Identifying the Arrhythmic Risk in Post-Myocardial Infarction Patients with Preserved Ejection Fraction: Positive Non-Invasive Indices Percentage Predicting an Inducible Programmed Ventricular Stimulation before an ICD implantation (PRESERVE-EF Study)

K.A Gatzoulis1, D. Tsiachris1, P. Arsenos1, A. Mendrinos1, K. Trahanas2, K. Vlachos3, I. Xenogiannis4, M. Vernardros5, K. Tsimos6, K. Triantafyllou7, D. Tousoulis1
1 First Cardiology Division, University of Athens, Hippokration Hospital, Greece
2 State Cardiology Department, Hippokration Hospital, Greece
3 Second State Cardiology Department, Evangelismos Hospital, Greece
4 Second Cardiology Division, University of Athens, Attikon Hospital, Greece
5 Department of Cardiology, University Hospital of Heraklion, University of Crete, Greece
6 Cardiology Division, University Hospital of Ioannina, University of Ioannina, Greece
7 Third Cardiology Division, Aristotle University Medical School, Hippokration Hospital, Greece

Aims: Although current clinical practice is focused in post Myocardial Infarction (MI) patients with an impaired Left Ventricular Ejection Fraction (LVEF) for ICD prophylaxis, there is evidence for the presence of increased arrhythmic risk and Sudden Cardiac Death (SCD) in some patients with preserved LVEF>35% as well. To detect among the post-MI revascularized patients with preserved systolic function and LVEF>40%, those, at increased risk for Arrhythmic SCD.
Methods: We introduced a combined Non-Invasive and Invasive Risk Stratification Approach in post-MI patients 40 days after revascularization who had a LVEF≥40% (Hellenic J Cardiol 2014;55:361-368 and NCT02124018 ). Patients with one positive out of the following seven Non Invasive Criteria of: ≥30 premature ventricular complexes (PVCs)/hour, ≥1 non-sustained VT (NSVT) episode(s)/24 hour, 2/3 positive criteria for late potentials (LPs), QTc≥440 ms (♂) or QTc≥450ms (♀), Ambulatory T wave alternans (TWA) ≥65 μV, SDNN from Heart Rate Variability ≤75 ms , Deceleration Capacity of Heart Rate ≤4.5 ms and Heart Rate Turbulence (HRT) Onset ≥0% and HRT slope ≤2.5 ms were considered of increased arrhythmic risk and they were referred for Programmed Ventricular Stimulation (PVS).
Results: From the first two hundrend eighty three (283) patients who were screened non invasively, 77 patients (27%) had at least one positive non invasive marker and were referred for PVS. Fourteen (14) out of these 77 patients (18%) had inducible Sustained Ventricular Tachycardia on PVS and 13 received an ICD while one denied the implantation. The percentage of the presence of the Non Invasive indices in these 14 patients with possitive PVS was as follows: NSVT: 85% (n=12), LPs 64% (n=9), VPCs 57% (n=8), QTc 29% (n=4), combined DC/HRT 29% (n=4), TWA 14% (n=2), SDNN 7% (n=1).
Conclusions: Preliminary data suggest that multifactorial non invasive risk screening may detect a subpopulation of post-MI patients with preserved LVEF under risk for Inducible Ventricular Tachycardia. Prospective follow up is expected to clarify the extent of ICD activations in this population.