Berisso M Z, Molini D, Camerini A, Mela G S, Vecchio C
Divisione di Cardiologia, E.O. Ospedali Galliera, Genova.
G Ital Cardiol. 1994 May;24(5):503-15.
Programmed ventricular stimulation performed early after acute myocardial infarction allows to identify patients at risk of sudden death and sustained ventricular tachycardia with high degree of predictive accuracy. This procedure, however, because of its invasive nature, is not desirable as a screening test for large numbers of patients. Therefore, it should be performed on a smaller group of postinfarction patients preselected on the basis of noninvasive testing. The aim of the present study was to identify, early after acute myocardial infarction, any procedure among noninvasive testing, able to selected with the highest sensitivity patients at risk of sudden death and sustained ventricular tachycardia to submit to programmed ventricular stimulation.
Two hundred and sixty four consecutive patients with recent myocardial infarction were evaluated and followed during a period of 12 months. In each patient 48 epidemiological, clinical and laboratory variables were evaluated. Laboratory variables were acquired between the 7th and the 12th day after the acute event.
Multiple linear regression analysis showed that only Killip class, the number of ventricular premature depolarizations per hour and the presence of ventricular late potentials were significantly and independently related to the occurrence of sudden death and sustained ventricular tachycardia (F = 18.7; p < 0.00001). Combinations of these variables, determined at cut off levels best discriminating two subgroups of patients at different risk of the end-point events, proved to be able to accurately predict the outcome of our patients. The presence of at least one of the following conditions: Killip class > or = 2, ventricular premature depolarizations > or = 30 per hour, ventricular late potentials allowed to identify a first subgroup of patients at risk with a sensitivity of 100% (p = 0.00007), whereas the presence, at the same time, of all the above mentioned parameters allowed to identify a second subgroup of patients at risk with a 44% of positive predictive value (p = 0.00007).
Our findings suggest that the first subgroup of postinfarction patients selected on the basis of noninvasive testing should undergo programmed ventricular stimulation, the second might be treated by adequate antiarrhythmic therapy without undergo any further investigation, whereas the remaining patients (without late potentials, in Killip class 1 and with ventricular premature depolarizations < 30 per hour) might be discharged without any antiarrhythmic therapy.
急性心肌梗死后早期进行的程控心室刺激能够以较高的预测准确性识别猝死和持续性室性心动过速风险患者。然而，由于该操作具有侵入性，作为对大量患者的筛查试验并不理想。因此，应在基于无创检查预先选择的较小梗死患者群体中进行。本研究的目的是在急性心肌梗死后早期，确定无创检查中能够以最高敏感性选择猝死和持续性室性心动过速风险患者以进行程控心室刺激的任何方法。
对264例近期心肌梗死患者进行了为期12个月的评估和随访。对每位患者评估了48项流行病学、临床和实验室变量。实验室变量在急性事件后第7天至第12天之间获取。
多元线性回归分析显示，只有Killip分级、每小时室性早搏数量和室性晚电位的存在与猝死和持续性室性心动过速的发生显著且独立相关（F = 18.7；p < 0.00001）。这些变量在区分终点事件不同风险患者的两个亚组的最佳截断水平下的组合，被证明能够准确预测我们患者的结局。存在以下至少一种情况：Killip分级≥2、每小时室性早搏≥30次、室性晚电位，能够识别出一个风险患者的第一亚组，敏感性为100%（p = 0.00007），而同时存在上述所有参数能够识别出一个风险患者的第二亚组，阳性预测值为44%（p = 0.00所07）。
我们的研究结果表明，基于无创检查选择的第一组梗死患者应接受程控心室刺激，第二组可能通过适当的抗心律失常治疗进行处理而无需进一步检查，而其余患者（无晚电位、Killip分级为1且每小时室性早搏<30次）可能无需任何抗心律失常治疗即可出院。
