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Observational Study
. 2017 Mar;47(3):231-240.
doi: 10.1111/eci.12729. Epub 2017 Feb 11.

Risk of arrhythmic death in ischemic heart disease: a prospective, controlled, observer-blind risk stratification over 10 years

Thomas Pezawas  1 , André Diedrich  2 , David Robertson  2 , Robert Winker  3 , Bernhard Richter  1 , Li Wang  4 , Herwig Schmidinger  1
Affiliations
Observational Study

Risk of arrhythmic death in ischemic heart disease: a prospective, controlled, observer-blind risk stratification over 10 years

Thomas Pezawas et al. Eur J Clin Invest. 2017 Mar.

Abstract

Background: Risk of arrhythmic death is considered highest in ischemic heart disease with severe left ventricular ejection fraction (LVEF) reduction. Non-invasive testing should improve decision-making of prophylactic defibrillator (ICD) implantation.

Design: We enrolled 120 patients with ischemic heart disease and LVEF < 50% and 30 control subjects without ischemic heart disease and normal LVEF. An initial assessment, a second assessment after 3 years and a final follow-up comprised of pharmacological baroreflex testing (BRS), short-term spectral [low-frequency (LF) to high-frequency (HF) ratio] and long-term time-domain analysis of heart rate variability (SDNN), exercise Microvolt T-wave alternans (MTWA) and others.

Results: The median follow-up was 7·5 years. Resuscitated cardiac arrest and arrhythmic death due to ventricular arrhythmias ≥ 240/min was observed in 18% and 15% of patients, respectively. Cardiac death was observed in 28% of patients. The incidence of arrhythmic death and resuscitated cardiac arrest was identical in patients with ischemic heart disease with LVEF < 30% and ≥ 30%. No significant difference between subgroups with LVEF of < 30%, 30-39% and ≥ 40% was found either. MTWA, BRS, SDNN and LF to HF ratio failed to identify patients at risk of arrhythmic death in a multiple regression model.

Conclusions: Ischemic heart disease patients with LVEF < 30% and ≥ 30% face the same risk of arrhythmic death. Stratification techniques fail to identify high-risk patients. Therefore, the current practice to constrain prophylactic ICDs to patients with severely reduced LVEF seems to be insufficient.

Keywords: Ischemic heart disease; non-invasive risk stratification; sudden cardiac death.

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Conflict of interest statement

For all authors: There is no conflict of interest.

Disclosures. None of the authors have any conflict of interest regarding this study.

Figures

Figure 1
Figure 1
Patient Selection and Outcomes (2002–2013). A total of 150 patients (120 ischemic heart disease patients with LVEF=<50%, 30 controls with LVEF>50%) underwent serial testing. They were enrolled from a larger sample of consecutive patients. Ineligibility was mainly due to permanent atrial fibrillation. Other patients refused participation or LVEF normalized. During a median follow-up of 7 years, 46 (45 ICM patients and one Control patient) deaths were observed. Of these, 34 were categorized as cardiac and 18 as arrhythmic. In 22 patients a resuscitated cardiac arrest was documented as their first event. Five of these 22 patients died during further follow-up from a non-cardiac and non-arrhythmic reason. (* marked as 5 non-qualifying events)
Figure 2
Figure 2
a–f. Kaplan-Meier curves show the association between non-invasive tests (MTWA, BRS, LVEF and SDNN) and secondary endpoint (2a, cardiac death) and primary endpoints (2b–f, arrhythmic death, resuscitated cardiac arrest) for ischemic heart disease patients.
See this image and copyright information in PMC

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