1
|
Manolis AS, Manolis AA, Manolis TA, Apostolopoulos EJ, Papatheou D, Melita H. COVID-19 infection and cardiac arrhythmias. Trends Cardiovasc Med 2020; 30:451-460. [PMID: 32814095 PMCID: PMC7429078 DOI: 10.1016/j.tcm.2020.08.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/04/2020] [Accepted: 08/14/2020] [Indexed: 02/07/2023]
Abstract
As the coronavirus 2019 (COVID-19) pandemic marches unrelentingly, more patients with cardiac arrhythmias are emerging due to the effects of the virus on the respiratory and cardiovascular (CV) systems and the systemic inflammation that it incurs, and also as a result of the proarrhythmic effects of COVID-19 pharmacotherapies and other drug interactions and the associated autonomic imbalance that enhance arrhythmogenicity. The most worrisome of all arrhythmogenic mechanisms is the QT prolonging effect of various anti-COVID pharmacotherapies that can lead to polymorphic ventricular tachycardia in the form of torsade des pointes and sudden cardiac death. It is therefore imperative to monitor the QT interval during treatment; however, conventional approaches to such monitoring increase the transmission risk for the staff and strain the health system. Hence, there is dire need for contactless monitoring and telemetry for inpatients, especially those admitted to the intensive care unit, as well as for outpatients needing continued management. In this context, recent technological advances have ushered in a new era in implementing digital health monitoring tools that circumvent these obstacles. All these issues are herein discussed and a large body of recent relevant data are reviewed.
Collapse
Affiliation(s)
- Antonis S Manolis
- First Department of Cardiology, Athens University School of Medicine, Athens, Greece.
| | | | | | | | | | | |
Collapse
|
2
|
Exner DV, Klein GJ. Do we need a randomized trial of defibrillator therapy in every subset of patients with increased risk of sudden death? J Cardiovasc Electrophysiol 2003; 14:574-7. [PMID: 12875415 DOI: 10.1046/j.1540-8167.2003.03081.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
MESH Headings
- Amiodarone/therapeutic use
- Anti-Arrhythmia Agents/therapeutic use
- Chagas Cardiomyopathy/epidemiology
- Chagas Cardiomyopathy/therapy
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Electrophysiologic Techniques, Cardiac
- Humans
- Randomized Controlled Trials as Topic
- Risk Factors
- Sotalol/therapeutic use
- Tachycardia, Ventricular/epidemiology
- Tachycardia, Ventricular/therapy
- Ventricular Dysfunction, Left/epidemiology
- Ventricular Dysfunction, Left/therapy
Collapse
|
3
|
Schläpfer J, Rapp F, Kappenberger L, Fromer M. Electrophysiologically guided amiodarone therapy versus the implantable cardioverter-defibrillator for sustained ventricular tachyarrhythmias after myocardial infarction: results of long-term follow-up. J Am Coll Cardiol 2002; 39:1813-9. [PMID: 12039497 DOI: 10.1016/s0735-1097(02)01863-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We sought to compare the long-term survival rates of patients with sustained ventricular tachyarrhythmia after myocardial infarction (MI) who were treated according to the results of electrophysiological (EP) study either with amiodarone or an implantable cardioverter-defibrillator (ICD). BACKGROUND Patients with sustained ventricular tachyarrhythmias after MI are at high risk of sudden cardiac death (SCD). However, data comparing the long-term survival rates of patients treated with amiodarone or ICD, according to the results of EP testing, are lacking. METHODS Patients underwent a first EP study at baseline and a second one after a loading dose of amiodarone of 14 +/- 2.9 g. According to the results of the second EP study, patients were classified either as responders or non-responders to amiodarone; non-responders were eventually treated with an ICD. RESULTS Eighty-four consecutive patients with MI (78 men; 21-77 years old; mean left ventricular (LV) ejection fraction 36 +/- 11%) were consecutively included. Forty-three patients (51%) were responders, and 41 patients (49%) were non-responders to amiodarone therapy. During a mean follow-up period of 63 +/- 30 months, SCD and total mortality rates were significantly higher in the amiodarone-treated patients (p = 0.03 and 0.02, respectively). CONCLUSIONS The long-term survival of patients with sustained ventricular tachyarrhythmias after MI, with depressed LV function, is significantly better with an ICD than with amiodarone therapy, even when stratified according to the results of the EP study. These patients should benefit from early ICD placement, and any previous amiodarone treatment seems to have no additional value.
Collapse
Affiliation(s)
- Jürg Schläpfer
- Division of Cardiology, University Hospital (CHUV), 1011 Lausanne, Switzerland.
| | | | | | | |
Collapse
|
4
|
Maury P, Zimmermann M, Metzger J, Reynard C, Dorsaz P, Adamec R. Amiodarone therapy for sustained ventricular tachycardia after myocardial infarction: long-term follow-up, risk assessment and predictive value of programmed ventricular stimulation. Int J Cardiol 2000; 76:199-210. [PMID: 11104875 DOI: 10.1016/s0167-5273(00)00379-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- P Maury
- Division of Cardiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | | | | | | | | |
Collapse
|
5
|
Link MS, Homound M, Foote CB, Wang PJ, Estes NA. Antiarrhythmic drug therapy for ventricular arrhythmias: current perspectives. J Cardiovasc Electrophysiol 1996; 7:653-70. [PMID: 8807411 DOI: 10.1111/j.1540-8167.1996.tb00573.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pharmacologic therapy for ventricular arrhythmias has undergone a remarkable change recently. Recognition of the importance of underlying structural heart disease on prognostic implications of ventricular arrhythmias has resulted in the refinement of the clinical classification of these arrhythmias. With refinement of techniques of risk stratification, it is now possible to identify patients ventricular arrhythmias at high risk for sudden death. Retrospective analyses of prior antiarrhythmic drug trials and new data from prospective randomized trials are now available and can more directly define the risks and benefits of antiarrhythmic therapy. Prevention of sudden death, reduction in total mortality, or improvement in symptoms remain the only benefits of antiarrhythmic drugs. With inclusion of total mortality as the major endpoint for assessment of pharmacologic interventions in high-risk patients, the potential for excess mortality due to antiarrhythmic agents is now recognized. The pharmacologic diversity of newly released antiarrhythmic agents and others under development has resulted in a re-evaluation of the traditional classification of these drugs. Multiple ongoing clinical trials will define the risks and benefits of antiarrhythmic therapy and other nonpharmacologic interventions in patients with ventricular arrhythmias.
Collapse
Affiliation(s)
- M S Link
- New England Medical Center, Division of Cardiology/Department of Medicine, Boston, Massachusetts 02111, USA
| | | | | | | | | |
Collapse
|
6
|
Rodríguez LM, Sternick EB, Smeets JL, Timmermans C, den Dulk K, Oreto G, Wellens HJ. Induction of ventricular fibrillation predicts sudden death in patients treated with amiodarone because of ventricular tachyarrhythmias after a myocardial infarction. HEART (BRITISH CARDIAC SOCIETY) 1996; 75:23-8. [PMID: 8624866 PMCID: PMC484216 DOI: 10.1136/hrt.75.1.23] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To examine the value of programmed electrical stimulation of the heart in predicting sudden death in patients receiving amiodarone to treat ventricular tachyarrhythmias after myocardial infarction. DESIGN Consecutive patients; retrospective study. SETTING Referral centre for cardiology, academic hospital. PATIENTS 106 patients with ventricular tachycardia (n = 77) or ventricular fibrillation (n = 29) late after myocardial infarction. INTERVENTIONS Programmed electrical stimulation was performed while on amiodarone treatment for at least one month. MEASUREMENTS AND MAIN RESULTS In 80/106 patients either ventricular fibrillation (n = 15) or sustained monomorphic ventricular tachycardia (n = 65) was induced. After a mean follow up of 50 (SD 40) months (1-144), 11 patients died suddenly and two used their implantable cardioverter debfibrillator. By multivariate analysis two predictors for sudden death were found: (1) inducibility of ventricular fibrillation under amiodarone treatment (P << 0.001), and (2) a left ventricular ejection fraction of < 40% (P < 0.05). The survival rate at one, two, three, and five years was 70%, 62%, 62%, and 40% respectively for patients in whom ventricular fibrillation was induced, and 98%, 96%, 94%, 94% for patients with induced sustained monomorphic ventricular tachycardia. Where there was no sustained arrhythmia, five year survival was 100%. CONCLUSIONS In patients receiving amiodarone because of life threatening ventricular arrhythmias after myocardial infarction, inducibility of ventricular fibrillation, but not of sustained monomorphic ventricular tachycardia, indicates a high risk of sudden death.
Collapse
Affiliation(s)
- L M Rodríguez
- Department of Cardiology, University of Limburg, Academic Hospital, Maastricht, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
7
|
Kupersmith J, Holmes-Rovner M, Hogan A, Rovner D, Gardiner J. Cost-effectiveness analysis in heart disease, Part III: Ischemia, congestive heart failure, and arrhythmias. Prog Cardiovasc Dis 1995; 37:307-46. [PMID: 7871179 DOI: 10.1016/s0033-0620(05)80017-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Cost-effectiveness analyses were reviewed in the following diagnostic and treatment categories: acute myocardial infarction (MI) and diagnostic strategies for coronary artery disease (CAD), coronary artery bypass graft (CABG) surgery, percutaneous transluminal coronary angioplasty (PTCA), congestive heart failure (CHF), and arrhythmias. In the case of acute MI, coronary care units, as presently used, are rather expensive but could be made much more efficient with more effective triage and resource utilization; reperfusion via thrombolysis is cost-effective, as are beta-blockers and angiotensin-converting enzyme (ACE) inhibitors post-MI in appropriate patients. Cost-effectiveness of CAD screening tests depends strongly on the prevalence of disease in the population studied. Cost-effectiveness of CABG surgery depends on targeting; eg, it is highly effective for such conditions as left-main and three-vessel disease but not for lesser disease. PTCA appears to be cost-effective in situations where there is clinical consensus for its use, eg, severe ischemia and one-vessel disease, but requires further analysis based on randomized data; coronary stents also appear to be cost-effective. In preliminary analysis, ACE inhibition for CHF dominates, ie, saves both money and lives. Cardiac transplant appears to be cost-effective but requires further study. For arrhythmias, implantable cardioverter defibrillators are cost-effective, especially the transvenous device, in life-threatening situations; radiofrequency ablation is also cost-effective in patients with Wolff-Parkinson-White syndrome apart from asymptomatic individuals; and pacemakers have not been analyzed except in the case of biofascicular block, where results were variable depending on the situation and preceding tests.
Collapse
Affiliation(s)
- J Kupersmith
- Department of Medicine, College of Human Medicine, Michigan State University, East Lansing 48824
| | | | | | | | | |
Collapse
|
8
|
Martínez-Rubio A, Shenasa M, Chen X, Wichter T, Breithardt G, Borggrefe M. Response to sotalol predicts the response to amiodarone during serial drug testing in patients with sustained ventricular tachycardia and coronary artery disease. Am J Cardiol 1994; 73:357-60. [PMID: 7509121 DOI: 10.1016/0002-9149(94)90008-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
UNLABELLED It was analyzed whether the response to sotalol can predict the response to amiodarone as evaluated by programmed ventricular stimulation in 30 patients with coronary artery disease and documented recurrent sustained ventricular tachycardia (VT). Programmed ventricular stimulation was performed using 1 or 2 extrastimuli during sinus rhythm and 4 drive cycle lengths at 2 right ventricular sites. If no ventricular tachyarrhythmia was induced, a third extrastimulus was introduced during a paced cycle length of 500 ms. During the control study, VT (mean cycle length 305 +/- 63 ms) was induced in all patients, and the right ventricular effective refractory period (during S1-S1 = 500 ms) was 223 +/- 12 ms. After sotalol, sustained and nonsustained VT were inducible in 22 (73%) and 7 (23%) patients, respectively. One patient did not undergo stimulation on sotalol, because of side effects. After amiodarone, sustained and nonsustained VT were inducible in 23 (77%) and 7 (23%) patients, respectively. The mean cycle length of the induced VT was prolonged after both drugs by 17% (p < 0.001). The effective refractory period was prolonged by 15% (p < 0.001) after sotalol and by 13% (p < 0.001 compared with baseline study; p = NS between both drugs) after amiodarone. Thus, concordant results (effective or ineffective drug) between sotalol and amiodarone were found in 26 patients (87%). IN CONCLUSION (1) The effects of sotalol and amiodarone on the cycle length of induced VT and on right ventricular effective refractory period were similar; and (2) inability to suppress VT by amiodarone can be predicted from the response to sotalol.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- A Martínez-Rubio
- Department of Cardiology and Angiology, University of Münster, Germany
| | | | | | | | | | | |
Collapse
|
9
|
Ector H, Rogers R, Rubens A, De Geest H. Classification of death in patients under antiarrhythmic treatment. Pacing Clin Electrophysiol 1993; 16:2250-4. [PMID: 7508602 DOI: 10.1111/j.1540-8159.1993.tb02331.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In the evaluation of antiarrhythmic treatment, total mortality and total cardiac mortality are the only endpoints difficult to misclassify. End-stage cardiac failure competes with "suddenness" in many instances of sudden arrhythmic death. This observational study reports on 23 deaths in a group of 129 patients under antiarrhythmic treatment. In the 21 cases of cardiac death, with respect to the notion "sudden arrhythmic death," classification was problematic in 6 patients. According to different interpretations, the number of deaths listed as "sudden" could vary between one and six. A concise description of cause and circumstances of death, is presented.
Collapse
Affiliation(s)
- H Ector
- Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium
| | | | | | | |
Collapse
|
10
|
Callans DJ, Josephson ME. Future developments in implantable cardioverter defibrillators: the optimal device. Prog Cardiovasc Dis 1993; 36:227-44. [PMID: 8234776 DOI: 10.1016/0033-0620(93)90016-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Despite recent therapeutic advances, SCD remains the leading cause of mortality in industralized nations. The most frequent cause of SCD is ventricular tachyarrhythmias in the setting of advanced structural heart disease due to chronic coronary heart disease or idiopathic dilated cardiomyopathy. Although high-risk groups can be prospectively identified, attempts at primary prevention have been largely unsuccessful. Effective treatment strategies for SCD survivors include antiarrhythmic drug therapy guided by programmed stimulation, endocardial resection, and ICDs. Device therapy has proven extremely effective in preventing recurrent sudden death from ventricular tachyarrhythmias. Widespread application of ICD therapy, perhaps even to include members of high-risk populations that have not experienced cardiac arrest, will depend on many factors including the demonstration that device therapy improves total mortality, not just arrhythmia-related mortality, reduction in cost, and improvements in the devices themselves. Some of the important characteristics of the optimal ICD of the future are nonthoracotomy lead placement; subpectoral generator placement; multiprogrammable, tiered therapy; improved diagnostic specificity, whether based on electrogram or hemodynamic-sensing algorithms; improved integration of brady- and tachy-sensing systems; and enhanced electrogram storage capability with trans-telephonic retrieval of electrogram recordings. The creation of this ideal ICD will obviously require continued technological advances; however, given the tremendous improvements realized over the first three generations of ICD systems, optimism for the future seems warranted.
Collapse
Affiliation(s)
- D J Callans
- Clinical Electrophysiology Laboratories, Hospital of the University of Pennsylvania, Philadelphia
| | | |
Collapse
|
11
|
Sager PT, Uppal P, Follmer C, Antimisiaris M, Pruitt C, Singh BN. Frequency-dependent electrophysiologic effects of amiodarone in humans. Circulation 1993; 88:1063-71. [PMID: 8353868 DOI: 10.1161/01.cir.88.3.1063] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND In general, antiarrhythmic agents that prolong the action potential duration (APD) have attenuated effects on repolarization at short cycle lengths (reverse frequency dependence), and this may limit their efficacy for controlling ventricular arrhythmias. The frequency-dependent effects of amiodarone on repolarization may differ from those of other antiarrhythmic agents and have not been determined in humans. METHODS AND RESULTS The frequency-dependent effects of amiodarone on repolarization and conduction were determined during electrophysiologic study in 19 patients at drug-free baseline and after 11 days of amiodarone loading (1621 +/- 162 mg/d, group A) and in 15 additional patients after > or = 1 year of chronic amiodarone therapy (380 +/- 56 mg/d, group B). The two groups were similar in all clinical characteristics. The ventricular APD at 90% repolarization (APD90), right ventricular effective refractory period (VERP), and QRS duration were determined at paced cycle lengths of 300 to 600 milliseconds. In group A, amiodarone significantly (10% to 13%, P < .001) increased the APD90 at all paced cycle lengths by approximately 30 milliseconds compared with baseline. Similarly, there were no frequency-dependent effects on the percent increase in VERP. However, there was greater amiodarone-induced prolongation of the VERP magnitude at longer paced cycle lengths than at shorter cycle lengths (P = .04), although the VERP remained significantly prolonged at the shortest paced cycle length (300 milliseconds) by 33 +/- 22 milliseconds (16.9% increase from baseline, P < .001). Amiodarone significantly (P < .01) increased the QRS duration at paced cycle lengths < or = 500 milliseconds by a maximum of 28% compared with baseline measurements. The increase in ventricular conduction time was frequency dependent (P < .01), consistent with significant sodium channel blockade. The VERP/APD90 ratio (determined at twice diastolic threshold) was significantly prolonged by amiodarone (as compared with baseline) at cycle lengths > or = 400 milliseconds, indicative of both time- and voltage-dependent effects on refractoriness. The increase in induced sustained ventricular tachycardia cycle length in group A patients after amiodarone loading was significantly correlated with the increase in VERP (r = .68, P = .044) but not with increases in QRS duration or APD90. In addition, there were no significant differences in frequency-dependent effects of amiodarone between groups A and B. CONCLUSIONS The frequency-dependent response of the electrophysiologic effects of amiodarone are similar after 11 days of loading or > or = 1 year of chronic therapy. Amiodarone does not exert frequency-dependent effects on ventricular repolarization; it prolongs refractoriness by both time- and voltage-dependent mechanisms and exerts frequency-dependent effects on ventricular conduction. The absence of amiodarone-induced reverse frequency-dependent effects on repolarization, together with its time-dependent effects on refractoriness may account in part for the high efficacy of the drug and its low propensity to cause torsade de pointes.
Collapse
Affiliation(s)
- P T Sager
- Division of Cardiology, Veterans Affairs Medical Center of West Los Angeles, CA 90073
| | | | | | | | | | | |
Collapse
|
12
|
|
13
|
Proclemer A, Facchin D, Vanuzzo D, Feruglio GA. Risk stratification and prognosis of patients treated with amiodarone for malignant ventricular tachyarrhythmias after myocardial infarction. Cardiovasc Drugs Ther 1993; 7:683-9. [PMID: 8241012 DOI: 10.1007/bf00877822] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Seventy-seven consecutive patients (mean age 62 years) with episodes of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) after acute myocardial infarction (AMI) were evaluated to assess the long-term efficacy of first-line amiodarone treatment and to identify clinical and laboratory factors associated with a high risk of death or arrhythmia recurrence. The presenting arrhythmia was VT in 41 cases (53%) and VF in 36 (47%). VT or VF occurred between the 4th and 90th day after AMI in 45 cases (58%) and later (more than 90 days) in the remaining 32 (42%). The mean number of arrhythmic episodes was 4.2. Forty patients (52%) were in New York Heart Association (NYHA) class I or II, and 37 (48%) were in class III or IV. Mean left ventricular ejection fraction was 32%; ventricular aneurysm was present in 41 subjects. Most patients had multivessel coronary artery disease. Amiodarone was administered as a first-choice drug in all patients, in combination with other antiarrhythmic drugs in 14. By ventricular stimulation after loading doses of amiodarone, sustained VT was inducible in 46 (62%) and noninducible in 28 (38%). During a mean follow-up of 28 months the incidence of cardiac mortality at 1, 3, and 5 years was 21%, 37%, and 47%; of sudden death was 7%, 19%, and 23%; of nonfatal VT recurrence was 13%, 13%, and 24%, respectively. The overall incidence of amiodarone side effects was 35%.2+ was a weak predictor only by univariate analysis (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- A Proclemer
- Istituto di Cardiologia, Ospedale S.M. della Misericordia, Udine, Italy
| | | | | | | |
Collapse
|
14
|
Kowey PR, Marinchak RA, Rials SJ, Rubin AM, Smith L. Electrophysiologic testing in patients who respond acutely to intravenous amiodarone for incessant ventricular tachyarrhythmias. Am Heart J 1993; 125:1628-32. [PMID: 8498304 DOI: 10.1016/0002-8703(93)90751-t] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The outcome of patients who receive intravenous amiodarone for suppression of incessant ventricular tachyarrhythmia has not been studied conclusively. We conducted a prospective study in which all patients who responded acutely to intravenous amiodarone and went on to receive a subsequent oral loading dose were subjected to electrophysiologic testing before hospital discharge to determine whether additional or alternative therapy would be required. Among 18 patients (17 with ischemic heart disease) who entered the protocol, 16 had a clinical response to intravenous amiodarone alone (12 patients) or in combination with another antiarrhythmic drug (4 patients) and survived to study. Of these, 10 had monomorphic ventricular tachycardia (VT) when first seen, five had polymorphous VT or ventricular fibrillation (VF), and three had both. In seven patients sustained monomorphic VT was inducible (group 1), and in nine it was not (group 2). The only clinical factor that distinguished group 1 from group 2 was age (group 1 > group 2). Five patients in group 1 and one in group 2 received an implantable cardioverter defibrillator; one patient in group 1 had a successful endocardial resection. During a mean follow-up period of 11 months, four patients in group 1 have had appropriate implantable cardioverter defibrillator discharges, whereas only one patient in group 2 has had a clinical event (sudden death). We conclude that intravenous amiodarone is a highly effective drug used alone or in combination to suppress spontaneous incessant VT/VF. Predischarge electrophysiologic testing, even in patients who have polymorphous VT, has predictive value over and above the observed clinical response. These preliminary results favor predischarge testing and aggressive device treatment in this cohort.
Collapse
Affiliation(s)
- P R Kowey
- Cardiac Arrhythmia Service, Lankenau Hospital and Medical Research Center, Wynnewood, PA
| | | | | | | | | |
Collapse
|
15
|
Olson PJ, Woelfel A, Simpson RJ, Foster JR. Stratification of sudden death risk in patients receiving long-term amiodarone treatment for sustained ventricular tachycardia or ventricular fibrillation. Am J Cardiol 1993; 71:823-6. [PMID: 8456761 DOI: 10.1016/0002-9149(93)90831-v] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
One hundred twenty-two patients treated chronically with amiodarone for sustained ventricular tachycardia or ventricular fibrillation after failing conventional antiarrhythmic therapy were analyzed to determine which factors were predictive of sudden cardiac death during follow-up. The mean left ventricular ejection fraction in the study group was 0.32, and 87% of the patients had coronary artery disease with a prior myocardial infarction. During a median follow-up of 19.5 months, 30 patients died suddenly. The only variable that was predictive of sudden death was left ventricular ejection fraction. Twenty-nine of the 84 patients with ejection fractions < 0.40 died suddenly, compared with 1 of 35 patients with ejection fractions > or = 0.40. The actuarial probability of sudden death at 5 years was 49% when the ejection fraction was < 0.40, and 5% when the ejection fraction was > or = 0.40 (p = 0.0004). These results indicate that patients treated with amiodarone for sustained ventricular tachycardia or ventricular fibrillation whose ejection fractions are > or = 0.40 are at low risk for sudden death. Patients with ejection fractions < 0.40 remain at high risk for sudden death, and should be considered for additional or alternative therapy.
Collapse
Affiliation(s)
- P J Olson
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill
| | | | | | | |
Collapse
|
16
|
|
17
|
Summitt J, Morady F, Kadish A. A comparison of standard and high-dose regimens for the initiation of amiodarone therapy. Am Heart J 1992; 124:366-73. [PMID: 1636580 DOI: 10.1016/0002-8703(92)90599-q] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The effects of two regimens for the initiation of amiodarone therapy were compared in 92 patients with inducible sustained ventricular tachycardia (VT) at baseline electrophysiologic testing. Two groups of 46 patients each received a total of 16.8 gm of oral amiodarone before follow-up electrophysiologic testing. Group A (standard dose) received 1200 mg/day for 14 days, and group B (high dose) received 2400 mg/day for 7 days. Amiodarone suppressed the induction of sustained VT in six subjects (13%) in group A versus 10 (22%) in group B (p = NS). In subjects who continued to have inducible VT after amiodarone loading, the mean increase in cycle length of induced VT was similar in group A (delta = 85 +/- 73 msec) and group B (delta = 78 +/- 59 msec). The mean increase in sinus cycle length, AH and HV intervals, paced QRS duration, and ventricular refractory periods was also not significantly different between the two groups. Side effects developed in 10 (22%) patients in group B but were serious only in one, and one patient required a reduction in dosage. Thus compared to the 14-day standard-dose regimen, the 7-day high-dose regimen was well tolerated and had similar effects on VT inducibility and electrophysiologic variables. Its use may significantly shorten the duration of hospitalization in patients with life-threatening inducible VT who are undergoing loading with amiodarone on an inpatient basis.
Collapse
Affiliation(s)
- J Summitt
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor
| | | | | |
Collapse
|
18
|
Gill J, Heel RC, Fitton A. Amiodarone. An overview of its pharmacological properties, and review of its therapeutic use in cardiac arrhythmias. Drugs 1992; 43:69-110. [PMID: 1372862 DOI: 10.2165/00003495-199243010-00007] [Citation(s) in RCA: 114] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Amiodarone, originally developed over 20 years ago, is a potent antiarrhythmic drug with the actions of all antiarrhythmic drug classes. It has been successfully used in the treatment of symptomatic and life-threatening ventricular arrhythmias and symptomatic supraventricular arrhythmias. In patients with left ventricular dysfunction amiodarone does not usually produce any clinically significant cardiodepression and the drug has relatively high antiarrhythmic efficacy. Preliminary studies indicate that amiodarone may have a beneficial effect on mortality and survival in certain groups of patients with ventricular arrhythmias, an action probably related to both its antiarrhythmic and antifibrillatory effects. The adverse effect profile of amiodarone is diverse, involving the cardiac, thyroid, pulmonary, hepatic, gastrointestinal, ocular, neurological and dermatological systems. Interstitial pneumonitis and hepatitis are potentially fatal, but the vast majority of adverse events are less serious, and some may be dose dependent. Pretreatment monitoring, regular assessments and the use of minimum effective doses are, therefore, necessary. Thus, with appropriate monitoring to control its well recognised adverse effects amiodarone has an important place as an effective 'broad spectrum' antiarrhythmic drug which has, so far, been used when other treatments have proved ineffective. More recent preliminary data also suggest that it may also have a beneficial effect in the prevention of sudden death in some patients.
Collapse
Affiliation(s)
- J Gill
- Adis International Limited, Chester, UK
| | | | | |
Collapse
|
19
|
Larsen GC, Manolis AS, Sonnenberg FA, Beshansky JR, Estes NA, Pauker SG. Cost-effectiveness of the implantable cardioverter-defibrillator: effect of improved battery life and comparison with amiodarone therapy. J Am Coll Cardiol 1992; 19:1323-34. [PMID: 1564234 DOI: 10.1016/0735-1097(92)90341-j] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The implantable cardioverter-defibrillator (ICD) greatly reduces the incidence of sudden cardiac death among patients with recurrent sustained ventricular tachycardia and fibrillation who do not respond to conventional antiarrhythmic therapy. A cost-effectiveness analysis was performed, comparing the ICD, amiodarone and conventional agents. Actual variable costs of hospitalization and follow-up care were used for 21 ICD- and 43 amiodarone-treated patients. Life expectancy and total variable costs were predicted with use of a Markov decision analytic model. Clinical event rates and probabilities were based on published reports or expert opinion. Life expectancy with an ICD (6.1 years) was 50% greater than that associated with treatment with amiodarone (3.9 years) and 2.5 times that associated with conventional treatment (2.5 years). Assuming replacement every 24 months, ICD lifetime treatment costs (in 1989 dollars) for a 55-year old patient are expected to be $89,600 compared with $24,800 for amiodarone and $16,100 for conventional therapy, yielding a marginal cost/effectiveness ratio for ICD versus amiodarone therapy of 1f429,200/year of life saved, which is comparable to that of other accepted medical treatments. If technologic improvements extend average battery life to 36 months, the marginal cost/effectiveness ratio would be $21,800/year of life saved, and at 96 months it would be $13,800/year of life saved. Patient age at implantation did not significantly affect these results. If quality of life on amiodarone therapy is 30% lower than that with the ICD, the marginal cost/effectiveness ratio decreases by 35%. If the quality of life for patients receiving drugs is 40% lower than that of patients treated with an ICD, use of the defibrillator becomes the dominant strategy.
Collapse
Affiliation(s)
- G C Larsen
- Department of Medicine, New England Medical Center, Boston, Massachusetts
| | | | | | | | | | | |
Collapse
|
20
|
Evans SJ, Myers M, Zaher C, Simonson J, Nalos P, Vaughn C, Oseran D, Gang E, Peter T, Mandel W. High dose oral amiodarone loading: electrophysiologic effects and clinical tolerance. J Am Coll Cardiol 1992; 19:169-73. [PMID: 1729329 DOI: 10.1016/0735-1097(92)90069-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Although amiodarone is an effective drug for the treatment of life-threatening ventricular arrhythmias, no standard oral loading dose protocol has been defined, and patients often undergo prolonged hospitalization for amiodarone loading. High dose (greater than 1,800 mg/day) oral loading has usually been reserved for unstable patients with incessant ventricular tachyarrhythmias. The current study was designed to 1) examine the clinical and electrophysiologic effects of a high dose oral amiodarone loading regimen in more stable patients; and 2) ascertain its safety and tolerance, possibly allowing shortened amiodarone loading periods and potentially decreased length of hospital stay. The study group included 16 patients with a history of recurrent ventricular arrhythmias and decreased left ventricular function, who were refractory to prior antiarrhythmic drug therapy. The oral loading protocol was 50 mg/kg per day of amiodarone for 3 days, then 30 mg/kg per day for 2 days, followed by maintenance therapy of 300 to 400 mg twice daily. Electrophysiologic testing was performed at baseline, on days 1 and 5 and during week 6. Amiodarone and desethylamiodarone levels were measured and symptoms monitored. Clinically, the high dose loading protocol was well tolerated in 15 of the 16 patients. Arrhythmias were rendered noninducible by day 1 in three patients and remained noninducible throughout the study period in two of the three. The remaining patients continued to have inducible ventricular tachycardia. Ventricular tachycardia cycle length and right ventricular effective refractory period both progressively increased significantly over baseline, starting on day 1. The 15 patients who remained in the study had no significant side effects during the loading period.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- S J Evans
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles 90048
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Abstract
Nonpharmacologic therapy for ventricular arrhythmias has gained growing attention with the development of the implantable cardioverter-defibrillator. In addition, the reports of adverse effects of drug therapy from several studies, including the Cardiac Arrhythmia Suppression Trial (CAST), have supported the need for these devices. The development of new implantable cardioverter-defibrillators that have the capability of antitachycardia pacing, bradycardia pacing, cardioversion and defibrillation has enhanced their clinical utility. The currently available implantable cardioverter-defibrillators have been shown to significantly improve survival after sudden cardiac arrest in patients with life-threatening ventricular arrhythmias. Newer devices with expanded capabilities may reduce mortality even further. In this report the features of currently available antitachycardia devices and implantable cardioverter-defibrillators are reviewed and the features and current implant data on newer antitachycardia devices are discussed.
Collapse
Affiliation(s)
- L S Klein
- Krannert Institute of Cardiology, Indianapolis, Indiana 46202-4800
| | | | | |
Collapse
|
22
|
Shannon JA, Hammill SC, Gersh BJ. Predictive value of early electrophysiologic testing in determining long-term outcome with amiodarone treatment in patients with sustained ventricular tachycardia. Mayo Clin Proc 1991; 66:1114-9. [PMID: 1943242 DOI: 10.1016/s0025-6196(12)65790-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This prospective study sought to determine whether programmed ventricular stimulation before hospital dismissal in patients who had received a loading dose of amiodarone would identify those at risk for recurrent ventricular arrhythmias. Between January 1985 and January 1989, 64 patients (55 men and 9 women; mean age, 64 years) with a history of sustained ventricular tachycardia (VT) or ventricular fibrillation were referred to our institution for electrophysiologic testing. Of these patients, 52 had coronary artery disease, 11 had dilated cardiomyopathy, and 1 had hypertrophic cardiomyopathy. Of the 64 patients, 47 had baseline tests while no drugs were administered and repeated electrophysiologic testing after 10 days of amiodarone loading (1.2 g/day). The other 17 patients had no baseline study because of instability of their arrhythmias but underwent electrophysiologic testing after amiodarone loading. Follow-up ranged from 7 to 1,536 days (mean, 652 days). During the follow-up period, recurrent arrhythmias were detected in 22 patients. Of the 64 patients, 14 had suppression of VT. Of 43 patients in whom the cycle lengths of VT were determined both at baseline and after amiodarone therapy, 20 had an increase of 100 ms or more, and 23 had no substantial change. The mean ejection fraction was 31%. Of a total of 16 deaths in the series, 8 were sudden. Suppression of VT during amiodarone therapy suggested a lower rate of fatal and nonfatal recurrent arrhythmias, but the difference was not statistically significant. An increase in the cycle length of VT did not predict an improved outcome. The age of the patient and the presence of a left ventricular aneurysm were slightly predictive of mortality.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- J A Shannon
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN 55905
| | | | | |
Collapse
|
23
|
Abstract
The antiarrhythmic properties of amiodarone at the ventricular level were discovered in the early 1970s. The unanimously recognised efficacy of amiodarone includes a weak negative inotropic effect and compensatory vasodilatory properties, making amiodarone particularly suitable for treating the potentially malignant arrhythmias associated with organic disease. In a review of 611 hospitalised patients on amiodarone, and 353 patients in whom the drug had been prescribed, over a 52-month period in our 60-bed department, we noted that amiodarone was prescribed in 53% of patients for arrhythmias and in 47% of patients for coronary insufficiency. Ventricular arrhythmias represented 13% of the rhythmic indications. These indications differ from those in the USA. The efficacy (70 to 90%) of amiodarone in ventricular extrasystoles has been shown in open studies. In coronary patients, the antiarrhythmic activity of amiodarone is superior to that of propranolol. However, there has been no controlled study because the need for a loading dosage, and the electrocardiographic effects render such studies difficult. After myocardial infarction, ventricular arrhythmias constitute a significant risk factor independently of prognosis; amiodarone may be useful in this indication, and studies of the European Myocardial Infarction Amiodarone Trial (EMIAT) type will examine its value here. Since 1973, it has been recognised that amiodarone can prevent ventricular tachycardia in 55 to 89% of patients in the clinical situation. After a long-standing controversy, the positive predictive value of programmed stimulation has finally been agreed on. In hypertrophic cardiomyopathy, retrospective studies suggest a reduction in mortality in patients treated with amiodarone. By contrast, the value of amiodarone in dilated cardiomyopathy requires more intensive investigation. We consider amiodarone to be indicated in ventricular arrhythmic complexes, particularly if they are associated with an ejection fraction of less than 35% and/or atrial fibrillation. The value of amiodarone in arrhythmias associated with heart failure needs to be evaluated. In conclusion, amiodarone is a powerful antiarrhythmic agent but, because of the possibility of dose- and duration-dependent side effects, evaluation of the risk: benefit ratio in each indication is needed.
Collapse
Affiliation(s)
- S Levy
- Department of Cardiology, Hôpital Nord, University of Aix, Marseille, France
| |
Collapse
|
24
|
Abstract
With the limitations of currently available modalities for treating clinically important tachycardias, the role of implanted antitachycardia devices will continue to expand. The challenge of the future will not only involve continued technological advances but the socioeconomic impact of this efficacious but expensive mode of therapy in an era of increasing financial restraints. Further studies to definitively prove the efficacy of more widespread use of antitachycardia device therapy will be needed.
Collapse
Affiliation(s)
- M E Rosenthal
- Clinical Electrophysiology Laboratory, Hospital of the University of Pennsylvania, Philadelphia 19104
| | | |
Collapse
|
25
|
Strasberg B, Kusniec J, Zlotikamien B, Mager A, Sclarovsky S. Long-term follow-up of postmyocardial infarction patients with ventricular tachycardia or ventricular fibrillation treated with amiodarone. Am J Cardiol 1990; 66:673-8. [PMID: 2399883 DOI: 10.1016/0002-9149(90)91128-s] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Amiodarone in a low dose (200 mg/day) was administered alone or in combination with other type I antiarrhythmic drugs as a first-line agent in 33 patients with ventricular tachycardia (VT) (n = 24) or ventricular fibrillation (VF) (n = 9) secondary to coronary artery disease with healed myocardial infarction. There were 30 men and 3 women (mean age 69 +/- 9 years). Left ventricular ejection fraction ranged from 16 to 45% (mean 29 +/- 8). Therapy was guided by the results of electrophysiologic studies without the use of a control study (without drugs). Predischarge electrophysiologic studies revealed inducible sustained VT in 8 patients (24%), nonsustained VT in 7 and noninducible VT in 18 patients. Mean follow-up time was 27 +/- 7 months. Eleven patients (33%) died, 5 suddenly (15%) and 6 from nonarrhythmic causes. Five patients (15%) had nonfatal recurrences of VT. Life-table analysis showed that arrhythmic recurrences or fatalities (VT or sudden death) were related to the results of the predischarge electrophysiologic studies and not to the baseline arrhythmia (VT or VF). Toxicity from amiodarone was uncommon and no patient discontinued taking the drug.
Collapse
Affiliation(s)
- B Strasberg
- Coronary Care Unit, Beilinson Medical Center, Petah Tiqva, Israel
| | | | | | | | | |
Collapse
|
26
|
Wilber DJ, Olshansky B, Moran JF, Scanlon PJ. Electrophysiological testing and nonsustained ventricular tachycardia. Use and limitations in patients with coronary artery disease and impaired ventricular function. Circulation 1990; 82:350-8. [PMID: 2372886 DOI: 10.1161/01.cir.82.2.350] [Citation(s) in RCA: 203] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Electrophysiological testing was performed in 100 consecutive patients with spontaneous asymptomatic nonsustained ventricular tachycardia, chronic coronary artery disease, and ejection fraction of less than 40%. Fifty-seven patients without inducible sustained ventricular arrhythmias were discharged on no antiarrhythmic therapy. Sustained monomorphic ventricular tachycardia was induced in 37 patients, and polymorphic ventricular tachycardia or ventricular fibrillation was induced in six patients. Of the 43 patients with inducible sustained ventricular arrhythmias, three had spontaneous cardiac arrest during serial drug testing and were excluded from further analysis. Twenty patients were discharged on drug therapy, resulting in suppression of inducible sustained ventricular arrhythmias. The remaining 20 patients with persistently inducible sustained arrhythmias were discharged on drug therapy, resulting in maximal rate slowing of the induced tachycardia. During a mean follow-up of 16.7 months, there were 10 recurrent cardiac arrests or sudden deaths. The 1- and 2-year actuarial incidence of these events was 2% and 6%, respectively, in patients without inducible sustained ventricular arrhythmias; 0% and 11%, respectively, in patients in whom inducible arrhythmias were suppressed; and 34% and 50%, respectively, in patients with persistently inducible sustained ventricular arrhythmias. Multivariate Cox analysis identified only the persistence of inducible sustained ventricular arrhythmias as a significant independent predictor of sudden death or recurrent sustained arrhythmias (p less than 0.001; relative risk, 3.5; 95% confidence intervals, 2.1-4.9). In this population, therapeutic intervention to prevent sudden death is unnecessary in patients without inducible sustained ventricular arrhythmias.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- D J Wilber
- Loyola University Medical Center, Maywood, IL 60153
| | | | | | | |
Collapse
|
27
|
Affiliation(s)
- J P DiMarco
- Department of Medicine, University of Virginia School of Medicine, Charlottesville
| | | |
Collapse
|
28
|
Manolis AS, Tan-DeGuzman W, Lee MA, Rastegar H, Haffajee CI, Huang SK, Estes NA. Clinical experience in seventy-seven patients with the automatic implantable cardioverter defibrillator. Am Heart J 1989; 118:445-50. [PMID: 2773768 DOI: 10.1016/0002-8703(89)90256-1] [Citation(s) in RCA: 96] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Seventy-seven patients with drug-refractory sustained ventricular tachycardia (VT) (28 patients) or ventricular fibrillation (VF) (49 patients) underwent implantation of an automatic cardioverter defibrillator (AICD). The 67 men and 10 women, with a mean age of 60 +/- 12 years (range 18 to 79), had coronary artery disease (60 patients), idiopathic cardiomyopathy (eight patients), mitral valve prolapse (four patients), hypertensive heart disease (one patient), Ebstein's anomaly (one patient), long QT syndrome (one patient), and primary electrical disease (two patients). The mean left ventricular ejection fraction was 35 +/- 16% (range 10% to 75%). Sustained VT/VF was induced in 64 patients (83%) at baseline electrophysiologic testing. A mean of 4.1 +/- 1.3 antiarrhythmic drugs failed to control the arrhythmia. Associated surgery at AICD implantation included coronary artery bypass in 19 patients, coronary bypass with aneurysmectomy in six patients, and aneurysmectomy alone in one patient. Five patients had only prophylactic patches implanted during aneurysmectomy or coronary bypass and the AICD device was subsequently implanted under local anesthesia to prevent arrhythmia recurrence or to control persistently inducible VT. Operative mortality was 2.6% with two deaths from intractable VF. Fifty-two patients (69%) continued receiving antiarrhythmic drugs to suppress spontaneous VT. During a mean follow-up of 15 +/- 13 months (range 1 to 63), six patients died: two suddenly due to probable pulse generator failure (greater than 2 years old), one of acute myocardial infarction, two of heart failure, and one of respiratory failure.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- A S Manolis
- Department of Medicine, Tufts University School of Medicine, Boston, MA 02111
| | | | | | | | | | | | | |
Collapse
|