[Limits and Scopes of Invasive Risk Stratification. Do We Still Need Programmed Ventricular Stimulation?]

Overview

Journal Herz

Specialty Cardiology & Vascular Diseases

Date 2010 Jan 22

PMID 20091252

Citations 1

Authors

Sascha Rolf

Wilhelm Haverkamp

Affiliations

Soon will be listed here.

Abstract

Patients with ischemic heart disease and left ventricular systolic dysfunction (ICM), dilated (DCM), hypertrophic (HCM), or arrhythmogenic right ventricular cardiomyopathy (ARVCM) carry a high risk of sudden cardiac death (SCD). Ventricular tachyarrhythmias are most often the cause of SCD, which can be treated with internal cardioverter defibrillators (ICDs). However, a great proportion of these high-risk patients will never experience potentially lethal ventricular arrhythmias, and as such will never be in need of these devices. Given the risks, inconvenience, and costs of ICDs, markers that adequately stratify patients according to their risk of SCD are needed. Programmed ventricular stimulation (PVS) has long been used to identify the patients' risk of SCD. However, the prognostic ability of PVS is only modest and the negative predictive value is poor. As far as patients with ICM are concerned, recent data from the MUSTT and MADIT II trials demonstrate that in patients with a left ventricular ejection fraction between 30% and 40%, inducibility by PVS can help to identify patients who are at particularly increased risk of SCD. The value of PVS in patients with DCM, HCM, and ARVCM for risk stratification of SCD is less clear and the available data even more limited. In these patients, the inducibility of ventricular tachyarrhythmias does not clearly correlate with VT/VF (ventricular tachycardia/ventricular fibrillation) risk, and more importantly, noninducibility does not portend good prognosis. The current German guidelines appreciate these uncertainties of PVS for risk stratification with class IIb recommendations in certain patients with ICM, HCM or ARVCM. In the future, combining the results of invasive PVS with other noninvasive parameters may improve its prognostic value. Furthermore, expanding the role of PVS to guiding therapeutic ablation of ventricular arrhythmias may influence patient's future risk of SCD.

Citing Articles

Ventricular arrhythmias: from risk assessment for sudden cardiac death to therapeutic intervention.

Wissner E, Kuck K Herz. 2010; 34(7):503-4.

PMID: 20091249 DOI: 10.1007/s00059-009-3310-x.

References

Maron B, McKenna W, Elliott P, Spirito P, Frenneaux M, Keren A . Hypertrophic cardiomyopathy. JAMA. 1999; 282(24):2302-3. DOI: 10.1001/jama.282.24.2302. View

Saumarez R, Pytkowski M, Sterlinski M, Bourke J, Clague J, Cobbe S . Paced ventricular electrogram fractionation predicts sudden cardiac death in hypertrophic cardiomyopathy. Eur Heart J. 2008; 29(13):1653-61. DOI: 10.1093/eurheartj/ehn111. View

Gorgels A, Van Ree J, Daemen M, Houben L, Wellens H . Out-of-hospital cardiac arrest in the 1990's: a population-based study in the Maastricht area on incidence, characteristics and survival. J Am Coll Cardiol. 1997; 30(6):1500-5. DOI: 10.1016/s0735-1097(97)00355-0. View

Brachmann J, Hilbel T, Grunig E, Benz A, Haass M, Kubler W . Ventricular arrhythmias in dilated cardiomyopathy. Pacing Clin Electrophysiol. 1997; 20(10 Pt 2):2714-8. DOI: 10.1111/j.1540-8159.1997.tb06121.x. View

Kuck K, Kunze K, Schluter M, Nienaber C, Costard A . Programmed electrical stimulation in hypertrophic cardiomyopathy. Results in patients with and without cardiac arrest or syncope. Eur Heart J. 1988; 9(2):177-85. DOI: 10.1093/oxfordjournals.eurheartj.a062472. View

Moss A, Zareba W, Hall W, Klein H, Wilber D, Cannom D . Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002; 346(12):877-83. DOI: 10.1056/NEJMoa013474. View

Daubert J, Winters S, Subacius H, Berger R, Ellenbogen K, Taylor S . Ventricular arrhythmia inducibility predicts subsequent ICD activation in nonischemic cardiomyopathy patients: a DEFINITE substudy. Pacing Clin Electrophysiol. 2009; 32(6):755-61. DOI: 10.1111/j.1540-8159.2009.02362.x. View

Baerman J, Morady F, de Buitleir M, DiCarlo Jr L, Kou W, Nelson S . A prospective comparison of programmed ventricular stimulation with triple extrastimuli versus single and double extrastimuli during infusion of isoproterenol. Am Heart J. 1989; 117(2):342-7. DOI: 10.1016/0002-8703(89)90777-1. View

Dec G, Fuster V . Idiopathic dilated cardiomyopathy. N Engl J Med. 1994; 331(23):1564-75. DOI: 10.1056/NEJM199412083312307. View

10.

Buxton A, Lee K, Hafley G, Wyse D, Fisher J, Lehmann M . Relation of ejection fraction and inducible ventricular tachycardia to mode of death in patients with coronary artery disease: an analysis of patients enrolled in the multicenter unsustained tachycardia trial. Circulation. 2002; 106(19):2466-72. DOI: 10.1161/01.cir.0000037224.15873.83. View

11.

Richards D, Byth K, Ross D, UTHER J . What is the best predictor of spontaneous ventricular tachycardia and sudden death after myocardial infarction?. Circulation. 1991; 83(3):756-63. DOI: 10.1161/01.cir.83.3.756. View

12.

Jung W, Andresen D, Block M, Bocker D, Hohnloser S, Kuck K . [Guidelines for the implantation of defibrillators]. Clin Res Cardiol. 2006; 95(12):696-708. DOI: 10.1007/s00392-006-0475-7. View

13.

Milner P, DiMarco J, Lerman B . Electrophysiological evaluation of sustained ventricular tachyarrhythmias in idiopathic dilated cardiomyopathy. Pacing Clin Electrophysiol. 1988; 11(5):562-8. DOI: 10.1111/j.1540-8159.1988.tb04551.x. View

14.

Bourke J, Richards D, Ross D, Wallace E, McGuire M, UTHER J . Routine programmed electrical stimulation in survivors of acute myocardial infarction for prediction of spontaneous ventricular tachyarrhythmias during follow-up: results, optimal stimulation protocol and cost-effective screening. J Am Coll Cardiol. 1991; 18(3):780-8. DOI: 10.1016/0735-1097(91)90802-g. View

15.

Meinertz T, Hofmann T, Kasper W, Just H . [Determinants of the prognosis in dilated cardiomyopathy: significance of ventricular cardiac arrhythmias]. Herz. 1985; 10(3):134-7. View

16.

Maron B, Shen W, Link M, EPSTEIN A, Almquist A, Daubert J . Efficacy of implantable cardioverter-defibrillators for the prevention of sudden death in patients with hypertrophic cardiomyopathy. N Engl J Med. 2000; 342(6):365-73. DOI: 10.1056/NEJM200002103420601. View

17.

Pezawas T, Stix G, Kastner J, Schneider B, Wolzt M, Schmidinger H . Ventricular tachycardia in arrhythmogenic right ventricular dysplasia/cardiomyopathy: clinical presentation, risk stratification and results of long-term follow-up. Int J Cardiol. 2006; 107(3):360-8. DOI: 10.1016/j.ijcard.2005.03.049. View

18.

Buxton A, Lee K, DiCarlo L, Gold M, Greer G, Prystowsky E . Electrophysiologic testing to identify patients with coronary artery disease who are at risk for sudden death. Multicenter Unsustained Tachycardia Trial Investigators. N Engl J Med. 2000; 342(26):1937-45. DOI: 10.1056/NEJM200006293422602. View

19.

Vandepol C, Farshidi A, Spielman S, Greenspan A, Horowitz L, Josephson M . Incidence and clinical significance of induced ventricular tachycardia. Am J Cardiol. 1980; 45(4):725-31. DOI: 10.1016/0002-9149(80)90114-9. View

20.

CARUSO A, MARCUS F, Hahn E, Hartz V, Mason J . Predictors of arrhythmic death and cardiac arrest in the ESVEM trial. Electrophysiologic Study Versus Electromagnetic Monitoring. Circulation. 1997; 96(6):1888-92. DOI: 10.1161/01.cir.96.6.1888. View