Should Asymptomatic Ventricular Arrhythmia Patients with Congestive Heart Failure Be Treated? An Antagonist% Viewpoint
in
Philip J. Podrid, MD, and John S. Wilson, MD
T
he importance of ventricular arrhythmia is based on its association with sudden cardiac death. It has become increasingly recognized that in some groups of patients (e.g. those with a recent myocardial infarction) the presence of runs of nonsustained ventricular tachycardia significantly increases the risk for a malignant ventricular tachyarrhythmia and sudden cardiac death.i,2 A similar association has been reported in patients with a cardiomyopathy and congestive heart failure (CHF), but data are conflicting.3,4 More importantly, the role of antiarrhythmic drug therapy for prevention of sudden death has not been established. This paper reviews the prognostic importance of repetitive ventricular arrhythmia and the benefits and hazards of antiarrhythmic drugs in such patients, concluding that routine therapy for such patients is of no proven benefit. Prevalence of arrhythmia and sudden cardiac death in patients with cardiomyopathy and congestive heart failure: Ventricular premature beats are particularly
frequent in patients with a cardiomyopathy and CHF (Table I). Frequent ventricular premature beats occur in 70 to 95% of patients with cardiomyopathy of any etiology while runs of nonsustained ventricular tachycardia are documented in 40 to 80%. Their frequency and complexity are not closely associated with the degree of left ventricular impairment. There are many factors that predispose to ventricular arrhythmia in such patients (Table II). Structural factors resulting from the underlying cardiac pathology provide the appropriate substrate. As a result of myocardial damage, reentrant circuits capable of generating and sustaining arrhythmia may exist within the abnormal myocardium. Electrolyte depletion, most often diuretic-induced hypokalemia or low magnesium, is an important factor that can alter membrane excitability and automaticity. Hemodynamic factors, including ischemia, left ventricular dysfunction, contraction abnormalities, stretch on the myocardium and increased intracardiac pressure can induce ventricular arrhythmia. Neurohormonal mechanisms, particularly activation of the sympathetic nervous and renin-angiotensin sys-
terns, can interact with an unstable myocardium and precipitate arrhythmia. The drugs used for treatment of CHF, including digoxin, positive inotropic agents, p agonists and perhaps vasodilators, can induce or aggravate arrhythmia. A number of studies have reported a high yearly mortality in patients with a congestive cardiomyopathy, regardless of the etiology (Table III). It had been assumed that the cause of death in patients with a cardiomyopathy is progressive CHF. However, it has become apparent that a significant proportion of the deaths are sudden, the result of a sustained ventricular tachyarrhythmia (Table III). While a bradyarrhythmia has been observed to be the mechanism in a few patients, in the vast majority the etiology is a sustained ventricular tachyarrhythmia. The proportion of death that is sudden is unrelated to the nature of the underlying heart disease. Relation between arrhythmia and sudden cardiac death: In patients with a cardiomyopathy and CHF, the
relation between nonsustained ventricular tachycardia and an increased risk of sudden cardiac death continues to be controversial as data from the reported studies are conflicting (Table IV). Each of the trials involving patients with a recent myocardial infarction has reported that nonsustained ventricular tachycardia is an independent risk factor for sudden cardiac death, increasing mortality irrespective of left ventricular function, which is another independent factor (Table V). The highest mortality, however, is in those patients who have both nonsustained ventricular tachycardia and ventricular dysfunction (Table VI). In conclusion, runs of nonsustained ventricular tachycardia are associated with an increased risk of sudden death in patients with a recent myocardial infarction who have left ventricular dysfunction or CHF. The relation between this arrhythmia and sudden death in patients with an idiopathic-dilated cardiomyopathy remains uncertain, although most of the studies that involve a larger number of patients have reported a significant association. Role of electrophysiologic testing in predicting the patient at risk: Electrophysiologic testing is an impor-
From the Section of Cardiology and Department of Medicine, Boston University School of Medicine, Boston, LMassdchusetts. Manuscript received January 9, 1990; revised manuscript received and accepted March 30, 1990. Address for reprints: Philip J. Pcdrid. MD. Section of Cardiology. University Hospital, 88 E Newton Street, Boston. Massachusetts 02118.
tant and useful technique for evaluating arrhythmia mechanism and establishing drug efficacy in patients with sustained tachyarrhythmias. The role of electrophysiologic testing for establishing risk in the patient with a cardiomyopathy and CHF who has nonsustained ventricular tachycardia remains uncertain, controversial THE AMERICAN
JOURNAL
OF CARDIOLOGY
AUGUST
15, 1990
451
TABLE
I Prevalence of Ventricular with Congestive Heart Failure
Arrhythmia
Predisposing Heart Failure
to Arrhythmia
structural disease-abnormal abnormalities
substrate
with Congestive % with VPB or
% with
Study
n
Couplets
NSVl
Huan&
35 77 74 35 60 31 43 346 69 55 65 890
93 71 87 92 95 87 88 81 NA 76 95 78
60 50 49 71 80 39 51 28 41 40 80 45
Wilson* Meine& Maskinr Von Olshausent Holmes§ Chakko14 Francis11 Unverferth’s Costanzo Nordin’ Neri” Overall
TABLE II Factors
in Patients
Underlying Electrolyte
Potassium Magnesium Hemodynamic abnormalities LV dysfunction and contraction Stretch on myocardium-increased Increased ventricular pressure lschemia Neurohormonal changes Renin angiotensin Sympathetic nervous system Therapeutic interventions Digoxin Diuretics 0 agonists Phosphodiesterase inhibitors Vasodilators ACE inhibitors
* JACC 1983; 2403: f Am Heart J 1984: 107:896; f Br Heart J 1984; 61:995; 5 Am J Cardnl 1985:55:146: ‘1Am J Cardfol 1986:57:38; ’ Cathet Cardwasc Degn 1985; 1 I :445. NA = not avatlable: NSVT = nonsustamed ventricular tachycardla, VPB = ventrlcuIX premature beats.
ACE = angmtensmconverting
and investigational as data are conflicting (Table VII). The number of patients involved is small and protocols and endpoints have varied. Moreover, the patients with a decreased ejection fraction, but no clinical CHF, are often included. Effect of treatment ventricular
arrhythmia
of congestive heart failure en and survival: Given the high in-
cidence of sudden cardiac death in patients with a cardiomyopathy and CHF, an important question is whether treatment of CHF can decrease the frequency of ventricular arrhythmia and sudden death mortality. Some of these agents have been shown to decrease death from CHF. However, data about their role for suppressing ventricular arrhythmia and preventing sudden death are sparse and disappointing. A few studies evaluating the effects of direct-acting vasodilators on symptoms or survival reported the effect of this treatment on arrhythmia (Table VIII). No benefit from isosorbide dinitrate5 or hydralazine6 was observed, while
TABLE Ill Total Cardiac
I
Mortality
Cardiac
Death
Follow-Up Study
n
Francis* Huang4 Sakurait Wilson* Meinert Masking Von Olshausenl Holmes’ Chakko14 Franciosa**
159 35 190 77 74 35 60 43 43 182 56 178 28 106 1,266
Massieff Lee** Burggraf§§ Cohn1111 Overall * Am J Cardiol1986;57:36; 1983;51:831; tt Circulabon NA = not avalable.
452
and Sudden
THE AMERICAN
JOURNAL
20 34 NA 12 11 NA 12 14 16 12 13 36 60
in Patients
73 4 87 77 19 25 7 14 16 88 29 155 17 60 671
l-62
abnormalities ventricular
enzyme;
LV = left ventricular
with Congestive
(“h)
w (11) (6) (1W (2’3 (71)
(12) (33) (37) W)
W-3 (76)
61) (57) 52
Heart
Failure Sudden Death
VOLUME
66
(%) Sudden Death
(63
46 2 19 19 12 1 3 12 10 40 13 57 9 28 271
* JACC 1983;2:403:~ Am Heart 4 1984;107:896; 11 Br Heart 1 1984;51:995; ’ Am J Cardlol 1984:7o(supplll): 11-l 13; ~%Tirculation 1975;51:146; ‘111N EnglJ Med 1984;311:819.
OF CARDIOLOGY
volume
with minoxidil,7 there was a trend toward increased arrhythmia. While the impact of phosphodiesterase inhibitors (amrinone and milrinone) on survival has not been adequately studied, these positive inotropic agents may have an adverse effect on ventricular arrhythmia.8 The orally active /3 agonists have an uncertain effect on survival and may provoke arrhythmias.9 Diuretics may also play an important role in arrhythmogenesis due to electrolyte depletion, especially hypokalemia and low magnesium, which are factors known to increase the frequency of ventricular arrhythmia in patients with heart disease. Angiotensin-converting enzyme inhibitors decrease mortality from CHF and there have been interesting findings with respect to their effect on ventricular arrhythmias. Captopril does decrease ventricular arrhythmia, although enalapril is of less benelit,lOJ1 suggesting that this effect is independent of inhibition of angiotensin II. These studies, however, did not report mortality data.
Total Deaths
(mm)
t Jap Card J 1983:47:581; 1981:63:269; ** Circulation
in Patients
(50)
G-W (25)
(63) (4) (43)
(86) (62) (45) (34) (37) (53) (47) 41 1985:55:146:
* * Am J Cardiol
TABLE IV Relation and Sudden Cardiac Heart Failure
TABLE VII Predictive
Between Ventricular Ectopic Activity Death in Patients with Congestive
Accuracy of Electrophysiologic Studies in Patients with Cardiomyopathy and Nonsustained Ventricular Tachycardia
Follow-Up (mos)
Relation of VEA to SCD
Study
35
34
0
Veltn*
6
77 74 60 43 43
12 11 12 14 16
0 + 0 + +
Sulplzi+
9
Das+ Poll§ Gomesi Zheutlin’
61
12
+
Buxton**
Follansbeeli
55 19
16 19
0 +
Gradman’
295
16
+
Study
n
Huang“ Wilson* Meinertz3 Von Olshausent Holmest
Chakko14 UnvefferthL5 Costanzo-Nordins
* JACC 1983.2W3. ’ Br Heart J. 1984;51’995: + Am J Cardrol Cathet Cardwax Dlagn 1985.11 445: Am J Med 1980,92 1989:14:564. SCD = sudden cardtac death; VEA = ventricular ectopfc actlwty
No. wrth Cardromyopathy
24 20 10 13 la
After
Myocardial Sudden
Study
n
Duratron of Monitoring (W
Follow-Up (mos)
Kotler’ Moss+ Mukhar)?
a20 160 978 388
24 6 6 24
12 36 36 14
Rappaportl
139
24
12
1,739 64 al
1 10 24
42 26 7
Bigger’
Rubermanfi Vismara’, Schultz’
Sudden
Death
3 5 a 1 ? 7 9
23 29 12 ia 30 22 33
0 0 0 0 + f’ 0
Treatment Arrhythmia
of Congestive
Heart
IAm J Cardlo/ ’ Am Heart J
Failure-Effect Effect on Arrhythmra
infarction Death
n
Study
Drug
Franciosa5
32
0
Franciosae Franciosa7 Packer* Anderson+ Ferricki
lsosorbide dinitrate Hydralazfne Minoxidrl Amrinone Milrinone Mrlrinone
32 17 103 12 33
0 t t ’ t
DrBi ancoe Holmess Ludmerb
Mrlrinone Milrinone Milrinone
230 15 74
: 0
Mettauer’ Sharmag
Salbutamol Prrbuterol Captopril Captopril
20 14 14 300
: 1 1
20 19
0-l ;
(%)
No Complex VEA
Complex VEA
12 20 4 3 6 a 11 0
36 60 15 16 34 25 30 28
* Crculat~on 1973.47 959. ’ Qrculatmn 1979:60,998: r JACC 1983,1:391,* J Med 1977.297750~11 AmJMed 1975.59-6.’ Am J Med1977.62 192 VEA = ventricular ectopfc actwy
TABLE VI Percent
Predictrve
1985.55 146, 741, ’ JACC
VIII on Ventricular
Arrhythmia
Follow-Up (mos)
*Am J Cardni J985.56309. ‘Am J Cardioi 1987.59841. 1986.58 998, Am J Card/o/ 1986.58 992. Crculation 1984.70.43 1986;l J 1 860. * * Am J Cardrot J 984.53 1275 * Only nonrnduclbllity predlctlve
TABLE TABLE V Ventricular
1
No. Inducible
Clelandl” Captopril-Dtgoxrn Multicenter Group** Clelandll Webster++
N fngl
at 1 Year
Enalapnl Enalapril
1984,70 1038. 1 Am Heart J 1986. J 11 461, 1 Circulatnn * Cmulatmn Crculat!on 1984,7O(suppl I/)~/-J 1, Am J Cardrol J 986.74(suppl II) 11-508. J987,59135J.‘AmHeartJJ985J04840. ** JAMA J 988.259 539, +’ Am J Cardioi J 985.56.566 VPBs = ventricular premature beats.
[-
* N Engl J Med J 977,297 750. I Am J Med J 977:62 192. LV = left ventricular: VEA = ventricular ectoplc actwty
The effect of treatment for CHF on outcome has now been reported by several large multicenter studies. In the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS), enalapril decreased mortality by 27% compared to placebo.i2 However, the decrease was entirely due to a reduction in death from progressive CHF. The largest trial to date evaluating the effect of CHF therapy on mortality is the Veterans Administration Cooperative Study on Vasodilator Therapy of Heart FailureI involving placebo, hydralazine or prazosin. Those receiving hydralazine and nitrate therapy, but not the prazosin group, had a 28% decrease in mortality compared to placebo. However, no specific
analysis was performed to establish the cause of death or the impact of therapy on the occurrence of ventricular arrhythmia. In conclusion, some direct-acting vasodilators and angiotensin-converting enzyme inhibitors have been shown to decrease symptoms from CHF and improve quality of life. Their effect on ventricular arrhythmia is variable but probably clinically unimportant. While they have been shown to improve survival by decreasing the mortality due to CHF, they have not been shown to affect sudden death mortality. Rote of antiarrhythmic sudden death in patiints congestive heart failure:
drug therapy in preventing with a cardiomyopathy and
The association between sudden death and ventricular arrhythmia remains uncertain and controversial and the role of antiarrhythmic drugs for suppressing nonsustained ventricular tachycardia and preventing sudden death in patients with a cardiomyopathy and CHF remains unknown as there are only a few studies. Chakko and Gheorghiadei4 ran-
THE AMERICAN
JOURNAL
OF CARDIOLOGY
AUGUST
15.
1990
453
TABLE
IX Randomized
Trials
of Antiarrhythmic
Drugs
In Patients
Post Myocardial
Infarction % Mortality or Sudden Cardiac Death
Study
Drug
”
Duration Therapy
Morgensen* Bennett+ Lie* Bydens Campbellt~ Chamberlain’! IMPACT** Hugenholtztt Gottleibf’ Jane@ Holmbergllli Jennings!‘1 Zainel*** Koch Weser+t+ Kosowsky*** Collaborative§§§ Peter11 III/ CAST’”
Lidocaine Lidocaine Lidocaine Tocainide Mexiletine Mexiletine Mexiletine Aprindine Aprindine Quinidine Quinidine Disopyramide Disopyramide Procainamide Procainamide Phenytoin Phenytoin Encainide Flecainide
79 610 212 112 97 344 630 193 143 103 104 95 60 70 78 560 150 1,455
days days days 6 months 4yrs 1 yr 1 yr 1 yr 1 yr 3 days 15 days 1 yr 3 weeks 3 weeks 1 yr 1 yr 2 yrs 10 months
of Placebo
Drug
p Value
11.0 7.0 10.8 8.9 1.8 11.6 4.8 9.3 22.2 12.4 7.2 10.2 26.7 6.1 10.3 11.0 18.0 3.0
12.0 16.0 0 8.9 2.3 13.2 7.6 7.3 17.8 8.9 10.7 4.0 3.3 0 3.7 9.4 24.0 7.7
NS NS
in
Philip J. Podrid, MD, and John S. Wilson, MD
T
he importance of ventricular arrhythmia is based on its association with sudden cardiac death. It has become increasingly recognized that in some groups of patients (e.g. those with a recent myocardial infarction) the presence of runs of nonsustained ventricular tachycardia significantly increases the risk for a malignant ventricular tachyarrhythmia and sudden cardiac death.i,2 A similar association has been reported in patients with a cardiomyopathy and congestive heart failure (CHF), but data are conflicting.3,4 More importantly, the role of antiarrhythmic drug therapy for prevention of sudden death has not been established. This paper reviews the prognostic importance of repetitive ventricular arrhythmia and the benefits and hazards of antiarrhythmic drugs in such patients, concluding that routine therapy for such patients is of no proven benefit. Prevalence of arrhythmia and sudden cardiac death in patients with cardiomyopathy and congestive heart failure: Ventricular premature beats are particularly
frequent in patients with a cardiomyopathy and CHF (Table I). Frequent ventricular premature beats occur in 70 to 95% of patients with cardiomyopathy of any etiology while runs of nonsustained ventricular tachycardia are documented in 40 to 80%. Their frequency and complexity are not closely associated with the degree of left ventricular impairment. There are many factors that predispose to ventricular arrhythmia in such patients (Table II). Structural factors resulting from the underlying cardiac pathology provide the appropriate substrate. As a result of myocardial damage, reentrant circuits capable of generating and sustaining arrhythmia may exist within the abnormal myocardium. Electrolyte depletion, most often diuretic-induced hypokalemia or low magnesium, is an important factor that can alter membrane excitability and automaticity. Hemodynamic factors, including ischemia, left ventricular dysfunction, contraction abnormalities, stretch on the myocardium and increased intracardiac pressure can induce ventricular arrhythmia. Neurohormonal mechanisms, particularly activation of the sympathetic nervous and renin-angiotensin sys-
terns, can interact with an unstable myocardium and precipitate arrhythmia. The drugs used for treatment of CHF, including digoxin, positive inotropic agents, p agonists and perhaps vasodilators, can induce or aggravate arrhythmia. A number of studies have reported a high yearly mortality in patients with a congestive cardiomyopathy, regardless of the etiology (Table III). It had been assumed that the cause of death in patients with a cardiomyopathy is progressive CHF. However, it has become apparent that a significant proportion of the deaths are sudden, the result of a sustained ventricular tachyarrhythmia (Table III). While a bradyarrhythmia has been observed to be the mechanism in a few patients, in the vast majority the etiology is a sustained ventricular tachyarrhythmia. The proportion of death that is sudden is unrelated to the nature of the underlying heart disease. Relation between arrhythmia and sudden cardiac death: In patients with a cardiomyopathy and CHF, the
relation between nonsustained ventricular tachycardia and an increased risk of sudden cardiac death continues to be controversial as data from the reported studies are conflicting (Table IV). Each of the trials involving patients with a recent myocardial infarction has reported that nonsustained ventricular tachycardia is an independent risk factor for sudden cardiac death, increasing mortality irrespective of left ventricular function, which is another independent factor (Table V). The highest mortality, however, is in those patients who have both nonsustained ventricular tachycardia and ventricular dysfunction (Table VI). In conclusion, runs of nonsustained ventricular tachycardia are associated with an increased risk of sudden death in patients with a recent myocardial infarction who have left ventricular dysfunction or CHF. The relation between this arrhythmia and sudden death in patients with an idiopathic-dilated cardiomyopathy remains uncertain, although most of the studies that involve a larger number of patients have reported a significant association. Role of electrophysiologic testing in predicting the patient at risk: Electrophysiologic testing is an impor-
From the Section of Cardiology and Department of Medicine, Boston University School of Medicine, Boston, LMassdchusetts. Manuscript received January 9, 1990; revised manuscript received and accepted March 30, 1990. Address for reprints: Philip J. Pcdrid. MD. Section of Cardiology. University Hospital, 88 E Newton Street, Boston. Massachusetts 02118.
tant and useful technique for evaluating arrhythmia mechanism and establishing drug efficacy in patients with sustained tachyarrhythmias. The role of electrophysiologic testing for establishing risk in the patient with a cardiomyopathy and CHF who has nonsustained ventricular tachycardia remains uncertain, controversial THE AMERICAN
JOURNAL
OF CARDIOLOGY
AUGUST
15, 1990
451
TABLE
I Prevalence of Ventricular with Congestive Heart Failure
Arrhythmia
Predisposing Heart Failure
to Arrhythmia
structural disease-abnormal abnormalities
substrate
with Congestive % with VPB or
% with
Study
n
Couplets
NSVl
Huan&
35 77 74 35 60 31 43 346 69 55 65 890
93 71 87 92 95 87 88 81 NA 76 95 78
60 50 49 71 80 39 51 28 41 40 80 45
Wilson* Meine& Maskinr Von Olshausent Holmes§ Chakko14 Francis11 Unverferth’s Costanzo Nordin’ Neri” Overall
TABLE II Factors
in Patients
Underlying Electrolyte
Potassium Magnesium Hemodynamic abnormalities LV dysfunction and contraction Stretch on myocardium-increased Increased ventricular pressure lschemia Neurohormonal changes Renin angiotensin Sympathetic nervous system Therapeutic interventions Digoxin Diuretics 0 agonists Phosphodiesterase inhibitors Vasodilators ACE inhibitors
* JACC 1983; 2403: f Am Heart J 1984: 107:896; f Br Heart J 1984; 61:995; 5 Am J Cardnl 1985:55:146: ‘1Am J Cardfol 1986:57:38; ’ Cathet Cardwasc Degn 1985; 1 I :445. NA = not avatlable: NSVT = nonsustamed ventricular tachycardla, VPB = ventrlcuIX premature beats.
ACE = angmtensmconverting
and investigational as data are conflicting (Table VII). The number of patients involved is small and protocols and endpoints have varied. Moreover, the patients with a decreased ejection fraction, but no clinical CHF, are often included. Effect of treatment ventricular
arrhythmia
of congestive heart failure en and survival: Given the high in-
cidence of sudden cardiac death in patients with a cardiomyopathy and CHF, an important question is whether treatment of CHF can decrease the frequency of ventricular arrhythmia and sudden death mortality. Some of these agents have been shown to decrease death from CHF. However, data about their role for suppressing ventricular arrhythmia and preventing sudden death are sparse and disappointing. A few studies evaluating the effects of direct-acting vasodilators on symptoms or survival reported the effect of this treatment on arrhythmia (Table VIII). No benefit from isosorbide dinitrate5 or hydralazine6 was observed, while
TABLE Ill Total Cardiac
I
Mortality
Cardiac
Death
Follow-Up Study
n
Francis* Huang4 Sakurait Wilson* Meinert Masking Von Olshausenl Holmes’ Chakko14 Franciosa**
159 35 190 77 74 35 60 43 43 182 56 178 28 106 1,266
Massieff Lee** Burggraf§§ Cohn1111 Overall * Am J Cardiol1986;57:36; 1983;51:831; tt Circulabon NA = not avalable.
452
and Sudden
THE AMERICAN
JOURNAL
20 34 NA 12 11 NA 12 14 16 12 13 36 60
in Patients
73 4 87 77 19 25 7 14 16 88 29 155 17 60 671
l-62
abnormalities ventricular
enzyme;
LV = left ventricular
with Congestive
(“h)
w (11) (6) (1W (2’3 (71)
(12) (33) (37) W)
W-3 (76)
61) (57) 52
Heart
Failure Sudden Death
VOLUME
66
(%) Sudden Death
(63
46 2 19 19 12 1 3 12 10 40 13 57 9 28 271
* JACC 1983;2:403:~ Am Heart 4 1984;107:896; 11 Br Heart 1 1984;51:995; ’ Am J Cardlol 1984:7o(supplll): 11-l 13; ~%Tirculation 1975;51:146; ‘111N EnglJ Med 1984;311:819.
OF CARDIOLOGY
volume
with minoxidil,7 there was a trend toward increased arrhythmia. While the impact of phosphodiesterase inhibitors (amrinone and milrinone) on survival has not been adequately studied, these positive inotropic agents may have an adverse effect on ventricular arrhythmia.8 The orally active /3 agonists have an uncertain effect on survival and may provoke arrhythmias.9 Diuretics may also play an important role in arrhythmogenesis due to electrolyte depletion, especially hypokalemia and low magnesium, which are factors known to increase the frequency of ventricular arrhythmia in patients with heart disease. Angiotensin-converting enzyme inhibitors decrease mortality from CHF and there have been interesting findings with respect to their effect on ventricular arrhythmias. Captopril does decrease ventricular arrhythmia, although enalapril is of less benelit,lOJ1 suggesting that this effect is independent of inhibition of angiotensin II. These studies, however, did not report mortality data.
Total Deaths
(mm)
t Jap Card J 1983:47:581; 1981:63:269; ** Circulation
in Patients
(50)
G-W (25)
(63) (4) (43)
(86) (62) (45) (34) (37) (53) (47) 41 1985:55:146:
* * Am J Cardiol
TABLE IV Relation and Sudden Cardiac Heart Failure
TABLE VII Predictive
Between Ventricular Ectopic Activity Death in Patients with Congestive
Accuracy of Electrophysiologic Studies in Patients with Cardiomyopathy and Nonsustained Ventricular Tachycardia
Follow-Up (mos)
Relation of VEA to SCD
Study
35
34
0
Veltn*
6
77 74 60 43 43
12 11 12 14 16
0 + 0 + +
Sulplzi+
9
Das+ Poll§ Gomesi Zheutlin’
61
12
+
Buxton**
Follansbeeli
55 19
16 19
0 +
Gradman’
295
16
+
Study
n
Huang“ Wilson* Meinertz3 Von Olshausent Holmest
Chakko14 UnvefferthL5 Costanzo-Nordins
* JACC 1983.2W3. ’ Br Heart J. 1984;51’995: + Am J Cardrol Cathet Cardwax Dlagn 1985.11 445: Am J Med 1980,92 1989:14:564. SCD = sudden cardtac death; VEA = ventricular ectopfc actlwty
No. wrth Cardromyopathy
24 20 10 13 la
After
Myocardial Sudden
Study
n
Duratron of Monitoring (W
Follow-Up (mos)
Kotler’ Moss+ Mukhar)?
a20 160 978 388
24 6 6 24
12 36 36 14
Rappaportl
139
24
12
1,739 64 al
1 10 24
42 26 7
Bigger’
Rubermanfi Vismara’, Schultz’
Sudden
Death
3 5 a 1 ? 7 9
23 29 12 ia 30 22 33
0 0 0 0 + f’ 0
Treatment Arrhythmia
of Congestive
Heart
IAm J Cardlo/ ’ Am Heart J
Failure-Effect Effect on Arrhythmra
infarction Death
n
Study
Drug
Franciosa5
32
0
Franciosae Franciosa7 Packer* Anderson+ Ferricki
lsosorbide dinitrate Hydralazfne Minoxidrl Amrinone Milrinone Mrlrinone
32 17 103 12 33
0 t t ’ t
DrBi ancoe Holmess Ludmerb
Mrlrinone Milrinone Milrinone
230 15 74
: 0
Mettauer’ Sharmag
Salbutamol Prrbuterol Captopril Captopril
20 14 14 300
: 1 1
20 19
0-l ;
(%)
No Complex VEA
Complex VEA
12 20 4 3 6 a 11 0
36 60 15 16 34 25 30 28
* Crculat~on 1973.47 959. ’ Qrculatmn 1979:60,998: r JACC 1983,1:391,* J Med 1977.297750~11 AmJMed 1975.59-6.’ Am J Med1977.62 192 VEA = ventricular ectopfc actwy
TABLE VI Percent
Predictrve
1985.55 146, 741, ’ JACC
VIII on Ventricular
Arrhythmia
Follow-Up (mos)
*Am J Cardni J985.56309. ‘Am J Cardioi 1987.59841. 1986.58 998, Am J Card/o/ 1986.58 992. Crculation 1984.70.43 1986;l J 1 860. * * Am J Cardrot J 984.53 1275 * Only nonrnduclbllity predlctlve
TABLE TABLE V Ventricular
1
No. Inducible
Clelandl” Captopril-Dtgoxrn Multicenter Group** Clelandll Webster++
N fngl
at 1 Year
Enalapnl Enalapril
1984,70 1038. 1 Am Heart J 1986. J 11 461, 1 Circulatnn * Cmulatmn Crculat!on 1984,7O(suppl I/)~/-J 1, Am J Cardrol J 986.74(suppl II) 11-508. J987,59135J.‘AmHeartJJ985J04840. ** JAMA J 988.259 539, +’ Am J Cardioi J 985.56.566 VPBs = ventricular premature beats.
[-
* N Engl J Med J 977,297 750. I Am J Med J 977:62 192. LV = left ventricular: VEA = ventricular ectoplc actwty
The effect of treatment for CHF on outcome has now been reported by several large multicenter studies. In the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS), enalapril decreased mortality by 27% compared to placebo.i2 However, the decrease was entirely due to a reduction in death from progressive CHF. The largest trial to date evaluating the effect of CHF therapy on mortality is the Veterans Administration Cooperative Study on Vasodilator Therapy of Heart FailureI involving placebo, hydralazine or prazosin. Those receiving hydralazine and nitrate therapy, but not the prazosin group, had a 28% decrease in mortality compared to placebo. However, no specific
analysis was performed to establish the cause of death or the impact of therapy on the occurrence of ventricular arrhythmia. In conclusion, some direct-acting vasodilators and angiotensin-converting enzyme inhibitors have been shown to decrease symptoms from CHF and improve quality of life. Their effect on ventricular arrhythmia is variable but probably clinically unimportant. While they have been shown to improve survival by decreasing the mortality due to CHF, they have not been shown to affect sudden death mortality. Rote of antiarrhythmic sudden death in patiints congestive heart failure:
drug therapy in preventing with a cardiomyopathy and
The association between sudden death and ventricular arrhythmia remains uncertain and controversial and the role of antiarrhythmic drugs for suppressing nonsustained ventricular tachycardia and preventing sudden death in patients with a cardiomyopathy and CHF remains unknown as there are only a few studies. Chakko and Gheorghiadei4 ran-
THE AMERICAN
JOURNAL
OF CARDIOLOGY
AUGUST
15.
1990
453
TABLE
IX Randomized
Trials
of Antiarrhythmic
Drugs
In Patients
Post Myocardial
Infarction % Mortality or Sudden Cardiac Death
Study
Drug
”
Duration Therapy
Morgensen* Bennett+ Lie* Bydens Campbellt~ Chamberlain’! IMPACT** Hugenholtztt Gottleibf’ Jane@ Holmbergllli Jennings!‘1 Zainel*** Koch Weser+t+ Kosowsky*** Collaborative§§§ Peter11 III/ CAST’”
Lidocaine Lidocaine Lidocaine Tocainide Mexiletine Mexiletine Mexiletine Aprindine Aprindine Quinidine Quinidine Disopyramide Disopyramide Procainamide Procainamide Phenytoin Phenytoin Encainide Flecainide
79 610 212 112 97 344 630 193 143 103 104 95 60 70 78 560 150 1,455
days days days 6 months 4yrs 1 yr 1 yr 1 yr 1 yr 3 days 15 days 1 yr 3 weeks 3 weeks 1 yr 1 yr 2 yrs 10 months
of Placebo
Drug
p Value
11.0 7.0 10.8 8.9 1.8 11.6 4.8 9.3 22.2 12.4 7.2 10.2 26.7 6.1 10.3 11.0 18.0 3.0
12.0 16.0 0 8.9 2.3 13.2 7.6 7.3 17.8 8.9 10.7 4.0 3.3 0 3.7 9.4 24.0 7.7
NS NS
