Prognostic value of life-threatening ventricular arrhythmias - sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) occurred in patients with acute myocardial infarction-segment elevation ST (STEMI) subjected to primary percutaneous coronary intervention (PCI) remains undetermined. This issue was devoted to the secondary analysis of data from randomized, double-blind clinical study APEX AMI.
The study was conducted in 296 centers in 17 countries and from 2004 to 2006, included 5,745 patients STEMI up to six hours if the criteria of high risk. It defined as ST-segment elevation of at least 2 mm in at least two leads from the front wall or in two leads from the bottom wall with reciprocal ST depression in two contiguous leads at a total displacement of ST at least 8 mm. Almost all (93.5%) participants received primary PCI stenting with infarct-related coronary artery (ISA) and accompanying modern therapy.
The primary endpoint was total mortality for 30 days in groups of drug's research - pekselizumaba (pexelizumab) or placebo, a secondary endpoint - a combination of death, cardiogenic shock, congestive heart failure at 30 and 90 days.
For this analysis, participants were divided into groups: without VT / VF, with a registered VT / VF at any time before or after PCI, with VT / VF before the end of PCI (early VT / VF), VT / VF that developed after percutaneous coronary intervention ( late VT / VF).
Life-threatening ventricular arrhythmias were recorded in 329 (5.7%) study participants, 90% of cases - in the first 48 hours of onset. Early VT / VF was observed in 205 patients (25 - prior to cardiac catheterization), late VT / VF - in 117 patients (70% - in the first 48 hours of illness).
The presence of ventricular arrhythmias recorded at any time of hospitalization, followed by a significantly higher 90-day mortality: 23.2% versus 3.6% in those without VT / VF (adjusted risk ratio [RRR] - 3.63, 95% confidence interval [CI], 2,59-5,09). In this case, outcomes were worse in patients with early VT / VF (90-day mortality rate - 17,2%; GRA - 2,34, 95% CI 1,44-3,80), and especially in patients with late VT / VF (90-day mortality rate - 33,3%; GRA - 5,59, 95% CI 3,71-8,43). In multivariate analysis with adjustment for baseline clinical and demographic differences and angiographic factors independently associated with early VT / VF were: occlusion of the ISA to PCI (0 degree of blood flow to TIMI) (OR - 2.54, 95% CI 1.93 - 4.47), lower localization of MI (RR - 2.16, 95% CI 1,58-2,93), the total displacement of the segment ST (RR - 1.39 per 5 mm increase, 95% CI 1.19 - 1.63), creatinine clearance (RR - 0.88 per 10 ml / min increase, 95% CI 0,83-0,94), class of higher Killipu I (OR - 1.88, 95% CI 1, 29-2,76), systolic blood pressure on admission (RR - 0.92 for every 10 mm Hg. Art. Increase, 95% CI 0,87-0,98), body weight (RR - 1.16 per 10 kg increase, 95% CI 1,04-1,29) and heart rate at admission above 70 per minute (RR - 1.10 per 10 beats per minute, 95% CI 1,01-1,20). Factors associated with the development of late VT / VF were: systolic blood pressure on admission (RR - 0.83 for every 10 mm Hg. Art. Increase, 95% CI 0,76-0,91), the return of the ST segment to isoline after PCI less than 70% of the original (OR - 3.17, 95% CI 1,60-6,28), heart rate at admission above 70 per minute (RR - 1.20 per 10 beats per minute, 95 % CI 1,08-1,33), cumulative ST-segment deviation on admission (RR - 1.43 per 5 mm increase, 95% CI 1,14-1,79), occlusion of the ISA to PCI (RR - 2 12, 95% CI 1,20-3,75), the degree of blood flow in the ISA after percutaneous coronary intervention on a scale of less than TIMI 3 (OR - 2.09, 95% CI 1,24-3,52) and the appointment of beta-blockers in the first 24 (RR - 0.52, 95% CI 0,32-0,85).
The development of life-threatening ventricular arrhythmias in patients with STEMI, primary PCI is subject to, associated with increased risk of death within the first 90 days, including more than the 2-fold increase for its early VT / VF, and more than the 5-fold increase for late VT / VF. Data obtained on the time of occurrence of VT / VF, and its predictors can help identify high-risk patients requiring prolonged observation in the ICU. The authors believe the publication.
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