Risk stratification using heart rate turbulence and ventricular arrhythmia in MADIT II: usefulness and limitations of a 10-minute holter recording

Abstract

Background: We evaluated the usefulness of heart rate turbulence (HRT) parameters and frequency of ventricular premature beats (VPBs) for risk-stratifying postinfarction patients with depressed left ventricular function enrolled in Multicenter Automatic Defibrillator Trial II (MADIT II).

Methods: In 884 MADIT II patients, 10-minute Holter monitoring at enrollment was used to evaluate HRT parameters and frequency of VPBs. The primary endpoints were defined as all-cause mortality in patients randomized to conventional treatment and as appropriate therapy for ventricular tachycardia or fibrillation in patients randomized to implantable cardioverter defibrillator (ICD) therapy.

Results: The median turbulence slope was lower in patients who died in comparison to survivors in the conventional arm (2.3 vs 4.5 ms/RR; P < 0.05); but it was not a significant predictor of mortality after adjustment for clinical covariates (age, ejection fraction, beta-blocker use, and BUN levels). There was no association between HRT parameters and arrhythmic events in ICD patients. Conventionally treated patients who died and ICD patients who had appropriate ICD therapy had significantly more frequent VPBs than those without such adverse events. After adjustment for clinical covariates, frequent VPBs>3/10 min were associated with death in the conventional arm (HR = 1.63; P = 0.070) and were predictive for appropriate ICD therapy in the ICD arm (HR = 1.75; P = 0.003).

Conclusion: In postinfarction patients with severe left ventricular dysfunction, frequent VPBs are associated with increased risk of mortality and with appropriate ICD therapy. HRT obtained from 10-min Holter ECG showed a trend toward the association with mortality in univariate analysis but HRT parameters were not predictive of the outcome in multivariate analyses.

Figure 1

Top Panel: Cumulative probability of survival in MADIT II patients randomized to conventional therapy in relation to levels of turbulence slope (TS). Bottom Panel: Cumulative probability of first appropriate therapy for VT/VF in MADIT II patients randomized to ICD therapy in relation to the levels of turbulence slope.

Figure 2

Top Panel: Cumulative probability of survival in MADIT II patients randomized to conventional therapy in relationship to the categories of heart rate turbulence levels. Bottom Panel: Cumulative probability of first appropriate therapy for VT/VF in MADIT II patients randomized to ICD therapy in relationship to heart rate turbulence levels. (HRT0‐if both TO and TS were normal; HRT1‐if either TO or TS were abnormal; HRT2‐if both TO and TS were abnormal.

Figure 3

Top Panel: Cumulative probability of survival in MADIT II patients randomized to conventional therapy in relationship to presence or absence of frequent VPBs. Bottom Panel: Cumulative probability of first appropriate therapy for VT/VF in MADIT II patients randomized to ICD therapy in relationship to the presence or absence of frequent VPBs.