Prediction of sudden cardiac arrest: Risk stratification by anatomic substrate

doi:10.1016/0002-8703(93)90692-3

American Heart Journal

Volume 126, Issue 4, October 1993, Pages 807-815

https://doi.org/10.1016/0002-8703(93)90692-3 Get rights and content

Abstract

The prognostic importance of coronary artery anatomy to specific outcomes including ventricular tachycardia/fibrillation was evaluated in 372 consecutive patients undergoing cardiac catheterization at University Hospital at Stony Brook between 1981 and 1984. The hypothesis that proximal left anterior descending artery narrowing before the first septal perforator had a specific relationship to survival was again tested in this cohort. The population was prospectively followed for 8 years, with all clinical management decisions made independently by the patient's primary or referring physician. Multivariate statistical and life table analyses were performed after comprehensive follow-up. Significant narrowing in the proximal left anterior descending artery was associated with an increased risk of sudden cardiac death (p = 0.0002). Abnormalities of contractility in the diaphragmatic segment of the left ventricle in addition to an elevation of the left ventricular end-diastolic pressure and the presence of congestive heart failure (p < 0.05) were other contributory variables. Outcome in patients with proximal left anterior descending coronary artery disease who underwent aortocoronary artery bypass to the artery demonstrated improved survival (p < 0.05). Risk stratification of patients at high risk for sudden cardiac death is possible and may allow identification for an aggressive approach or interventional trials.

References (22)

EV Platia et al.
Clinical and arteriographic variables predictive of survival in coronary artery disease
Am J Cardiol
(1980)
EH Schuster et al.
Preponderance of acute proximal left anterior descending coronary arterial lesions in fatal myocardial infarction: a clinicopathologic study
Am J Cardiol
(1981)
JS Webster et al.
Natural history of severe proximal coronary artery disease as documented by coronary cineangiography
Am J Cardiol
(1974)
SC Vlay et al.
Relationship of specific coronary lesions and regional left ventricular dysfunction to prognosis in survivors of sudden cardiac death
Am Heart J
(1984)
LW Klein et al.
Prognostic significance of severe narrowing of the proximal portion of the left anterior descending coronary artery
Am J Cardiol
(1986)
Z Abedin et al.
Isolated left anterior descending artery disease: choice of therapy
Am J Cardiol
(1977)
AG Kumpuris et al.
Isolated stenosis of left anterior descending or right coronary artery: relation between site of stenosis and ventricular dysfunction; therapeutic implications
Am J Cardiol
(1980)
J Van Lierde et al.
Long-term prognosis of male patients with an isolated chronic occlusion of the left anterior descending coronary artery
Am Heart J
(1991)
RM Califf et al.
“Left main equivalent” coronary artery disease: its clinical presentation and prognostic significance with nonsurgical therapy
Am J Cardiol
(1984)
SH Rahimtoola
Left main equivalence is still an unproved hypothesis but proximal left anterior descending coronary artery disease is a “high risk” lesion
Am J Cardiol
(1984)

DA Killen et al.

Fifteen-year results of coronary artery bypass for isolated left anterior descending coronary artery disease

Ann Thorac Surg

(1989)

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There are scarce and sometimes contradictory data about ventricular fibrillation (VF) during the acute phase of MI. In-hospital VF most often occurs with inferior MI, when treated with fibrinolytics. Out-of-hospital VF seems to be associated with anterior MI. We studied characteristics of patients with VF during reperfusion therapy by primary angioplasty (PCI) versus patients with VF before PCI.
From January 1995 until December 2001, we treated 2826 patients for acute MI and reviewed clinical records of all patients who developed VF and classified the patients according to the first episode of VF: either before or during the angioplasty procedure.
VF developed in 219 (8%) patients. Patients with VF during reperfusion therapy (n=74, 3%) were older (p=0.03), more frequently female (0.04), less often had heart failure (p=0.04), when compared with patient with VF before PCI (n=145, 5%). Patients with VF during PCI experienced more often preinfarction angina (p=0.009) and suffered more often from inferior MI (p=0.001), when compared with patients with VF before PCI.
Patients with early VF before reperfusion have different characteristics when compared with patients with VF during reperfusion. Infarct location is a major determinant of timing of VF, when both groups are compared (p<0.001).
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Citation Excerpt :
This theoretical prediction was in concert with observations of Davies and Thomas (21)in sudden ischemic death. Later studies, however, found associations of early VF and IRAs inconsistent (7–14), but some either included few or no patients with out-of-hospital VF or had no angiographic data (7,10–12). Other studies did not specifically address AMI complicated by out-of-hospital VF and possibly included a heterogeneous group of patients with cardiac arrest (13,14).
OBJECTIVES
The study intended to compare the acute coronary anatomy of patients with acute myocardial infarction (AMI) complicated by out-of-hospital ventricular fibrillation (VF) versus patients with AMI without this complication.
BACKGROUND
More than half of the deaths associated with AMI occur out of the hospital and within 1 h of symptom onset. The angiographic determinants of out-of-hospital VF in patients with AMI have not been investigated in detail.
METHODS
Acute coronary angiographic findings of 72 consecutive patients with AMI complicated by out-of-hospital VF were compared with findings from 144 matched patients with AMI without this complication.
RESULTS
Patients with an acute occlusion of the left anterior descending coronary artery (LAD) or left circumflex coronary artery (LCx) had a higher risk for out-of-hospital VF compared with patients with an acute occlusion of the right coronary artery (RCA) (odds ratio and 95% confidence interval, respectively, 4.82 [2.35 to 9.92] and 4.92 [2.34 to 10.39]). With regard to extent of coronary artery disease (CAD), the location of the culprit lesion in the coronary arteries (proximal vs. mid or distal), the flow in the infarct related artery (IRA), the presence or absence of collaterals to the IRA and chronic occlusions, there were no differences between the two groups.
CONCLUSIONS
Acute myocardial infarction due to occlusion in the left coronary artery (LCA) is associated with greater risk for out-of-hospital VF compared to the RCA. The location of occlusion within LCA (LAD, LCx, proximal or distal), amount of myocardium at risk for necrosis and extent of CAD are not related to out-of-hospital VF.
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2000, Zeitschrift fur Kardiologie

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Prediction of sudden cardiac arrest: Risk stratification by anatomic substrate

Abstract

Am J Cardiol

Am J Cardiol

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Ann Thorac Surg