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In science, generally to solve one Case Illustration torial and include myocardial salvage,
set of problems may be to create A 54-year-old man was admitted to the reduced infarct size, and improved left
or discover a whole new set, and hospital after he experienced severe ventricular function and remodeling
of no science is this more true chest pain for approximately 8 hours. (Figure 1). Other factors that probably
than in medicine. He had an acute anterior Q-wave in- contribute substantially to the im-
George P. Elliott, farction, and he underwent coronary proved long-term prognosis include
The American Scholar, 1975 angiography with subsequent recanali- the use of aspirin, -blockers, and
zation of a totally occluded left ante- angiotensin-converting enzyme inhibi-
S
udden cardiac death (SCD) rior descending coronary artery. In ad- tors, frequent concomitant coronary re-
causes approximately 3 million dition, the right coronary artery vascularization by bypass surgery or
fatalities in the United States showed a 50% narrowing. At the time percutaneous coronary intervention,
annually.1 With the advent of the im- of discharge, echocardiography dem- and, more recently, aggressive lipid-
plantable cardioverter-defibrillator onstrated a left ventricular ejection lowering therapy.
(ICD), an intervention that reduces the fraction of 33%. Exercise stress testing
risk of arrhythmogenic death is avail- revealed no evidence of ongoing myo- Epidemiological Impact of
able.2 4 The challenge is to identify cardial ischemia. The patient requested Risk Stratification
risk factors for SCD among most pa- advice concerning his risk for subse- To be epidemiologically meaningful,
tients at relatively low risk, specifi- quent arrhythmias and SCD. prognostic tests must have a high pos-
cally including survivors of acute itive predictive accuracy with a rea-
myocardial infarction (MI), in an era Implications of sonable degree of sensitivity to ensure
when the prognosis is substantially Contemporary Therapeutic that the findings are not restricted to a
better than before the widespread use Guidelines on Mortality small minority of patients. The first
of reperfusion therapy. As in the de- After MI step toward this goal requires knowl-
scription of medicine in the epigraph The in-hospital and late survival rates edge of the total number of sudden
above, reperfusion therapy has solved of patients with acute MI have im- deaths within a specific patient popu-
one set of problems, but the improved proved substantially in the past 2 de- lation expressed as a fraction of total
prognosis has generated a whole new cades. In-hospital mortality decreased mortality within this group. Thus, for
set of questions about risk stratifica- from approximately 16% in the late an intervention specific for SCD, one
tion. This review discusses risk strati- 1970s and early 1980s to 8% to 10% in must not only identify survivors of
fication in contemporary cardiology the early 1990s. The reasons for the acute MI who are at high risk for death
for patients after acute MI. decrease in late mortality are multifac- but also predict whether arrhythmic or
From the J.W. Goethe University, Department of Medicine, Division of Cardiology, Frankfurt, Germany (S.H.H.), and the Division of Cardiovascular
Diseases and Internal Medicine, Mayo Clinic, Rochester, Minn (B.J.G.).
Correspondence to Dr Bernard J. Gersh, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
(Circulation. 2003;107:941-946.)
2003 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org DOI: 10.1161/01.CIR.0000054211.00668.9B
941
942 Circulation February 25, 2003
frequency of nonsustained VT among of a search for new methods of risk has declined after reperfusion therapy,
a series of patients (60% of whom stratification, which remain a pivotal the correlation between impaired
received thrombolytic therapy)11 does component of the assessment of the LVEF and late mortality persists.6
not seem to be substantially different survivor of MI. According to Bayesian Nonetheless, compared with earlier
from that of earlier studies. principles, the goal of risk stratifica- studies, recent series suggest that the
tion is to identify which patients in a curve relating mortality to ejection
Modifying Factors group with a low pretest likelihood of fraction has shifted to the left, imply-
The autonomic nervous system is a an event occurring are, in fact, at ing that for a given degree of left
pivotal modifier of arrhythmic risk ac- intermediate risk and are most likely to ventricular dysfunction, the increase in
cording to both experimental and clin- receive the greatest incremental bene- mortality is somewhat less than previ-
ical data.12 Studies of patients after fit from diagnostic testing (Figure 2). ously reported (Figure 3). Another
infarction have demonstrated that study emphasized the importance of
baroreflex sensitivity as a marker of Clinical and Demographic Data
impaired diastolic function, the predic-
sympathetic-parasympathetic balance The GISSI-2 (Gruppo Italiano per lo
tive power of which was independent
is substantially and unfavorably in- Studio della Sopravvivenza nellInfarto
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proach to the predischarge assessment the implantation of an ICD. In the of highest risk for arrhythmic events,
of the asymptomatic patient who had MADIT II study, patients were as- will be investigated by these studies.
reperfusion therapy within 6 hours, or signed randomly to receive either ICD Besides allowing evaluation of the ef-
at the most 12 hours, after the onset of therapy or no ICD therapy solely on fectiveness of the respective treat-
symptoms and who had an uncompli- the basis of the finding of an LVEF ments, results of these trials will help
cated clinical course. Available data less than 31% after MI. After enroll- to establish the future role of methods
integrated into a Bayesian approach ment of 1232 patients, the trial was of risk stratification.
suggest the following stepwise ap- stopped because of a significant reduc-
proach to arrhythmic risk stratification tion in all-cause mortality in patients References
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Changing Late Prognosis of Acute Myocardial Infarction: Impact on Management of
Ventricular Arrhythmias in the Era of Reperfusion and the Implantable
Cardioverter-Defibrillator
Stefan H. Hohnloser and Bernard J. Gersh
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Circulation. 2003;107:941-946
doi: 10.1161/01.CIR.0000054211.00668.9B
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