Michael F. O'Toole

Electrophysiologic Testing to Identify Patients with Coronary Artery Disease Who Are at Risk for Sudden Death

BACKGROUND The mortality rate among patients with coronary artery disease, abnormal ventricular function, and unsustained ventricular tachycardia is high. The usefulness of electrophysiologic testing for risk stratification in these patients is unclear. METHODS We performed electrophysiologic testing in patients who had coronary artery disease, a left ventricular ejection fraction of 40 percent or less, and asymptomatic, unsustained ventricular tachycardia. Patients in whom sustained ventricular tachyarrhythmias could be induced were randomly assigned to receive either antiarrhythmic therapy guided by electrophysiologic testing or no antiarrhythmic therapy. The primary end point was cardiac arrest or death from arrhythmia. Patients without inducible tachyarrhythmias were followed in a registry. We compared the outcomes of 1397 patients in the registry with those of 353 patients with inducible tachyarrhythmias who were randomly assigned to receive no antiarrhythmic therapy in order to assess the prognostic value of electrophysiologic testing. RESULTS Patients were followed for a median of 39 months. In a Kaplan-Meier analysis, two-year and five-year rates of cardiac arrest or death due to arrhythmia were 12 and 24 percent, respectively, among the patients in the registry, as compared with 18 and 32 percent among the patients with inducible tachyarrhythmias who were assigned to no antiarrhythmic therapy (adjusted P<0.001). Overall mortality after five years was 48 percent among the patients with inducible tachyarrhythmias, as compared with 44 percent among the patients in the registry (adjusted P=0.005). Deaths among patients without inducible tachyarrhythmias were less likely to be classified as due to arrhythmia than those among patients with inducible tachyarrhythmias (45 and 54 percent, respectively; P=0.06). CONCLUSIONS Patients with coronary artery disease, left ventricular dysfunction, and asymptomatic, unsustained ventricular tachycardia in whom sustained ventricular tachyarrhythmias cannot be induced have a significantly lower risk of sudden death or cardiac arrest and lower overall mortality than similar patients with inducible sustained tachyarrhythmias.

ACCF/AHA/AMA-PCPI 2011 performance measures for adults with coronary artery disease and hypertension: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association-Physician Consortium for Performance Improvement.

Eric D. Peterson, MD, MPH, FACC, FAHA, Chair; Frederick A. Masoudi, MD, MSPH, FACC, FAHA[†††][1]; Elizabeth DeLong, PhD; John P. Erwin III, MD, FACC; Gregg C. Fonarow, MD, FACC, FAHA; David C. Goff, Jr., MD, PhD, FAHA, FACP; Kathleen Grady, PhD, RN, FAHA, FAAN; Lee A. Green, MD, MPH; Paul A.

Prediction of Sustained Ventricular Tachycardia Inducible by Programmed Stimulation in Patients With Coronary Artery Disease Utility of Clinical Variables

BACKGROUND Cardiologists often use clinical variables to determine the need for electrophysiological studies to stratify patients for risk of sudden death. It is not clear whether this is rational in patients with coronary artery disease, left ventricular dysfunction, and nonsustained ventricular tachycardia. METHODS AND RESULTS We analyzed the first 1721 patients enrolled in the Multicenter UnSustained Tachycardia Trial to determine whether clinical variables could predict which patients would have inducible sustained monomorphic ventricular tachycardia. The rate of inducibility of sustained ventricular tachycardia was significantly higher in patients with a history of myocardial infarction and in men compared with women. There was a progressively increased rate of inducibility with increasing numbers of diseased coronary arteries. There was a significantly lower rate of inducibility in patients with prior coronary artery bypass surgery and in patients who also had noncoronary cardiac disease. The rate of inducibility was higher in patients of white race, patients with recent (</=6 weeks) angina, left ventricular dyskinesis, and in patients with greater numbers of fixed thallium defects. Inducibility was more likely in patients who had a prior myocardial infarction complicated by congestive heart failure, ventricular tachycardia, or fibrillation </=48 hours after the onset of infarction. Although these associations are statistically significant, the accuracy of the clinical variables in discriminating between patients with and those without inducible ventricular tachycardia is only modest (receiver operator characteristic area <0.70). CONCLUSIONS Multiple clinical variables are independently associated with inducible sustained ventricular tachycardia. However, they have limited utility to guide clinical decisions regarding the use of electrophysiological testing for risk stratification in this patient population.

ACCF/AHA/AMA–PCPI 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension

Developed in Collaboration With the American Academy of Family Physicians, American Association of Cardiovascular and Pulmonary Rehabilitation, American Association of Clinical Endocrinologists, American College of Emergency Physicians, American College of Radiology, American Nurses Association, American Society of Health-System Pharmacists, Society of Hospital Medicine, and Society of Thoracic Surgeons

The safety and efficacy of chronic ventricular pacing at 1.6 volts using a steroid eluting lead.

Steroid eluting leads may allow for lower chronic pacing thresholds and therefore lower pacing outputs. Twenty‐two patients (15 presenting with syncope) were implanted with VVI or VVIR pacemakers and transvenous steroid eluting leads and followed for a mean of 20.6 months while being paced at 1.6 V and 0.6 msec. Mean acute voltage pacing thresholds were 0.40 V at 0.5 msec and chronic pulse width thresholds were 0.22 msec at 0.8 V. Pacemaker function was documented with one to three 24‐hour Holter monitors, attached during the 2–6 week postimplant period, bimonthly transtelephonic monitoring, and monthly pacemaker clinic visits. No patient developed recurrent symptoms and consistent capture ivas verified in all patients on every 24‐hour Holter recording and transtelephonic monitor. Chronic ventricular pacing at an output of 1.6 V at 0.6 msec is safe and effective when using a steroid eluting lead and potentially has implications for pacemaker longevity.

Permanent Pacemaker Implantation in the Cardiac Catheterization Laboratory Versus the Operating Room: An Analysis of Hospital Charges and Complications

Permanent pacemakers may be implanted in operating rooms, special procedure laboratories, or cardiac Catheterization laboratories. Previous investigators have shown no difference in efficacy or complications in the operating room versus the cardiac Catheterization laboratory. We retrospectively analyzed the hospital bills of 30 patients undergoing permanent pacemaker implantation at our institution. Group I was 15 consecutive patients implanted in the operating room and group II was 15 consecutive patients implanted in the cardiac Catheterization laboratory, all by the same operators. Hospital charges that were specific to the site of implantation were analyzed. Physician charges for implantation, anesthesiologist, and radiologist charges were not analyzed. There were no in‐hospital complications in either group. The mean charges for group I were

Familial Occurrence of Neurocardiogenic Syncope

1,856.00 and group II were

A technique utilizing a steerable hydrophilic guidewire for permanent pacemaker implantation.

1,075.00 (P < 0.001). We conclude that implantation of permanent pacemakers in the cardiac Catheterization laboratory is associated with significantly lower hospital charges compared to implantation in the operating room and has an equally low complication rate.

Safety and efficacy of carvedilol titration by advanced practice nurses

To the Editor: Cooper et al. (July 21 issue)1 described neurocardiogenic syncope in a mother and daughter. The authors stated that they were “not aware of a familial clustering of this disorder.” I...

Effects of an electronic medical record system on compliance to proven pharmacologic therapies for heart failure

We report the use of a steerable hydrophilic guidewire for permanent pacemaker implantation. This wire, previously used for peripheral vascular and cardiac angiography, is able to be steered and passed in many situations when a standard guidewire cannot be used. We report three cases where the standard F‐tipped guidewire could not be passed fay either the cephalic or subclavian route and the hydrophilic guidewire allowed for successful atraumatic placement of a sheath and pacemaker lead.