The Alfred Hospital, Melbourne, Australia.
Central Clinical School, Monash University, Melbourne, Australia.
J Cardiovasc Electrophysiol. 2023 Apr;34(4):959-966. doi: 10.1111/jce.15868. Epub 2023 Feb 26.
The diagnostic work-up for cardiac arrest from ventricular tachyarrhythmias occurring in younger adults and structurally normal hearts is variable and often incomplete.
We reviewed records for all recipients of a secondary prevention implantable cardiac defibrillator (ICD) younger than 60 years at a single quaternary referral hospital from 2010 to 2021. Patients with unexplained ventricular arrhythmias (UVA) were identified as those with no structural heart disease on echocardiogram, no obstructive coronary disease, and no clear diagnostic features on ECG. We specifically evaluated the adoption rate of five modalities of "second-line" cardiac investigations: cardiac magnetic resonance imaging (CMR), exercise ECG, flecainide challenge, electrophysiology study (EPS), and genetic testing. We also evaluated patterns of antiarrhythmic drug therapy and device-detected arrhythmias and compared them with secondary prevention ICD recipients with a clear etiology found on initial assessment.
One hundred and two recipients of a secondary prevention ICD under the age of 60 were analyzed. Thirty-nine patients (38.2%) were identified with UVA and were compared with the remaining 63 patients with VA of clear etiology (61.8%). UVA patients were younger (35.6 ± 13.0 vs. 46.0 ± 8.6 years, p < .001) and were more often female (48.7% vs. 28.6%, p = .04). CMR was performed in 32 patients with UVA (82.1%), whereas flecainide challenge, stress ECG, genetic testing, and EPS were only performed in a minority of patients. Overall, the use of a second-line investigation suggested an etiology in 17 patients with UVA (43.5%). Compared to patients with VA of clear etiology, UVA patients had lower rates of antiarrhythmic drug prescription (64.1% vs. 88.9%, p = .003) and had a higher rate of device-delivered tachy-therapies (30.8% vs. 14.3%, p = .045).
In this real-world analysis of patients with UVA, the diagnostic work-up is often incomplete. While CMR was increasingly utilized at our institution, investigations for channelopathies and genetic causes appear to be underutilized. Implementation of a systematic protocol for work-up of these patients requires further study.
在年轻成人和结构正常心脏发生室性心动过速的情况下，心脏骤停的诊断工作各不相同，且通常不完整。
我们回顾了 2010 年至 2021 年期间在一家四级转诊医院接受二级预防植入式心脏除颤器 (ICD) 的所有年龄小于 60 岁的患者记录。将不明原因室性心律失常 (UVA) 患者定义为超声心动图无结构性心脏病、无阻塞性冠状动脉疾病和心电图无明确诊断特征的患者。我们专门评估了五种“二线”心脏检查方法的采用率：心脏磁共振成像 (CMR)、运动心电图、氟卡尼挑战、电生理研究 (EPS) 和基因检测。我们还评估了抗心律失常药物治疗和设备检测心律失常的模式，并将其与在初始评估中发现明确病因的二级预防 ICD 接受者进行了比较。
分析了 102 名年龄小于 60 岁的二级预防 ICD 接受者。39 名患者 (38.2%) 被确定为 UVA，并与其余 63 名明确病因的 VA 患者 (61.8%) 进行比较。UVA 患者年龄较小 (35.6 ± 13.0 岁 vs. 46.0 ± 8.6 岁，p < 0.001)，女性更多 (48.7% vs. 28.6%，p = 0.04)。32 名 UVA 患者进行了 CMR 检查 (82.1%)，而氟卡尼挑战、运动心电图、基因检测和 EPS 仅在少数患者中进行。总体而言，二线检查提示 UVA 患者病因 17 例 (43.5%)。与明确病因的 VA 患者相比，UVA 患者抗心律失常药物处方率较低 (64.1% vs. 88.9%，p = 0.003)，且设备治疗性心动过速的发生率较高 (30.8% vs. 14.3%，p = 0.045)。
在这项 UVA 患者的真实世界分析中，诊断工作通常不完整。虽然我们机构越来越多地使用 CMR，但对通道病和遗传原因的检查似乎利用不足。需要进一步研究来实施针对这些患者的系统工作流程。
