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A comparison of the predictive value of programmed electrical stimulation and holter monitoring in patients with malignant ventricular arrhythmias
ABSTRACTS
TUESDAY, APRIL 27, AM SUDDEN DEATH I 8:30- 10:00
1982
COMPLEX VENTRICULAR PREMATURE DEPOLARIZATIONS AS A PREDICTOR OF MORTALITY IN SURVIVORS OF OUT-OF-HOSPITAL CARDIAC ARREST Peter Temesy-Amos, MD, Sidney Goldstein, MD, FACC, J. Richard Landis, PhD, Richard F. Leighton, MD, FACC, George Ritter, MD, C. Mark Vasu, MD, Allyn Lantis, BS, Ruth Serokman, BA, Robert Wolfe, PhD, Medical Colleoe of Ohio, Toledo, Ohio. Characteristics of resuscitated out-of-hospital cardiac arrest victims were analyzed prospectively to determine risk of subsequent death and of sudden death (SD). The study group comprised 79 pts who had a 24-hour ambulatory electrocardiographic record (AECG) obtained within 6 months of their arrest event and survived 6 months after this event. Pts were followed from 6 months UP to 54 months. Deaths occurred in 24% (19/79); sudden death in Complex ventricular premature depolariza15% (12/79). tion (VPD) defined as multifocal VPD, two or more successive VPD, early cycle VPD or bigeminal VPD during AECG, occurred in 90% (71/79) of pts. It was the most siqnificant predictor of death and.SD of over 40 variables-testIn those pts without complex VPD no deaths occurred ed. (O/8) whereas death durin follow-up occurred in 27% (19/71) with complex VPD 4 p< .025) and sudden death occurred in 17% (12/71) (p' .05). It is concluded that complex VPD are useful predictors of death and SD occurring after 6 months fol‘lowing resuscitation in this population.
SUDDEN CARDIAC ARREST IN YOUNG ADULTS: CLINICAL AND ELECTROPHYSIOLOGICAL FINDINGS Benson DW Jr., MD Ph D; Hession Wl, FD; Zavoral JH, MD: Benditt DG, t@, University of Minnesota, Minneapolis, MN We report findings in six young (15-29 years) patients whose initial manifestation of cardiovascular disease was sudden cardiac arrest (SCA). Echocardiogra@ic and anaioaraohic studies were normal in 5 pts and revealed i?li diffuse left ventricular hypokinesia in (WPW) One of the 6 pts had Wolff-Parkinson-White one. syndrome. All pts tnderwent multicatheter electrophysiological In 4/6 ots a sustained rapid (cycle length < 260 studv. msecj wide QRS tachycardia was induced.- In 3 o? t&e pts ventricular tachycardia (VT) was diagnosed and in each case DC cardioversion was required during laboratory study to reverse hemodynamic collapse. In the WPW pt inducible antidromic recivocating tachycardia spantaneously converted to atria1 fibrillation with a rapid In the 3 patients with VT, tachyventricular response. cardia was induced with 3 or 4 right ventricular extrastimuli; however, following medical theraw VT induction was no longer possible and there have been no SCA recurrences in 6-36 months of follow-up. The WPW pt underwent successful surgical ablation of a posterior Induction of sustained VT septal accessory connection. was not possible in 2 pts, and the effects of therapy could not be tested. Both patients subsequently had recurrence of SCA, and one died. In conclusion, SCA can occur in apparently healthy Vigorous rogranmned intracardiac electriyoung adults. cal stimulation mav demonstrate life threatenina tachycardias, and 'the ability to initiate tachycardia in the electrophysiological laboratory may be useful in establishing management of these pts.
(pts)
928
March 1982
The American Journal of CARDIOLOGY
A COMPARISON OF THE PREDICTIVEVALUE OF PROGRAMMED ELECTRICAL STIMULATION AND HOLTER MONITORING IN PATIENTS WITH MALIGNANTVENTRICULARARRHYTHMIAS. Edward V. Platia, MD; Stephen C. Vlay, MD; Philip R. Reid, MD, FACC. The Johns Hopkins University, Baltimore, Maryland. Programmed electricalstimulation(PES) and Holter monitoring were carried out in 46patients (pts)with ventricularfibrillation (VF) (22 pts)or recurrent symptomatic ventriculartachycardia (VT) (24 pts) who were discharged and thereaftermointained on the same antiorrhythmicdrug(s at time of PES and Holter. PES (RV and LV stimulation)included burstV pacing and single and double vgntricularpremature beats following V drive. PES was defined as positive(+) ifsustdinedor nonsustained VT of 3 beats or more was induced. Holter monitoring was carried out for 54k.8 hr just before or after PES while the same drug(s)were maintained. A (+) Halter was defined as one showing 3 or more beats of VT, rate >lOO. Follawup time was 11.8~2 months, with positive endpoint being VF or symptomatic VT. Of 46 pts, 23 had VF or VT on followup (VF in I2 pts, VT in II). The predictive accuracy (PA), positive predictive value (+PV), and negative predictive value (-PV)of Holter and PES are shown below. Halter & ?& $k 86% 79% PES 95% Kaplan-Meier life table analysis was carried out, defining a goad clinical outcome as absence of symptomatic VT or VF during follow up. Life table analysis demonstrated a significantly worse prognosis in those pts in whom PES was (+) compared with those whose PES was(-) (p<.OOl). There was no significant difference in prognosis, however, between pts with a (+) Holter compared with those with a (-) Holter. These data suggest that I) although VT on Holter is associated with o poor clinical outcome, the overall PA of the Holter is of limited value in predicting those with a good clinical outcome, 2) PES is predictive of both good and poor clinical outcome, and 3) overoll, PES appears more useful than Halter in the management of pts with malignant ventricular arrhythmias.
ELECTROPHYSIOLOGICAL STUDY TO DIRECT THERAPY IN SURVIVORS OF PRE-HOSPITAL VENTRICULAR FIBRILLATION Richard F. Kehoe, MD; John M. Moran, MD; Terry Zheutlin, MD; Carl Tommaso, MD; Michael Lesch, MD, FACC. Northwestern University School of Medicine; Chicago, IL Survivors of out-of-hospital ventricular fibrillation (OOH-VF) remain et high risk for recurrence. Invasive electrophysiologic study (EPS) was used to direct therapy end assess risk of recurrence in 44 consecutive patients (pts) surviving OOH-VF unrelated to acute infarction. Organic heart disease was present in 42: ischemic, 35; cardiomyopathy, 6; valvular, 1. In twelve pts, VF was recurrent. All here studied within six weeks of the lest episode. Sustained, poorly tolerated ventricular tachycardia (VT) was lnitieble et control EPS in 28 end absent 3 dying periin 16. Forty-one pts survived hospitalization. operatively after endocardial resection. These 41 were divided into two groups on the basis of predischarge EPS results. Group I consisted of 32 pts with absence of inducible VT et predischarge EPS. VT induction was eventuelly prevented by antiarrhythmic drugs (AD) in 5, by endocerdial resection after failure of AD in 11, end was absent at control study in the remaining 16. All 32 Grouo I ots. 5 on end 27 off AD. remain free of recurrent VT/VF et 14.0 ; 5:8 months The S Group 11pts had persistence of inducible VT despite serial evaluations (mean = 5.2/pt) with conventional/experimental AD. These pts were followed for 9.1 + 5.2 months on therapy deemed ineffective by EPS. Seven of 9 pts (78%) recurred, 5 dying suddenly end 2 surviving OOH-VF. The difference in recurrence of OOH-VF or sudden death between Group I (O/32) end Group ll (7/9) was highly significant, p < 0.001. We conclude: 1) medical/surgical therapy preventing inducible VT protects against recurrent VF; 2) pts free of inducible VT et control EPS are unlikely to recur; 3) persistence of inducible VT identifies pts et high risk for recurrent VF. The effectiveness of endocardial resection in the treatment of VF survivors justifies consideration of its use in pts with persistent inducible VT.
Volume 49
TUESDAY, APRIL 27, AM SUDDEN DEATH I 8:30- 10:00
1982
COMPLEX VENTRICULAR PREMATURE DEPOLARIZATIONS AS A PREDICTOR OF MORTALITY IN SURVIVORS OF OUT-OF-HOSPITAL CARDIAC ARREST Peter Temesy-Amos, MD, Sidney Goldstein, MD, FACC, J. Richard Landis, PhD, Richard F. Leighton, MD, FACC, George Ritter, MD, C. Mark Vasu, MD, Allyn Lantis, BS, Ruth Serokman, BA, Robert Wolfe, PhD, Medical Colleoe of Ohio, Toledo, Ohio. Characteristics of resuscitated out-of-hospital cardiac arrest victims were analyzed prospectively to determine risk of subsequent death and of sudden death (SD). The study group comprised 79 pts who had a 24-hour ambulatory electrocardiographic record (AECG) obtained within 6 months of their arrest event and survived 6 months after this event. Pts were followed from 6 months UP to 54 months. Deaths occurred in 24% (19/79); sudden death in Complex ventricular premature depolariza15% (12/79). tion (VPD) defined as multifocal VPD, two or more successive VPD, early cycle VPD or bigeminal VPD during AECG, occurred in 90% (71/79) of pts. It was the most siqnificant predictor of death and.SD of over 40 variables-testIn those pts without complex VPD no deaths occurred ed. (O/8) whereas death durin follow-up occurred in 27% (19/71) with complex VPD 4 p< .025) and sudden death occurred in 17% (12/71) (p' .05). It is concluded that complex VPD are useful predictors of death and SD occurring after 6 months fol‘lowing resuscitation in this population.
SUDDEN CARDIAC ARREST IN YOUNG ADULTS: CLINICAL AND ELECTROPHYSIOLOGICAL FINDINGS Benson DW Jr., MD Ph D; Hession Wl, FD; Zavoral JH, MD: Benditt DG, t@, University of Minnesota, Minneapolis, MN We report findings in six young (15-29 years) patients whose initial manifestation of cardiovascular disease was sudden cardiac arrest (SCA). Echocardiogra@ic and anaioaraohic studies were normal in 5 pts and revealed i?li diffuse left ventricular hypokinesia in (WPW) One of the 6 pts had Wolff-Parkinson-White one. syndrome. All pts tnderwent multicatheter electrophysiological In 4/6 ots a sustained rapid (cycle length < 260 studv. msecj wide QRS tachycardia was induced.- In 3 o? t&e pts ventricular tachycardia (VT) was diagnosed and in each case DC cardioversion was required during laboratory study to reverse hemodynamic collapse. In the WPW pt inducible antidromic recivocating tachycardia spantaneously converted to atria1 fibrillation with a rapid In the 3 patients with VT, tachyventricular response. cardia was induced with 3 or 4 right ventricular extrastimuli; however, following medical theraw VT induction was no longer possible and there have been no SCA recurrences in 6-36 months of follow-up. The WPW pt underwent successful surgical ablation of a posterior Induction of sustained VT septal accessory connection. was not possible in 2 pts, and the effects of therapy could not be tested. Both patients subsequently had recurrence of SCA, and one died. In conclusion, SCA can occur in apparently healthy Vigorous rogranmned intracardiac electriyoung adults. cal stimulation mav demonstrate life threatenina tachycardias, and 'the ability to initiate tachycardia in the electrophysiological laboratory may be useful in establishing management of these pts.
(pts)
928
March 1982
The American Journal of CARDIOLOGY
A COMPARISON OF THE PREDICTIVEVALUE OF PROGRAMMED ELECTRICAL STIMULATION AND HOLTER MONITORING IN PATIENTS WITH MALIGNANTVENTRICULARARRHYTHMIAS. Edward V. Platia, MD; Stephen C. Vlay, MD; Philip R. Reid, MD, FACC. The Johns Hopkins University, Baltimore, Maryland. Programmed electricalstimulation(PES) and Holter monitoring were carried out in 46patients (pts)with ventricularfibrillation (VF) (22 pts)or recurrent symptomatic ventriculartachycardia (VT) (24 pts) who were discharged and thereaftermointained on the same antiorrhythmicdrug(s at time of PES and Holter. PES (RV and LV stimulation)included burstV pacing and single and double vgntricularpremature beats following V drive. PES was defined as positive(+) ifsustdinedor nonsustained VT of 3 beats or more was induced. Holter monitoring was carried out for 54k.8 hr just before or after PES while the same drug(s)were maintained. A (+) Halter was defined as one showing 3 or more beats of VT, rate >lOO. Follawup time was 11.8~2 months, with positive endpoint being VF or symptomatic VT. Of 46 pts, 23 had VF or VT on followup (VF in I2 pts, VT in II). The predictive accuracy (PA), positive predictive value (+PV), and negative predictive value (-PV)of Holter and PES are shown below. Halter & ?& $k 86% 79% PES 95% Kaplan-Meier life table analysis was carried out, defining a goad clinical outcome as absence of symptomatic VT or VF during follow up. Life table analysis demonstrated a significantly worse prognosis in those pts in whom PES was (+) compared with those whose PES was(-) (p<.OOl). There was no significant difference in prognosis, however, between pts with a (+) Holter compared with those with a (-) Holter. These data suggest that I) although VT on Holter is associated with o poor clinical outcome, the overall PA of the Holter is of limited value in predicting those with a good clinical outcome, 2) PES is predictive of both good and poor clinical outcome, and 3) overoll, PES appears more useful than Halter in the management of pts with malignant ventricular arrhythmias.
ELECTROPHYSIOLOGICAL STUDY TO DIRECT THERAPY IN SURVIVORS OF PRE-HOSPITAL VENTRICULAR FIBRILLATION Richard F. Kehoe, MD; John M. Moran, MD; Terry Zheutlin, MD; Carl Tommaso, MD; Michael Lesch, MD, FACC. Northwestern University School of Medicine; Chicago, IL Survivors of out-of-hospital ventricular fibrillation (OOH-VF) remain et high risk for recurrence. Invasive electrophysiologic study (EPS) was used to direct therapy end assess risk of recurrence in 44 consecutive patients (pts) surviving OOH-VF unrelated to acute infarction. Organic heart disease was present in 42: ischemic, 35; cardiomyopathy, 6; valvular, 1. In twelve pts, VF was recurrent. All here studied within six weeks of the lest episode. Sustained, poorly tolerated ventricular tachycardia (VT) was lnitieble et control EPS in 28 end absent 3 dying periin 16. Forty-one pts survived hospitalization. operatively after endocardial resection. These 41 were divided into two groups on the basis of predischarge EPS results. Group I consisted of 32 pts with absence of inducible VT et predischarge EPS. VT induction was eventuelly prevented by antiarrhythmic drugs (AD) in 5, by endocerdial resection after failure of AD in 11, end was absent at control study in the remaining 16. All 32 Grouo I ots. 5 on end 27 off AD. remain free of recurrent VT/VF et 14.0 ; 5:8 months The S Group 11pts had persistence of inducible VT despite serial evaluations (mean = 5.2/pt) with conventional/experimental AD. These pts were followed for 9.1 + 5.2 months on therapy deemed ineffective by EPS. Seven of 9 pts (78%) recurred, 5 dying suddenly end 2 surviving OOH-VF. The difference in recurrence of OOH-VF or sudden death between Group I (O/32) end Group ll (7/9) was highly significant, p < 0.001. We conclude: 1) medical/surgical therapy preventing inducible VT protects against recurrent VF; 2) pts free of inducible VT et control EPS are unlikely to recur; 3) persistence of inducible VT identifies pts et high risk for recurrent VF. The effectiveness of endocardial resection in the treatment of VF survivors justifies consideration of its use in pts with persistent inducible VT.
Volume 49