Management of Nonsustained Ventricular Tachycardia Guided By Electrophysiological Testing (original) (raw)
1993, Pace-pacing and Clinical Electrophysiology
Two hundred eighty patients with spontaneous nonsusfained ventricular tachycardia were treated based on the results of electrophysiological testing. Seventy-nine patients had no evidence of structural heart disease, 134 had coronary artery disease, 43 had idiopathic dilated cardiomyopathy, and 24 patients had miscellaneous types of heart disease. Sustained monomorphic ventricular tachycardia was induced during electrophysiological testing in the drug free state in 52 of 280 patients (19%). Ventricular tachycardia was induced more frequently in patients with coronary artery disease (32%) than in any of the other groups (P < 0.001). The patients with inducible sustained monomorphic ventricular tachycardia underwent a mean of 1.9 ± 1.3 drug trials. Twenty-five patients had the induction of ventricular tachycardia suppressed by pharmacological therapy and were treated with the drug judged to be effective during electropharmacological testing. Twenty-seven patients continued to have inducible sustained monomorphic ventricular tachycardia despite antiarrhythmic therapy and were discharged on the drug that made induced ventricular tachycardia best tolerated. Forty-five of 280 patients (16.1%) died during a mean follow-up period of 19.6 ± 14.4 months, There were 15 sudden cardiac deaths, 21 nonsudden cardiac deaths, 6 noncardiac deaths, and 3 deaths that could not be classified. Sudden cardiac death mortality was lowest in the patients without structural heart disease (0% at 2 years), intermediate in the patients with coronary artery disease and miscellaneous heart disease (4% al 2 years), and highest in the patients with idiopathic dilated cardiomyopathy (13% at 2 years; P < 0.01 for pairwise comparisons). No patient treated with a drug that had suppressed the induction of sustained ventricular tachycardia died suddenly during the follow-up period whereas four of 27 patients who were discharged on “ineffective antiarrhythmic drugs” and 11 of 228 patients without inducible sustained ventricular tachycardia experienced sudden cardiac death during the follow-up period. By multivariate analysis, ejection fraction and inducible ventricular tachycardia during the predischarge eiectrophysiological test were independent predictors of sudden cardiac death. In conclusion, in patients with spontaneous nonsustained ventricular tachycardia: (1) Arrhythmia inducibility varies depending on the underlying heart disease. Ventricular tachycardia is most often inducible in patients with coronary artery disease and least often in patients without structural heart disease; (2) With the exception of patients with idiopathic dilated cardiomyopathy, management of patients with nonsustained ventricular tachycardia guided by electrophysiological testing appears to result in a low incidence of sudden cardiac death although effects on total mortality are less impressive; and (3) Patients with idiopathic dilated cardiomyopathy and patients with other heart diseases who continue to have inducible ventricular tachycardia despite antiarrhythmic drug therapy are at substantial risk of sudden cardiac death.
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The American Journal of Cardiology, 1982
This study examined the usefulness of programmed electrical stimulation in managing 83 patients who had ventricular tachycardia not due to coronary artery disease. Among 39 patients with a history of sustained ventricular tachycardia, programmed stimulation induced ventricular tachycardia in 14 of 14 patients with mitral valve prolapse or primary electrical disease (arrhythmias without evidence of structural heart disease) and in 13 of 25 with cardiomyopathy (total 27 of 39, 89 percent). Programmed stimulation induced nonsustained ventricular tachycardia in 15 (34 percent) of 44 patients with a history of nonsustained tachycardia (5 of 13 with mitral valve prolapse, 8 of 19 with primary electrical disease and 4 of 12 with cardiomyopathy). Seventy-three of the 83 patients were treated with antiarrhythmic drugs and then followed up for 14.4 f 11.4 months (mean f standard deviation). Drug therapy was determined with serial electrophysiologic testing in 31 patients. Twenty-four of these 31 patients had a history of sustained ventricular tachycardia, and drugs prevented induction of ventricular tachycardia in 9 (none of whom manifested symptomatic events) but did not prevent it in 15 (8 of whom had symptomatic events). Among seven patients with a history of nonsustained ventricular tachycardia, drugs prevented induction of ventricular tachycardia in five (none of whom had symptomatic events) and did not prevent it in two (none of whom had symptomatic events). Forty-two patients were treated using the results of noninvasive testing. Drugs suppressed spontaneous ventricular tachycardia in 15 of 15 patients with a history of sustained tachycardia (7 of whom had symptomatic events including one sudden death), and in 28 of 27 with a history of nonsustained tachycardia (8 of whom had symptomatic events including one sudden death).
International Journal of Cardiology, 1994
Sustained ventricular tachyarrhythmias unrelated to coronary artery disease are uncommon. Currently there are no clear guidelines to aid selection of the most appropriate treatment strategy. Therefore, factors potentially predictive of arrhythmia recurrence and death and the ability of the electrophysiologic study to predict treatment outcome in patients with spontaneous sustained ventricular tachyarrhythmias unrelated to coronary artery disease were examined in 41 medically treated patients followed for a median of 25 (range l-76) months. Examined factors were: syncope associated with the spontaneous arrhythmia, the morphology and cycle length of the presenting arrhythmia, underlying ventricular function, cardiac pathology, and the results of drug assessment at electrophysiologic study. Random variability in the ease of arrhythmia induction at electrophysiologic study was measured for the group as a whole and was allowed for in prediction of an effective drug response. The 95% confidence intervals for variability in the ease of repeat arrhythmia induction at the same study were 5 1 extrastimulus and for variability in the ease of repeat arrhythmia inductions at different studies were s 2 extrastimuli. Poisson regression models were used for data analysis. Arrhythmia recurrence was most likely in: (1) patients on treatment not predicted to be anti-arrhythmic at electrophysiologic study; (2) patients whose treatment was not assessable at electrophysiologic study because the arrhythmia was not reliably inducible; (3) patients with impaired ventricular function; and (4) re-entered patients whose arrhythmia had recurred on previously allocated therapy. The risk of arrhythmia recurrence decreased with time from hospital assessment. All five deaths occurred in patients with impaired ventricular function. Conclusions: drug efficacy should be tested at electrophysiologic study in patients with reproducibly inducible clinical arrhythmias. Treatment not proven to be anti-arrhythmic at electrophysiologic study is usually ineffective. Patients with ventricular dysfunction are at highest risk of death from arrhythmia recurrence and should be considered for an implantable defibrillator, arrhythmia surgery, or heart transplantation if drug treatment is not predicted to be effective or is not assessable at electrophysiologic study.
Although nonsustained ventricular tachycardia after myocardial infarction may be associated with an increased risk of sudden cardiac death, there are no clear guidelines as to which is the most effective management of this arrhythmia. In this paper, we present our experience in the treatment of patients with asymptomatic nonsustained ventricular tachycardia, prior myocardial infarction, and left ventricular ejection fraction <40%, based on electropharmacological testing performed in 130 patients. Eighty-two of them had noninducible, and 48 inducible sustained monomorphic ventricular tachycardia. Patients with noninducible ventricular tachycardia were randomized to treatment with no antiarrhythmogenic drugs (n=46) or beta-blockers (n=36). Among patients with inducible ventricular tachycardia, 23 were treated with electropharmacologically guided drug therapy, and 25 with drugs slowing inducible ventricular tachycardia. During a mean follow-up period of 24 months, seven patients die...
Pacing and Clinical Electrophysiology, 1989
CONSTANTIN, L., ET AL.: Induced Sustained Ventricular Tachycardia in Nonischemic Dilated Cardiomyopathy: Dependence on Clinical Presentation and Response to Antiarrhythmic Agents. Thirly-one patienis with iionischemic dilated cardiomyopathy eiiher idiopfi(hic or due lo regurgitant valvular disease were studied in the cardiac electrophysiology lab. The indicafions for study were sustained ventricular lachycardI'a (VT) in 26, ventricular fibrilialion (VF) in 11, and syncope of unknown etiology in 4. Sustained VT was reproducj'bJy induced in 17 patients, including 12 with a history o/sustained VT, 2 with VF and 3 with syncope. 0/ 15 patients undergoing serial antiarrhythmic drug studies, sustained VT was rendered noninducible or nonsustained in 23. Three had recurrent arrhythmic events while on therapy predicted to be effective. One of 2 patients discharged on a regimen predicted to be ineffective had a recurrence of sustained VT that resulted in cardiac arrest. 0/24 patients in whom sustained VT could not he reproducibJy induced, 2 subsequently had spontaneous occurrences of sustained VT, and 2 experienced aborted sudden death. These results suggest the following; (2j the induction of sustained VT in the setting o/nonischemic dilated cardiomyopathy is dependent on the ciinical presentation; (2) antiarrhythmic drugs frequently render sustained VT noninducible or nonsustained; (3) antiarrhythmic drug suppression of inducible sustained VT predicts long-term prevention of spontaneous recurrences; and [4) noninducibility of sustained VT in the baseline state does not predict freedom from subsequent episodes of VT or sadden death.
Ten-Years Follow-Up of 20 Patients with Idiopathic Ventricular Tachycardia
Pacing and Clinical Electrophysiology, 1990
foUow-up and characteristics of 20 patients with ventricular tachycardia (VT) and no detectable heart disease is reported. These were 16 men and /our women with a mean age of 44 years. Symptoms were present in 18 patients feight had syncope and ten palpitations or dizziness], VT was sustained in 11 patients and a left bundle branch block morphology with inferior axis was found in 17 patients. In three patients, VT had a right bundle branch block morphology and left-axis deviation. The VT was inducible in 13 patients during the electrophysiological testing (EPj and was sustained in five patients. Medical treatment was introduced in 19 patients. During a mean follow-up of 10 years from the onset ofthe symptoms and 6 years from the EP testing, one patient died suddenly. He had stopped taking amiodarone 5 months be/ore. In seven patients symptoms recurred and were due to discontinuation of therapy in two cases and inefficacy of previous effective treatment in five patients. After modification ofthe treatment (three cases], implantation of a pacemaker (one case) and catheter ablation {one case), all patients became asymptomatic. Eleven patients became asymptomatic with the first administered antiarrhythmic therapy. One patient continues to be asymptomatic in spite o/discontinuation of his medical therapy. We conclude that patients with VT and no detectable heart disease have a good long-term prognosis and that appropriate therapy can be found in almost all patients.
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