Sudden cardiac death risk factors

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Risk Factors

Cardiac Arrest or VT/VF Occurring As A Complication of STEMI

VT/VF and/or sudden death may occur early after the presentation of STEMI symptoms (<48 hours) and late after presentation (>48 hours)[1] [2][3][4][5][6]. The occurrence of both early and late VT/VF is associated with higher mortality. In a large contemporary analysis which included 5,745 high risk patients undergoing primary PCI in the APEX AMI trial, about 6% of patients developed VT/VF. the majority of the cases (64%) occurred during cardiac catheterization, and 90% of cases occurred withing 48 hours of presentation of STEMI symptoms. 90 day mortality was higher in those patients who sustained VT/VF (23.2% vs 3.6%, a multivariate hazard ratio of 3.63)[7]. Mortality was higher among those patients with late VT/VF (33.3%) vs early VT/VF (17.2%). It should also be noted that while many of the subsequent deaths in patients with VT/VF were due to sudden cardiac death, sudden cardiac death accounted for less than 50% of the mortality in VT/VF patients. Although VT/VF was not associated with one year mortality in the Primary Angioplasty and Myocardial Infarction (PAMI) trials [8], this is likely due to the fact that the PAMI population was of lower risk and had a lower one year mortality (4.5% in PAMI vs 23.2% reported in the present study).

Multivariate Predictors of Early VT/VF in the Setting of STEMI

  1. Pre-PCI thrombolysis in MI (TIMI) flow grade 0 (HR, 2.94; 95% CI, 1.93-4.47)
  2. Inferior infarction (HR, 2.16;95%CI, 1.58-2.93)
  3. Total baseline ST deviation (HR, 1.39;95%CI, 1.19-1.63)
  4. Creatinine clearance (HR, 0.88; 95% CI, 0.83-0.94)
  5. Killip class greater than I (HR, 1.88;95%CI, 1.29-2.76)
  6. Baseline systolic blood pressure (HR, 0.92;95%CI, 0.87-0.98)
  7. Body weight (HR, 1.16; 95% CI, 1.04-1.29)
  8. baseline heart rate greater than 70/min (HR,1.10;95%CI, 1.01-1.20)

c index for the model = 0.75

Multivariate Predictors of Late VT/VF in the setting of STEMI

  1. Systolic blood pressure (HR, 0.83; 95% CI, 0.76-0.91)
  2. ST resolution less than 70% (HR, 3.17; 95% CI,1.60-6.28)
  3. Baseline heart rate greater than 70/min (HR, 1.20; 95% CI, 1.08-1.33)
  4. Total baseline ST deviation (HR, 1.43; 95% CI, 1.14-1.79)
  5. Post-PCI TIMI flow less than grade 3(HR, 2.09;95%CI, 1.24-3.52)
  6. Pre-PCI TIMI flow grade 0(HR, 2.12;95%CI, 1.20-3.75),
  7. Blockers less than 24 hours (HR, 0.52; 95% CI, 0.32-0.85)

c index for the model = 0.74

Multivariate modeling did demonstrate that about one-fifth of the variability in 90 day mortality was explained by VT/VF. It should be noted that many patients did not undergo left ventriculography in this study. When left ventricular ejection fraction was available and included in the multivariate model, it failed to be statistically significant. This is likely because it was co-linear with other variables such as Killip class, infarct location, TIMI flow and pulse.

Clinical Implications

Those patients with < TIMI grade 3 flow and < 70% ST resolution following PCI are at higher risk of VT/VF and should be monitored more carefully in an ICU or telemetry setting.

VT/VF Complicating AMI (both STEMI and NSTEMI taken together)

While the prior information focuses on STEMI, a study by Piccini et al of 9,000 patients focused on both STEMI as well as NSTEMI who underwent PCI within 24 hours of acute MI in the New York State Coronary Angioplasty Reporting System database [9]. 5.2% of patients sustained VT/VF and mortality was over 4 times higher among patients with VT/VF (16.3% vs 3.7%). Operator reported successful PCI was associated with a lower subsequent mortality associated with VT/VF. The following were identified as independent predictors of early VT/VF:

  1. Cardiogenic shock (OR, 4.10; 95%CI, 3.20-5.58)
  2. Heart failure (OR, 2.86;95% CI, 2.24-3.67)
  3. Chronic kidney disease (OR, 2.58; 95% CI, 1.27-5.23)
  4. Early presentation (6 hours from symptom onset; OR, 1.46; 95% CI, 1.18-1.81)

The following variables were found to be independently associated with a lower risk of VT/VF:

  1. History of hypertension (OR, 0.81; 95% CI, 0.65-1.00)
  2. Lleft circumflex as infarct artery (OR, 0.80; 95% CI, 0.65-0.99)
  3. Diabetes mellitus (OR,0.57; 95% CI, 0.42-0.78)
  4. Higher left ventricular ejection fraction (every 5% increment; OR, 0.93; 95% CI, 0.91-0.96)

2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT)[10]

Assessment of Risk for Sudden Cardiac Death (DO NOT EDIT)[10]

Class I
"1. Patients with an initially reduced LV ejection fraction who are possible candidates for implantable cardioverter-defibrillator therapy should undergo reevaluation of LV ejection fraction 40 or more days after discharge.[11][12][13][14](Level of Evidence: B)"

References

  1. Zehender M, Utzolino S, Furtwängler A, Kasper W, Meinertz T, Just H (November 1991). "Time course and interrelation of reperfusion-induced ST changes and ventricular arrhythmias in acute myocardial infarction". Am. J. Cardiol. 68 (11): 1138–42. PMID 1951071.
  2. Gressin V, Louvard Y, Pezzano M, Lardoux H (January 1992). "Holter recording of ventricular arrhythmias during intravenous thrombolysis for acute myocardial infarction". Am. J. Cardiol. 69 (3): 152–9. PMID 1731450.
  3. Six AJ, Louwerenburg JH, Kingma JH, Robles de Medina EO, van Hemel NM (August 1991). "Predictive value of ventricular arrhythmias for patency of the infarct-related coronary artery after thrombolytic therapy". Br Heart J 66 (2): 143–6. PMID 1883665.
  4. Buckingham TA, Devine JE, Redd RM, Kennedy HL (September 1986). "Reperfusion arrhythmias during coronary reperfusion therapy in man. Clinical and angiographic correlations". Chest 90 (3): 346–51. PMID 3743145.
  5. Berger PB, Ruocco NA, Ryan TJ, Frederick MM, Podrid PJ (December 1993). "Incidence and significance of ventricular tachycardia and fibrillation in the absence of hypotension or heart failure in acute myocardial infarction treated with recombinant tissue-type plasminogen activator: results from the Thrombolysis in Myocardial Infarction (TIMI) Phase II trial". J. Am. Coll. Cardiol. 22 (7): 1773–9. PMID 8245327.
  6. Newby KH, Thompson T, Stebbins A, Topol EJ, Califf RM, Natale A (December 1998). "Sustained ventricular arrhythmias in patients receiving thrombolytic therapy: incidence and outcomes. The GUSTO Investigators". Circulation 98 (23): 2567–73. PMID 9843464.
  7. Mehta RH, Starr AZ, Lopes RD, Hochman JS, Widimsky P, Pieper KS, Armstrong PW, Granger CB (May 2009). "Incidence of and outcomes associated with ventricular tachycardia or fibrillation in patients undergoing primary percutaneous coronary intervention". JAMA : the Journal of the American Medical Association 301 (17): 1779–89. doi:10.1001/jama.2009.600. PMID 19417195.
  8. Mehta RH, Harjai KJ, Grines L, et al; Primary Angioplasty in Myocardial Infarction (PAMI) Investigators. Sustained ventricular tachycardia or fibrillation in the cardiac catheterization laboratory among patients receiving primary percutaneous coronary intervention: incidence, predictors, and outcomes. JAmColl Cardiol. 2004;43(10):1765-1772.
  9. Piccini JP, Berger JS, Brown DL. Early sustained ventricular arrhythmias complicating acute myocardial infarction. Am J Med. 2008;121(9):797-804.
  10. 10.0 10.1 O'Gara PT, Kushner FG, Ascheim DD, et al. (December 2012). "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e3182742c84. PMID 23247303.
  11. Leppo JA, O'Brien J, Rothendler JA, Getchell JD, Lee VW (April 1984). "Dipyridamole-thallium-201 scintigraphy in the prediction of future cardiac events after acute myocardial infarction". N. Engl. J. Med. 310 (16): 1014–8. doi:10.1056/NEJM198404193101603. PMID 6708976.
  12. Hohnloser SH, Kuck KH, Dorian P, et al. (December 2004). "Prophylactic use of an implantable cardioverter-defibrillator after acute myocardial infarction". N. Engl. J. Med. 351 (24): 2481–8. doi:10.1056/NEJMoa041489. PMID 15590950.
  13. Epstein AE, DiMarco JP, Ellenbogen KA, et al. (May 2008). "ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons". Circulation 117 (21): e350–408. doi:10.1161/CIRCUALTIONAHA.108.189742. PMID 18483207.
  14. Steinbeck G, Andresen D, Seidl K, et al. (October 2009). "Defibrillator implantation early after myocardial infarction". N. Engl. J. Med. 361 (15): 1427–36. doi:10.1056/NEJMoa0901889. PMID 19812399.

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