Risk stratification following myocardial infarction in the thrombolytic era: two-step strategy using noninvasive and invasive methods

Objectives. We prospectively performed two-step risk assessment in patients in the early phase after acute myocardial infarction (MI). Background. Noninvasive methods like Holter electrocardiographic monitoring (HM) and determination of the left ventricular ejection fraction (EF) as well as the invasive technique of programmed ventricular stimulation (PVS) have been used to identify patients in the late phase after MI as candidates for prophylactic implantation of cardioverter/defibrillator. However, it is unclear whether these results can be transferred to patients following acute MI. Methods. series of 657 patients with acute MI (≤75 years) underwent HM and EF. If one of the two methods yielded abnormal findings (HM ≥20 ventricular ectopic beats/h/≥10 ventricular pairs/day/ventricular tachycardia; EF ≤40%), PVS was done (abnormal PVS: induction of monomorphic ventricular tachycardia, duration >10 s, cycle length ≥230 ms). Results. Of 657 patients, 304 (46%) had either an abnormal HM or EF. The PVS performed in 146 of 304 patients was abnormal in 22. During mean follow-up of 37 months, there were 106 (16%) deaths, being sudden in 24 (3.6%), nonsudden cardiac in 45 (6.8%). The incidence of arrhythmic events (sudden cardiac death, symptomatic ventricular tachycardia, cardiac arrest) was 18% (4/22) with an abnormal PVS and only 4% (5/124) with normal PVS (odds ratio 4.0, p = 0.032). Conclusions. The rate of arrhythmic events is low in post-MI patients in the 1990s. Nevertheless, two-step risk stratification is helpful in selecting candidates for defibrillator trial aiming at primary prevention of sudden cardiac death after MI.