manifestation of such malignant rhythms. Optimal risk stratification strategies in this population are of utmost importance. In this review the authors discuss the background and clinical use of invasive tests, such as electrophysiologic study and implantable loop recorders, and noninvasive tests, such as signal-averaged electrocardiography, heart rate variability, and T-wave alternans. The utility, indications, and limitations of each test in clinical practice are discussed, especially for the purpose of postmyocardial infarction risk stratification in the elderly population.
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Affiliation(s)
- Shahriar Iravanian
- Division of Cardiology, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY 10025, USA
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91
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Arora R, Frisch DR, Kadish AH. The Role of Implantable Cardioverter-Defibrillators in Primary and Secondary Prevention of Sudden Cardiac Death. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50027-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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92
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Sandercock GRH, Brodie DA. The role of heart rate variability in prognosis for different modes of death in chronic heart failure. Pacing Clin Electrophysiol 2006; 29:892-904. [PMID: 16923007 DOI: 10.1111/j.1540-8159.2006.00457.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Classic risk factors for mortality due to chronic heart failure (CHF), such as low left ventricular ejection fraction, NYHA functional stage, and increased heart rate perform well in the prediction of death from pump failure. The prediction of sudden cardiac death (SCD) remains somewhat problematic. Numerous studies have analyzed the potential contribution heart rate variability (HRV) can make to risk assessment in CHF. The aim of this review was to summarize the literature and identify the role HRV might play in identifying mode of death, as well as overall mortality risk. In studies where all-cause mortality or cardiac events were the clinical end point(s), global and slow oscillatory measures of HRV were the strongest risk predictors. In the fewer studies that used SCD as an end point, the strongest risk factors were HRV measures of short-term oscillations and sympathovagal interaction. We concluded from these findings that different HRV measurements predict different modes of death in CHF.Additionally, further studies using short-term analysis of HRV and non-linear analyses are warranted. Furthermore, studies with multiple end points, which clearly delineate pump failure from SCD, may be useful to identify more clearly the role HRV measures can play in the prediction of SCD.
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93
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Benchimol-Barbosa P. Noninvasive prognostic markers for cardiac death and ventricular arrhythmia in long-term follow-up of subjects with chronic Chagas' disease. Braz J Med Biol Res 2006. [DOI: 10.1590/s0100-879x2006005000061] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- P.R. Benchimol-Barbosa
- Universidade do Estado do Rio de Janeiro, Brasil; Corpo de Bombeiros Militar do Estado do Rio de Janeiro, Brasil
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94
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247-346. [PMID: 16949478 DOI: 10.1016/j.jacc.2006.07.010] [Citation(s) in RCA: 867] [Impact Index Per Article: 48.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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95
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Blanc JJ, Budaj A, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114:e385-484. [PMID: 16935995 DOI: 10.1161/circulationaha.106.178233] [Citation(s) in RCA: 807] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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96
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Abstract
PURPOSE OF REVIEW This article reviews mechanisms and available therapeutic options for arrhythmias leading to sudden cardiac death in patients with coronary artery disease. RECENT FINDINGS Intensive efforts have led to a better understanding of the pathophysiology and various treatments of sudden cardiac death. Antiarrhythmic medications have not demonstrated a survival benefit. Beta-adrenergic blocking agents have been revalidated in recent studies to improve survival and reduce risk of sudden cardiac death in patients with myocardial infarction. Angiotensin-converting enzyme inhibitors and aldosterone antagonists should also be used in these patients. Data from randomized trials demonstrate significant survival benefit with an implantable cardioverter-defibrillator and indications have expanded. Patients with established ischemic cardiomyopathy do not require electrophysiologic studies for induction of tachyarrhythmias based on these trials. One recent trial did not demonstrate mortality reduction with implantable defibrillators in patients with recent myocardial infarction. Devices may not provide survival benefit in patients with advanced New York Heart Association class IV heart failure. SUMMARY The incidence of arrhythmia-related sudden death in the general population remains relatively high. Better risk stratification tools are needed to identify high-risk patients in the general population and in those with known coronary disease and to exclude low-risk patients.
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MESH Headings
- Adrenergic beta-Antagonists/therapeutic use
- Angiotensin-Converting Enzyme Inhibitors/therapeutic use
- Anti-Arrhythmia Agents/therapeutic use
- Arrhythmias, Cardiac/complications
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/physiopathology
- Arrhythmias, Cardiac/therapy
- Coronary Artery Disease/complications
- Coronary Artery Disease/physiopathology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/pathology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Fatty Acids, Omega-3/therapeutic use
- Humans
- Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use
- Mineralocorticoid Receptor Antagonists/therapeutic use
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Affiliation(s)
- Adnan Siddiqui
- Main Line Health Heart Center and the Lankenau Hospital and Institute for Medical Research, Main Line Health Systems, Wynnewood, Pennsylvania 19096, USA.
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97
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Jolly S, Dorian P, Alter DA. The impact of implantable cardiac defibrillators for primary prophylaxis in the community: baseline risk and clinically meaningful benefits. J Eval Clin Pract 2006; 12:190-5. [PMID: 16579828 DOI: 10.1111/j.1365-2753.2006.00616.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To estimate the baseline risk of arrhythmic death required for prophylactic implantable cardiac defibrillators (ICDs) to result in clinically meaningful survival benefits in the population. BACKGROUND While proven efficacious, the absolute survival impact of ICDs for the primary prevention of sudden cardiac death among patients with left ventricular (LV) dysfunction is highly dependent upon patient's baseline risk of arrhythmic death. METHODS Using echocardiographic data from a random sample of patients identified from community echocardiographic laboratories, patients with moderate or severe LV dysfunction (ejection fraction < 35%) were linked to administrative databases to characterize baseline mortality risk (median follow-up duration of 4.85 years). Relative efficacy was ascertained from meta-analysis and clinical trial data. The baseline annual risk of arrhythmic death required for prophylactic ICDs to result in clinically meaningful survival benefits in the population was estimated at different ranges of relative efficacy and numbers needed to treat (NNTs) thresholds. RESULTS LV dysfunction was a significant independent predictor of adverse outcomes. In total, 35.4% of the patients with moderate to severe LV dysfunction died during the follow-up period. Assuming a base-case relative efficacy of 66%, we estimated that the baseline risk for arrhythmic death required to exert a clinically meaningful NNT threshold of 50 in order to prevent one death (from any cause) was 3% per year or higher. CONCLUSIONS The survival impact and cost-effectiveness of prophylactic ICDs in the population will depend upon the ability to risk-stratify and identify patients whose baseline risk for sudden cardiac death exceed 3% per year.
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Affiliation(s)
- S Jolly
- St. Michael's Hospital, University of Toronto, Ontario, Canada
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98
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Winslow RD, Pinney S, Fuster V. Impact of implantable-cardioverter-defibrillator trials on clinical management of patients with heart failure. ACTA ACUST UNITED AC 2006; 3:86-93. [PMID: 16446777 DOI: 10.1038/ncpcardio0450] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Accepted: 09/27/2005] [Indexed: 11/08/2022]
Abstract
Heart failure is a deadly disease. Every year, tens of thousands of patients die from this condition, many of them suddenly. Efforts aimed at reducing mortality centered initially on antagonizing the neurohormonal system, which is maladaptively upregulated in response to myocardial failure. Antagonists of the renin-angiotensin-aldosterone and adrenergic nervous systems have reduced the rates of cardiovascular mortality and sudden cardiac death. Antiarrhythmic drug therapy has not fared as well. Consequently, efforts to reduce the risk of sudden death have focused on the use of implantable cardioverter-defibrillators (ICDs). How best to identify patients who will benefit from this invasive and expensive therapy has yet to be clearly determined. In this review, we discuss the effectiveness of ICDs in primary and secondary prevention of sudden death in heart failure patients, and examine the impact that the use of ICDs has had on clinical decision making.
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99
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Bosch JL, Beinfeld MT, Muller JE, Brady T, Gazelle GS. A Cost-Effectiveness Analysis of a Hypothetical Catheter-Based Strategy for the Detection and Treatment of Vulnerable Coronary Plaques with Drug-Eluting Stents. J Interv Cardiol 2005; 18:339-49. [PMID: 16202108 DOI: 10.1111/j.1540-8183.2005.00074.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIM Extensive efforts are underway to develop methods for the detection and treatment of vulnerable/high-risk coronary artery plaques. We utilized decision analysis to evaluate the hypothetical clinical benefits and cost-effectiveness of a catheter-based strategy. METHODS AND RESULTS Currently, stenotic coronary plaques are treated without regard to vulnerability. In a new strategy, vulnerable coronary plaques are detected with a catheter-based test and treated with a drug-eluting stent, regardless of degree of stenosis. A Markov-decision model was developed to compare the new strategy with current practice. Monte Carlo simulations were performed from a societal perspective, costs were converted to year 2003 U.S. dollars, and future costs and outcomes were discounted at 3%. Sensitivity analyses were performed to evaluate the effect of assumptions on variables such as the prevalence of vulnerable plaques and treatment effect. In 60-year-old male patients with coronary stenoses the new strategy would be less expensive and more effective than current practice (37,045 dollars vs 38,257 dollars and 10.23 vs 9.86 quality-adjusted life years (QALYs), respectively). The benefits of the new strategy were robust in sensitivity analyses (e.g., if the prevalence of vulnerable plaques in this patient group was 50% or more and the sensitivity and specificity of the new test were at least 0.80). CONCLUSION In selected patients with coronary artery stenosis, the detection of vulnerable plaques with a catheter-based test followed by their treatment with a drug-eluting stent could be a less expensive and more effective strategy than current practice. If applied to 1 million such patients in the United States undergoing catheterization, the new strategy would add 370,000 QALYs and save 1.2 billion dollars per year.
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Affiliation(s)
- Johanna L Bosch
- Institute for Technology Assessment, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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100
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Fallavollita JA, Riegel BJ, Suzuki G, Valeti U, Canty JM. Mechanism of sudden cardiac death in pigs with viable chronically dysfunctional myocardium and ischemic cardiomyopathy. Am J Physiol Heart Circ Physiol 2005; 289:H2688-96. [PMID: 16085676 DOI: 10.1152/ajpheart.00653.2005] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pigs with viable chronically dysfunctional myocardium and ischemic cardiomyopathy are at high risk of sudden cardiac death (SCD). We sought to identify the arrhythmic mechanism of SCD, the relation to changes in left ventricular (LV) function, and inducibility of malignant arrhythmias before SCD. Juvenile pigs (n = 72) were instrumented with chronic stenoses on proximal left anterior descending and circumflex arteries. Survival was only 29% 3 mo after instrumentation, and all deaths were sudden and without prodromal symptoms of heart failure. Triphenyltetrazolium chloride staining demonstrated necrosis in only nine animals averaging 2.3 +/- 0.9% of the LV, with no difference between SCD animals and survivors. Implantable loop recorders (n = 13) documented both ventricular fibrillation (n = 6) and bradyasystole (n = 2) as the arrhythmic mechanism of death. Although regional and global function were depressed [anteroseptal wall thickening 1.8 +/- 0.2 vs. 4.2 +/- 0.2 mm in Sham animals (P < 0.001); fractional shortening 21 +/- 2 vs. 31 +/- 1% in Sham animals (P < 0.01)], there were no differences between SCD animals and survivors. LV mass increased in animals with ischemic cardiomyopathy and was greater in animals with SCD (4.0 +/- 0.2 vs. 3.1 +/- 0.1 g/kg in survivors; P < 0.001). Serial programmed ventricular stimulation failed to induce any sustained arrhythmias. We conclude that pigs with viable dysfunctional myocardium and globally reduced LV function have a high rate of SCD with a spectrum of arrhythmias similar to patients with ischemic cardiomyopathy. The risk is independent of necrosis but appears to increase with LV hypertrophy. Like patients with ischemic cardiomyopathy, programmed stimulation is insensitive to predict SCD when viable dysfunctional myocardium is the pathological substrate.
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Affiliation(s)
- James A Fallavollita
- Biomedical Research Bldg., Rm. 347, Dept. of Medicine/Cardiology, University at Buffalo, 3435 Main St., Buffalo, NY 14214, USA.
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