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Outcomes in patients with sustained ventricular tachyarrhythmias occurring within 48 h of acute myocardial infarction: when is ICD appropriate?

Jackson J. Liang , David O. Hodge , Ramila A. Mehta , Andrea M. Russo , Abhiram Prasad , Yong-Mei Cha
DOI: http://dx.doi.org/10.1093/europace/euu138 1759-1766 First published online: 6 August 2014

Abstract

Aims Recent guidelines for implantable cardioverter-defibrillator (ICD) use in patients with early ventricular arrhythmia (VA) after acute myocardial infarction (MI) are based on systolic function and revascularization status, yet decision to implant an ICD remains highly subjective. We aimed to determine characteristics, utilization of ICDs, and long-term outcomes of survivors of early VA (<48 h) after acute MI.

Methods and results We retrospectively analyzed clinical characteristics, ICD therapies, and survival in 128 patients with early VA after acute MI from 2002–12. Patients were classified for appropriateness of ICD implantation, per 2013 Appropriate Use Criteria (AUC). In 128 early VA survivors after MI, older age, female gender, history of coronary artery bypass graft surgery (CABG) or MI, non-ST-elevation MI or ventricular tachycardia (VT) at presentation predicted worse overall survival (all P < 0.05). While left ventricular ejection fraction (LVEF) did not predict mortality (HR = 1; P = 0.86), post-MI ventricular fibrillation (VF) portended a better long-term prognosis than VT (HR = 0.37; P = 0.001). Twenty-six (20%) early VA survivors received ICD, corresponding well with AUC. Implantable cardioverter-defibrillator recipients had lower post-MI LVEF (P = 0.02) and more frequently presented with non-ST-elevation MI (P = 0.007). Over 2.4 years of median follow-up, ICD recipients had a greater mortality rate than non-ICD recipients (42 vs. 17%; P = 0.02). Appropriate and inappropriate ICD discharges were high in ICD recipients.

Conclusion Early VA survivors after MI receiving ICD due to suspected non-reversible arrhythmogenic substrate have high rates of appropriate ICD therapy and mortality. Our ICD implantation practice corresponds well with the AUC. Sustained monomorphic VT and non-ST-elevation MI at presentation predict increased risk for death. Larger prospective studies are necessary to confirm our findings, such as to provide evidence for future ICD guidelines.

  • Ventricular arrhythmia
  • Appropriateness
  • Myocardial infarction
  • Sudden cardiac death
  • Implantable cardioverter-defibrillator
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