Long-term prognostic significance of ventricular late potentials after a first acute myocardial infarction

doi:10.1016/S0002-8703(97)70021-8

American Heart Journal

Volume 134, Issue 6, December 1997, Pages 1019-1028

https://doi.org/10.1016/S0002-8703(97)70021-8 Get rights and content

Abstract

Ventricular late potentials (VLP) have been shown to be independent predictors of arrhythmic events after myocardial infarction. However, many studies have had one or more limitations: limited follow-up period, small study group, possible selection bias, inadequate statistical analysis, or inclusion of patients with previous infarction. The purpose of this study was to assess the long-term prognostic value of VLP in a large group of unselected patients after a first acute myocardial infarction. Time-domain signal averaging was performed in 458 patients (380 male, 78 female, mean age 59 ± 11 years) a mean of 10 days (range 7 to 13 days) after a first acute myocardial infarction. The overall prevalence of VLP was 20% (90 of 458 patients). By univariate analysis a left ventricular ejection fraction <40% (p = 0.002) and the presence of an occluded infarct-related artery (p = 0.006) were the only statistically significant predictors for the development of VLP. During a median follow-up of 70 months, 21 (5%) patients died suddenly, and 11 (2%) patients had documented sustained ventricular tachycardia. The presence of VLP (p < 0.0001), older age (p = 0.02), and an occluded infarct-related artery (p = 0.045) were the only variables significantly associated with the occurrence of serious arrhythmic events during follow-up. The probability of having no arrhythmic events was 99% at 1 year and 96% at 5 years in the absence of VLP and 87% at 1 year and 80% at 5 years in the presence of VLP (4.6-fold increase in arrhythmic risk; 95% confidence interval: 2.3 to 9.1). VLPs are powerful predictors of serious arrhythmic events in patients after a first acute myocardial infarction, and their prognostic value, although waning with time, persists for at least 7 years. This study also provides further evidence that an open infarct-related artery may reduce the arrhythmic risk after myocardial infarction. (Am Heart J 1997;134:1019-28.)

Section snippets

Patient population

The study population consisted of 597 unselected patients who were admitted to the Coronary Care Unit of our institution with an acute myocardial infarction and who survived the first 10 days of admission. Patients with a history of myocardial infarction (n = 59), patients who underwent bypass surgery before day 10 (n = 8), patients with bundle branch block (n = 38) or permanent pacemakers (n = 4), and patients who were not in sinus rhythm at the time of signal averaging (atrial fibrillation, n

Prevalence of ventricular late potentials

The overall prevalence of ventricular late potentials was 20% (90 of 458 patients). The characteristics of patients with and of patients without late potentials are listed in Table II. Univariate analysis demonstrated that a low left ventricular ejection fraction and an occluded infarct-related artery were the only statistically significant predictors for the development of late potentials (Table II). The prevalence of ventricular late potentials was significantly higher in patients with a left

Discussion

This study shows that the presence of ventricular late potentials is a strong predictor of serious arrhythmic events after myocardial infarction and that the prognostic value of an abnormal signal-averaged electrocardiogram, although decreasing over time, persists for at least 7 years. The presence of late potentials represents a 4.6-fold increase in the risk of having serious arrhythmic events after myocardial infarction and appears to be a stronger predictor of arrhythmic events than a low

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Effects of reperfusion obtained two to six months after acute myocardial infarction on myocardial electrical stabilization in patients with an occluded infarct-related coronary artery
2005, American Journal of Cardiology
To assess the changes in electrical stability markers in patients with previous myocardial infarction after very late reopening of the infarct-related artery, we studied QT dispersion, corrected-QT dispersion, and late potentials before and 1, 3, and 6 months after an attempt at late percutaneous coronary intervention (PCI) in 31 consecutive patients with single-vessel disease (infarct-related artery occlusion or subocclusion) diagnosed ≥4 weeks after the ST-elevation myocardial infarction. Patients underwent PCI 3.9 ± 2 months after ST-elevation myocardial infarction. PCI was successful in 24 patients (group A) and unsuccessful in 7 (group B). The 2 groups were similar in clinical and angiographic characteristics, as well as the prevalence of basal late potentials, average QT dispersion, and corrected-QT dispersion. One month after PCI, the successful reperfusion group had a significant 67% decrease in the prevalence of late potentials and average QT dispersion and corrected QT dispersion (51 ± 9 vs 72 ± 11 ms, p <0.00001, and 51 ± 10 vs 76 ± 15 ms, p <0.00001, respectively). These benefits remained stable at 3 and 6 months after PCI. Conversely, the unsuccessful group did not show any improvement in electrical stability markers after PCI failed. Thus, reperfusion obtained very late after ST-elevation myocardial infarction confers significant electrical stabilization that may contribute to a better outcome in patients with patent infarct-related arteries.
Noninvasive Electrophysiology
2005, Electrophysiological Disorders of the Heart
Electrocardiographic arrhythmia risk testing
2004, Current Problems in Cardiology
Among the most compelling challenges facing cardiologists today is identification of which patients are at highest risk for sudden death. Automatic implantable cardioverter-defibrillators are now indicated in many of these patients, yet the role of noninvasive risk stratification in classifying patients at high risk is not well defined. The purpose of this review is to evaluate the various electrocardiographic (ECG) techniques that appear to have potential in assessment of risk for arrhythmia. The resting ECG (premature ventricular contractions, QRS duration, damage scores, QT dispersion, and ST segment and T wave abnormalities), T wave alternans, late potentials identified on signal-averaged ECGs, and heart rate variability are explored. Unequivocal evidence to support the widespread use of any single noninvasive technique is lacking; further research in this area is needed. It is likely that a combination of risk evaluation techniques will have the greatest predictive power in enabling identification of patients most likely to benefit from device therapy.
Combination of QT variability and signal-averaged electrocardiography in association with ventricular tachycardia in postinfarction patients
2003, Journal of Electrocardiology
The authors investigate incidence of ventricular tachycardia/ventricular fibrillation (VT/VF) in relationship with combination of noninvasive arrhythmia risk markers as left ventricular ejection fraction (LVEF), late potentials (LP), and QT variability index (QTVI) and compare the utility of their combination in association with sustained ventricular arrhythmias in patients after myocardial infarction (MI). Fifty-four patients with old MI, among them 27 with documented spontaneous sustained VT/VF entered the study. All of them underwent evaluation for arrhythmias and noninvasive risk stratificaton. Logistic regression analysis demonstrated that the highest association with ventricular tachyarrhythmia had combination of LP and increased QTVI (13.8, P<.0002), followed then by combination of LVEF and LP (12.2, P<.0005), LP alone (P<.001), QTVI (P<.002) and LVEF (P<.003) alone and age (P<.01). After stepwise regression analysis showed that the model including association of LP and QTVI, age and EF is the best one for delineating patients having the risk of ventricular tachyarrhythmia development. In conclusion, patients with combination of positive LP and increased QTVI after MI have high likelihood for development of serious sustained arrhythmia.
Utility of current risk stratification tests for predicting major arrhythmic events after myocardial infarction
2001, Journal of the American College of Cardiology
Citation Excerpt :
The results of combining studies are shown in Figure 1and Tables 1 and 2. The incidences of MAE in the patient populations reported (references 18–61; column 2 in Table 1) are the prior probabilitiesfor MAE—that is, the probability of a MAE prior to a test. The individual values of prior probability varied widely (range 3.3% to 34.1%).
OBJECTIVES
We surveyed the literature to estimate prediction values for five common tests for risk of major arrhythmic events (MAEs) after myocardial infarction. We then determined feasibility of a staged risk stratification using combinations of noninvasive tests, reserving an electrophysiologic study (EPS) as the final test.
BACKGROUND
Improved approaches are needed for identifying those patients at highest risk for subsequent MAE and candidates for implantable cardioverter-defibrillators.
METHODS
We located 44 reports for which values of MAE incidence and predictive accuracy could be inferred: signal-averaged electrocardiography; heart rate variability; severe ventricular arrhythmia on ambulatory electrocardiography; left ventricular ejection fraction; and EPS. A meta-analysis of reports used receiver-operating characteristic curves to estimate mean values for sensitivity and specificity for each test and 95% confidence limits. We then simulated a clinical situation in which risk was estimated by combining tests in three stages.
RESULTS
Test sensitivities ranged from 42.8% to 62.4%; specificities from 77.4% to 85.8%. A three-stage stratification yielded a low-risk group (80.0% with a two-year MAE risk of 2.9%), a high-risk group (11.8% with a 41.4% risk) and an unstratified group (8.2% with an 8.9% risk equivalent to a two-year incidence of 7.9%).
CONCLUSIONS
Sensitivities and specificities for the five tests were relatively similar. No one test was satisfactory alone for predicting risk. Combinations of tests in stages allowed us to stratify 91.8% of patients as either high-risk or low-risk. These data suggest that a large prospective study to develop a robust prediction model is feasible and desirable.
Does an open infarct-related artery after myocardial infarction improve electrical stability?
2000, Progress in Cardiovascular Diseases
Arrhythmic events are responsible for the majority of sudden cardiac deaths after myocardial infarction. Many clinical studies have suggested that patency of the infarct-related artery, achieved by thrombolytic therapy or revascularization procedures, is a predictor of survival rates irrespective of myocardial salvage. The open-artery hypothesis suggests that an open infarct-related artery may result in other potential mechanisms, of benefits including electrical stability. This review focuses on the various levels and types of evidence supporting this contention. Copyright © 2000 by W.B. Saunders Company
Progress in Cardiovascular Diseases, Vol. 42, No. 6 (May/June), 2000: pp 439-454

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^☆: From the ^aCardiology Center, ^bCentre d'Informatique Hospitalière, University Hospital.

^☆☆: Supported in part by grant 3.805-0.86 from the Swiss National Foundation for Scientific Reasearch, Bern, Switzerland.

^★: Reprint requests: M. Zimmermann, MD, Cardiology Center, University Hospital, 24 rue Micheli-du-Crest, CH-1211 Geneva 14, Switzerland.

^★★: 4/1/86117

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Long-term prognostic significance of ventricular late potentials after a first acute myocardial infarction☆,☆☆,★,★★

Abstract

Section snippets

Patient population

Prevalence of ventricular late potentials

Discussion

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