This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Newby, K. H. Articles by Natale, A. Search for Related Content PubMed PubMed Citation Articles by Newby, K. H. Articles by Natale, A.

(Circulation. 1998;98:2567-2573.)
© 1998 American Heart Association, Inc.

Clinical Investigation and Reports

Sustained Ventricular Arrhythmias in Patients Receiving Thrombolytic Therapy

Incidence and Outcomes

Presented in part at the 68th Scientific Sessions of the American Heart Association, Anaheim, Calif, November 13–16, 1995, and published in abstract form (Circulation. 1995;92[suppl I]:I-420).

Keith H. Newby, MD; Trevor Thompson, BS; Amanda Stebbins, MS; Eric J. Topol, MD; Robert M. Califf, MD; Andrea Natale, MD; for the GUSTO Investigators

From the Divisions of Cardiology, Departments of Medicine, Duke University Medical Center and Durham Veterans Affairs Medical Center, Durham, NC.

Correspondence to Andrea Natale, MD, University of Kentucky, Division of Cardiovascular Medicine, Room L-543, Kentucky Clinic, Lexington, KY 40536-5479.

	Abstract

Top Abstract Introduction Methods Results Discussion References

 
Background—Sustained ventricular tachycardia (VT) and fibrillation (VF) occur in up to 20% of patients with acute myocardial infarction (MI) and have been associated with a poor prognosis. The relationships among the type of arrhythmia (VT versus VF or both), time of VT/VF occurrence, use of thrombolytic agents, and eventual outcome are unclear.

Methods and Results—In the GUSTO-I study, we examined variables associated with the occurrence of VT/VF and its impact on mortality. Of the 40 895 patients with ventricular arrhythmia data, 4188 (10.2%) had sustained VT, VF, or both. Older age, systemic hypertension, previous MI, Killip class, anterior infarct, and depressed ejection fraction were associated with a higher risk of sustained VT and VF (P<0.001). In-hospital and 30-day mortality rates were higher among patients with sustained VT/VF than among patients without sustained ventricular arrhythmias (P<0.001). Both early (<2 days) and late (>2 days) occurrences of sustained VT and VF were associated with a higher risk of later mortality (P<0.001). In addition, patients with both VT and VF had worse outcomes than those with either VT or VF alone (P<0.001). Among patients who survived hospitalization, no significant difference was found in 30-day mortality between the VT/VF and no VT/VF groups. However, after 1 year, the mortality rate was significantly higher in the VT alone and VT/VF groups (P<0.0001).

Conclusions—Despite the use of thrombolytic therapy, both early and late occurrences of sustained VT or VF continue to have a negative impact on patient outcome; patients with both VT and VF had the worst outcome; and among patients who survived hospitalization, the 1-year mortality rate was significantly higher in those who experienced VT alone or VT and VF.

Key Words: arrhythmia • myocardial infarction • thrombolysis

	Introduction

Top Abstract Introduction Methods Results Discussion References

 
Sustained ventricular arrhythmias occur in up to 20% of patients who present with an acute myocardial infarction (MI) and have been associated with a poor prognosis.^{1 2 3 4 5 6 7 8 9} However, their importance as an independent risk factor for mortality is still controversial. Previously, the majority of the clinical investigations have reported on the implications of primary ventricular fibrillation (VF). Some investigators have concluded that patients who develop primary VF (without evidence of left ventricular failure or shock) have outcomes similar to those of patients without ventricular arrhythmias.^{1 2} Others, however, have found evidence that disagrees with this theory.^{3 10 11} Conversely, very few studies have analyzed the prognostic value of sustained ventricular tachycardia (VT),¹² and most of them have considered VT and VF together.^{2 13} What is still unclear is whether the type of arrhythmia (VT, VF, or both), the time of occurrence, the presence or absence of left ventricular failure or cardiogenic shock, and the use of thrombolytic agents all have an independently important impact on patient outcome. We therefore examined variables associated with the occurrence of VT or VF and the impact of these arrhythmias on mortality in patients with acute MI treated with thrombolytic therapy.

	Methods

Top Abstract Introduction Methods Results Discussion References

 
Study Population
Data for the study were obtained from patients enrolled in the Global Use of Streptokinase t-PA for Occluded Coronary Arteries (GUSTO-I) trial. In the GUSTO-I study, 41 020 consecutive patients admitted within 6 hours of MI onset were randomized to receive 1 of 4 treatment strategies: streptokinase plus subcutaneous heparin, front-loaded tissue plasminogen activator plus intravenous heparin, streptokinase and intravenous heparin, or tissue plasminogen activator and streptokinase plus intravenous heparin. The primary end point of the study was 30-day mortality.

In each center, nurse coordinators reviewed the charts of patients enrolled in the study for the occurrence of sustained ventricular arrhythmias. An independent nurse was contracted to audit 10% of the charts to document concordance. No review of the rhythm strips was obtained to verify correct classification of ventricular arrhythmias.

Definitions
For the purpose of the study, VF was defined as irregular undulations of varying contour and amplitude on the ECG with absent distinct QRS and T waves and prompt hemodynamic compromise requiring DC cardioversion. Sustained VT is defined as a regular wide-complex tachycardia of ventricular origin lasting 30 seconds or accompanied by hemodynamic compromise requiring electrical cardioversion. Early sustained ventricular arrhythmias were considered to be those that occurred within 2 days of admission, and late arrhythmias were those observed >2 days after admission.

Statistical Analysis
Continuous variables are presented as medians and 25th and 75th percentiles and discrete variables as frequencies and percentages. Baseline characteristics and clinical outcomes of patients with ventricular arrhythmias were compared with those without ventricular arrhythmias by use of the likelihood ratio ² test for discrete variables and the Wilcoxon rank-sum test for continuous variables. Patients were further classified into the following 4 subgroups: VT only, VF only, both VT and VF, or neither. Differences in clinical outcomes among the 4 subgroups were tested. If significant differences existed, the 3 ventricular arrhythmia groups were each compared with the "neither" group, and the VT only group and the VF only group were each compared with the "both" group. Multivariable logistic regression techniques were used to determine the effect of ventricular arrhythmias on 30-day mortality after adjustment for the previously reported baseline predictors. Cox proportional hazards modeling was used to assess the effect of ventricular arrhythmias on 1-year mortality in 30-day survivors after adjustment for the significant baseline predictors.

	Results

Top Abstract Introduction Methods Results Discussion References

 
Of the 41 020 patients enrolled in GUSTO-I, 40 895 had ventricular arrhythmia data. Sustained VT, VF, or both occurred in 4188 patients (10.2%, Figure 1). Eight patients with ventricular arrhythmias had missing information and were not included in the analysis. The baseline characteristics of patients with and without ventricular arrhythmias are shown in Table 1. Variables associated with a higher incidence of VT and/or VF included older age, previous infarct, hypertension, heart rate, anterior wall infarct, history of coronary bypass, and higher Killip class. Another strong predictor of arrhythmia occurrence was ejection fraction. The mean ejection fraction in patients with sustained ventricular arrhythmias was 46% (39%, 58%), compared with 52% (45%, 60%) in those without VT (P<0.001). Variables that tested insignificant in the occurrence of either VT or VF included male sex and diabetes. Time to treatment with thrombolysis was slightly shorter in the VT/VF groups (median, 2.6 hours) than in the no VT/VF group (median, 2.8 hours).

View larger version (20K): [in this window] [in a new window]   Figure 1. Among patients enrolled in GUSTO-I, ventricular arrhythmic data were available in 40 895. Of these, 4188 had VT only, VF only, or both. Eight patients had missing data on either VT or VF (total patient number, 4180). Overall, 2529 patients (6.2%) had VT and 2744 (6.7%) VF.

View this table: [in this window] [in a new window]   Table 1. Baseline Characteristics by Ventricular Arrhythmia

We found significantly higher mortality rates and poor outcomes in groups with sustained ventricular arrhythmias compared with those without arrhythmias (P<0.001) (Table 2). Patients with both VT and VF had a higher mortality than those with VT alone or VF alone (P<0.001). This remained significant at 1-year follow-up (Figure 2). Mortality in the VT/VF groups remained significantly higher even after adjustment for the baseline predictors (30-day mortality: likelihood ratio ², 1376; odds ratio, 6.65; P<0.001; 1-year mortality of 30-day survivors: likelihood ratio ², 36.7; odds ratio, 1.75; P<0.001).

View this table: [in this window] [in a new window]   Table 2. Clinical Outcomes by Ventricular Arrhythmias

View larger version (15K): [in this window] [in a new window]   Figure 2. Cumulative survival rate in patients with and without sustained ventricular arrhythmias. Group with both VT and VF had highest in-hospital and 1-year mortality rates (P<0.001). Solid line indicates VT; short-dashed line, VF; long-dashed line, neither; and dotted line, both.

Table 3 shows the demographic characteristics of the patients with early (<2 days) and late (>2 days) sustained ventricular arrhythmias. Patients with late arrhythmias had a higher incidence of previous MI, anterior MI, and previous CABG and a longer time to treatment. Patients with early VF had a shorter time to treatment.

View this table: [in this window] [in a new window]   Table 3. Baseline Characteristics by Early and Late Ventricular Arrhythmias

The percentage of in-hospital mortality in patients with sustained VT (both early and late) remained high (Table 4). In addition, we found a similar trend with VF, although the late VF group had a higher mortality.

View this table: [in this window] [in a new window]   Table 4. Clinical Outcomes by Early and Late Ventricular Arrhythmias

Patients with both sustained VT <2 days after admission and VF during their hospitalization had a significantly higher mortality than those without ventricular arrhythmias. When patients with cardiogenic shock were excluded, the in-hospital mortality rate remained significantly higher in the sustained VT/VF group than in the non-VT/VF group (Table 5). In those patients who survived hospitalization, no significant difference was found with respect to 30-day mortality among the patient groups. When patients with sustained ventricular arrhythmias were divided into those with VF alone, those with VT alone, and those with both VT and VF, only the VT alone and both VT and VF groups had a higher 30-day to 1-year mortality than the group with no ventricular arrhythmias (P<0.001) (Table 5).

View this table: [in this window] [in a new window]   Table 5. Clinical Outcomes by Ventricular Arrhythmias in GUSTO-I Patients Without Cardiogenic Shock

Comparing the TIMI flow after administration of thrombolytics, we observed a lower incidence of TIMI 0 and a higher TIMI 3 flow in the patients with no ventricular arrhythmias (Table 6) and more ventricular arrhythmias in patients with a lower ejection fraction (Figure 3). The same results were observed when ejection fraction and TIMI flow were compared in the patients undergoing catheterization before the occurrence of ventricular arrhythmias (Table 7). In both tables, the time to cardiac catheterization expressed in hours from the onset of symptoms is reported.

View this table: [in this window] [in a new window]   Table 6. TIMI Flow and Hours to Catheterization From the Onset of Symptoms by Ventricular Arrhythmias

View larger version (14K): [in this window] [in a new window]   Figure 3. Ejection fraction (EF) and TIMI 0 flow after thrombolytic therapy. After administration of thrombolytic therapy, overall incidence of TIMI 0 flow was higher in VT/VF groups (P<0.001). This was associated with a reduced EF (P<0.001).

View this table: [in this window] [in a new window]   Table 7. Ejection Fraction and TIMI Flow by Ventricular Arrhythmia Group in the Patients Undergoing Catheterization Before the Occurrence of Sustained Ventricular Arrhythmia

Short- and long-term administration of ß-blockers and ACE inhibitors in the study groups was also analyzed (Table 8). Patients with ventricular arrhythmia were less likely to receive ß-blockers but more likely to be treated with ACE inhibitors.

View this table: [in this window] [in a new window]   Table 8. Administration of ß-Blockers and ACE Inhibitors in the Study Subgroups

	Discussion

Top Abstract Introduction Methods Results Discussion References

 
This study confirms previous reports showing that despite the use of thrombolytic therapy, occurrence of sustained VT, VF, or both after an MI is still associated with a high risk of mortality and morbidity. In our series, patients with early or late VF or VT had an excess of in-hospital mortality compared with patients without sustained ventricular arrhythmias. However, our study is the first to find that patients suffering from either VT alone or both VT and VF continue to have a higher postdischarge to 1-year mortality rate. Previous large studies, including MILIS² and GISSI,^{10 11} concluded that in-hospital mortality rates were significantly greater for patients with sustained ventricular tachyarrhythmias requiring resuscitation than for those without. In both studies, however, the 1-year prognosis for hospital survivors of acute MI was not adversely affected by the occurrence of VT or VF during the hospitalization.^{2 10 11} This finding led the investigators to infer that arrhythmias per se did not alter the probability of survival in the posthospital phase of MI, which is more likely to depend on the degree of myocardial damage or coronary disease rather than on the particularly high late susceptibility to VF recurrence. Thus, our data contrast with currently held views in finding that sustained VT alone or associated with VF represents a strongly negative predictor of long-term survival for MI patients. The conflicting conclusions reached by previous studies may be due to factors such as differences in definitions or in time from onset of infarction to patient inclusion, may reflect a limited number of patients involved, or may result from the inability to categorize patients on the basis of the occurrence of different types of sustained ventricular arrhythmias in large, simple trials.

There are several explanations for why these arrhythmias occur and why they correlate with a higher mortality rate. The relationship between the extent of the myocardial damage and the incidence of postinfarction VF is controversial. Our data, as well as a number of clinical and experimental studies,^{1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16} have found that the size of myocardial infarct correlates with the incidence of severe ventricular arrhythmias and VF or with the degree of electrical instability and the decrease in the VF threshold. In addition, the time to reperfusion or the TIMI grade flow could play an important role in determining the occurrence of severe ventricular arrhythmias. Recently, both experimental and clinical studies provided evidence that TIMI grade 2 perfusion is generally not associated with optimal myocardial salvage and clinical outcome.¹⁷ Therefore, grade 3 perfusion should be considered the best measure of success of thrombolytic therapy. This is consistent with an animal study by Battle and coauthors,¹⁶ who showed a bimodal occurrence of VF either resulting from acute coronary occlusion or after prolonged occlusion time. On the basis of these data, one would expect that with earlier reperfusion, sustained ventricular arrhythmias are less likely. In our study, sustained VT and VF were not associated with a longer time to thrombolysis. However, patients with ventricular arrhythmias had a higher rate of TIMI 0 and a lower rate of TIMI 3 flow. Whether myocardial conditioning during long-term chronic ischemia before infarction or the presence of collateral flow have any influence in this setting is unclear. Regardless of the mechanism, however, patients with sustained ventricular arrhythmia after acute MI did suffer a higher mortality despite treatment with thrombolysis. In view of the significant mortality in this subset of patients, more aggressive treatment options appear to be warranted when sustained ventricular arrhythmias occur in the acute setting. If the occurrence of sustained ventricular arrhythmias reflects inadequate perfusion after thrombolytic therapy, one could speculate that in those patients, the addition of further interventions aiming at improving coronary artery perfusion could significantly affect outcomes and mortality.

Although it is generally accepted that spontaneous VT in the absence of fresh MI is due to a reentry mechanism through patchy scar tissue at the edge of the infarcted area,¹⁸ available information has led to the belief that when the same arrhythmia occurs during acute myocardial ischemia and infarction, it does not bear any long-term increased risk of mortality.^{1 2 3 4 5 6 7 8 9 10 11 12 13} The results of our study suggest that this is true for early (<48 hours) VF alone, whereas the occurrence of late VF, or VT either alone or in association with VF, identifies patients at increased risk of 1-year mortality, even among in-hospital survivors.

This is consistent with the findings of Heidbuchel et al,¹⁹ who concluded that despite both VT and VF being markers for a larger infarct, the pathogeneses of VT and VF early during acute MI are distinct. The investigators based their conclusion on the remarkable contrast in patency rate between patients with VF and sustained VT. They also observed that sustained VT always developed >2.5 hours after treatment initiation, suggesting that VT reflects the presence of a more stable substrate in the border zone between viable and infarcted tissue. TIMI flow information in our patient population seems to validate this hypothesis.

On the basis of our data, it seems reasonable to conduct randomized studies to determine whether more aggressive measures, such as prophylactic defibrillator placement, medical therapy, earlier revascularization, or a combination of all 3 should be considered in patients with early VT/VF. Certainly, one of the major issues related to acceptance of the concept of a prophylactic implantable defibrillator is the cost of the device. From a strictly financial point of view, it was recently proposed that if the cost of a defibrillator drops to $2000, it could be given prophylactically to any patient with a 1-year risk of mortality >3.3%.²⁰ In our study, either group, that with VT alone and that with VT/VF, would then become eligible on the basis of their 30-day to 1-year mortality rates of 7.5% and 7.1%, respectively.

ß-Blocker therapy begun immediately after an acute MI may prevent fatal arrhythmias and may contribute to the reduction of early and late mortality.^{5 21 22 23} In our series, patients with sustained ventricular arrhythmias were indeed less likely to be treated with ß-blockers both during hospitalization and after discharge. The question arises as to whether this may have influenced the results. However, a recent prospective study was unable to support any protective effect of administration of ß-blocker compared with placebo in reducing the occurrence of VT and VF.¹⁹ Whether other medications may be beneficial in this patient population remains unknown. Recent clinical data indicated that ACE-inhibitor therapy may have an antiarrhythmic effect.^{24 25 26} In our study, ACE inhibitors were given more frequently to patients with sustained ventricular arrhythmias. Nevertheless, these patients still experienced a higher mortality rate.

Limitations
Although this study provides insight into the incidence and outcome of sustained ventricular arrhythmias in common clinical practice, several limitations exist. We are evaluating the impact of arrhythmias in a complex clinical setting in which patient treatment remains highly variable, thereby limiting some conclusions. Finally, the cause of death was not clearly characterized as sudden or nonsudden. This makes it more difficult to absolutely correlate death with recurrence of a life-threatening arrhythmia.

Conclusions
Despite the use of thrombolytic therapy, patients who sustain early VF and VT still have increased in-hospital mortality, which probably represents the final electrophysiological derangement superimposed on extensive myocardial damage. Adjunctive measures might further reduce the risk of VF or at least be clinically beneficial to patients who experience these arrhythmias. Finally, we identified a group of patients with VT either alone or associated with VF who experience an increased mortality rate after discharge. This represents novel information and certainly warrants further studies to identify therapies to reduce the risk of death in this patient subgroup.

Received May 29, 1998; revision received August 17, 1998; accepted September 6, 1998.

	References

Top Abstract Introduction Methods Results Discussion References

 

1. Nicod P, Gilpin E, Dittrich H, Wright M, Engler R, Rittlemeyer J, Henning H, Ross J. Late clinical outcome in patients with early ventricular fibrillation after myocardial infarction. J Am Coll Cardiol. 1988;11:464–470.[Abstract]
   
2. Tofler GH, Stone PH, Muller JE, Rutherford JD, Willich SN, Gustafson NF, Poole WE, Sobel BE, Willerson JT, Robertson T, Passamani E, Braunwald E, and the MILIS Study Group. Prognosis after cardiac arrest due to ventricular tachycardia or ventricular fibrillation associated with acute myocardial infarction (the MILIS study). Am J Cardiol. 1987;60:755–761.[Medline] [Order article via Infotrieve]
   
3. Behar S, Goldbourt U, Reicher-Reiss H, Kaplinsky E, Principal Investigators of the SPRINT study. Prognosis of acute myocardial infarction complicated by primary ventricular fibrillation. Am J Cardiol. 1990;66:1208–1211.[Medline] [Order article via Infotrieve]
   
4. Gruppo Italiano Per Lo Studio della Streptochinasi Nell'Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet. 1986;1:397–402.[Medline] [Order article via Infotrieve]
   
5. ISIS-1 (First International Study of Infarct Survival) Collaborative Group. Randomized trial of intravenous atenolol among 16,027 cases of suspected acute myocardial infarction: ISIS-1. Lancet. 1986;2:57–66.[Medline] [Order article via Infotrieve]
   
6. Lawrie DM, Higgins MR, Godman MJ, Oliver MF, Julian DG, Donald KW. Ventricular fibrillation complicating acute myocardial infarction. Lancet. 1968;1:523–528.
   
7. Lawrie DM. Long-term survival after ventricular fibrillation complicating acute myocardial infarction. Lancet. 1969;2:1085–1087.[Medline] [Order article via Infotrieve]
   
8. Goldberg R, Szklo M, Tonascia JA, Kennedy HL. Acute myocardial infarction: prognosis complicated by ventricular fibrillation or cardiac arrest. JAMA. 1979;241:2024–2027.[Abstract]
   
9. Conley MJ, McNeer JF, Lee KL, Wagner GS, Rosati RA. Cardiac arrest complicating acute myocardial infarction: predictability and prognosis. Am J Cardiol. 1977;39:7–12.[Medline] [Order article via Infotrieve]
   
10. Volpi A, Cavalli A, Franzosi MG, Maggioni A, Mauri F, Santoro E, Tognoni G, GISSI investigators. One-year prognosis of primary ventricular fibrillation complicating acute myocardial infarction. Am J Cardiol. 1989;63:1174–1178.[Medline] [Order article via Infotrieve]
    
11. Volpi A, Maggioni A, Franzosi MG, Pampallona S, Mauri F, Tognoni G. In-hospital prognosis of patients with acute myocardial infarction complicated by primary ventricular fibrillation. N Engl J Med. 1987;317:257–261.[Abstract]
    
12. Eldar M, Sievner Z, Goldbourt U, Reicher-Reiss H, Kaplinsky E, Behar S, SPRINT study group. Primary ventricular tachycardia in acute myocardial infarction: clinical characteristics and mortality. Ann Intern Med. 1992;117:31–36.
    
13. Berger PB, Ruocco NA, Ryan TJ, Frederick MM, Podrid PJ. Incidence and significance of ventricular tachycardia and fibrillation in the absence of hypotension or heart failure in acute myocardial infarction treated with recombinant tissue-type plasminogen activator: results from the Thrombolysis in Myocardial Infarction (TIMI) phase II trial. J Am Coll Cardiol. 1993;22:1773–1779.[Abstract]
    
14. Volpi A, Cavalli A, Santoro E, Tognoni G, GISSI Investigators. Incidence and prognosis of secondary ventricular fibrillation in acute myocardial infarction: evidence for a protective effect of thrombolytic therapy. Circulation. 1990;82:1279–1288.[Abstract/Free Full Text]
    
15. Maggioni AP, Zuanetti G, Franzosi MG, Rovelli F, Santoro E, Staszewsky L, Tavazzi L, Tognoni G, on behalf of GISSI-2 Investigators. Prevalence and prognostic significance of ventricular arrhythmias after acute myocardial infarction in the fibrinolytic era: GISSI-2 results. Circulation. 1993;87:312–322.[Abstract/Free Full Text]
    
16. Battle WE, Naimi S, Avitall B, Brilla AH, Banas JS, Bete JM, Levine HJ. Distinctive time course of ventricular vulnerability to fibrillation during and after release of coronary ligation. Am J Cardiol. 1974;34:42–47.[Medline] [Order article via Infotrieve]
    
17. Anderson JL, Karagounis LA, Becker LC, Sorensen SG, Menlove RL, for the TEAM-3 Investigators. TIMI perfusion grade 3 but not grade 2 results in improved outcome after thrombolysis for myocardial infarction: ventriculographic, enzymatic, and electrocardiographic evidence from the TEAM-3 study. Circulation. 1993;87:1829–1839.[Abstract/Free Full Text]
    
18. Richards DAB, Byth K, Ross DL, Uther JB. What is the best predictor of spontaneous ventricular tachycardia and sudden death after myocardial infarction? Circulation. 1991;83:756–763.[Abstract/Free Full Text]
    
19. Heidbuchel H, Tack J, Vanneste L, Ballet A, Ector H, Van de Werf F. Significance of arrhythmias during the first 24 hours of acute myocardial infarction treated with alteplase and effect of early administration of a ß-blocker or a bradycardiac agent on their incidence. Circulation. 1994;89:1051–1059.[Abstract/Free Full Text]
    
20. Brugada P, Wellens F, Andries E. A prophylactic implantable cardioverter-defibrillator? Am J Cardiol. 1996;78(suppl 5A):128–133.
    
21. Yusuf S, Peto R, Lewis J, Collins R, Sleight P. Beta blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis. 1985;27:335–371.[Medline] [Order article via Infotrieve]
    
22. Ryden L, Ariniego R, Arnman K, Herlitz J, Hjalmarson A, Holmberg S, Reyes C, Smedgard P, Svedberg K, Vedin A, Waagstein F, Waldenstrom A, Wilhelmsson C, Wedel H, Yamamoto M. A double-blind trial of metoprolol in acute myocardial infarction: effects on ventricular tachyarrhythmias. N Engl J Med. 1983;308:614–618.[Abstract]
    
23. Norris RM, Brown MA, Clarke ED, Barnaby PF, Geary GG, Logan RL, Sharpe DN. Prevention of ventricular fibrillation during acute myocardial infarction by intravenous propranolol. Lancet. 1984;2:883–886.[Medline] [Order article via Infotrieve]
    
24. Sogaard P, Gotzsche CO, Ravkilde J, Norgaard A, Thygesen K. Ventricular arrhythmias in the acute and chronic phases after acute myocardial infarction: effect of intervention with captopril. Circulation. 1994;90:101–107.[Abstract/Free Full Text]
    
25. Budaj A, Cybulski J, Karczmarewicz S, Maciejewicz J, Wisniewski M, Ceremuzynski L. Effects of captopril on ventricular arrhythmia in the early and late phase of suspected acute myocardial infarction. Eur Heart J. 1996;17:1506–1510.[Abstract/Free Full Text]
    
26. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators. Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. Lancet. 1993;342:821–828.In GUSTO-I, sustained ventricular arrhythmias occurred in 10.2% of the patients. Both early (<2 days) and late (>2 days) ventricular tachycardia (VT) and ventricular fibrillation (VF) had a higher in-hospital and 30-day mortality (P<0.0001). The 1-year mortality of the 30-day survivors was significantly higher in late VF, VT alone, and VT/VF groups (P<0.0001). Despite the use of thrombolytics, VT and VF continue to be associated with an increase in mortality. Patients experiencing VT either alone or with VF appeared to have the worst 30-day to 1-year outcome.[Medline] [Order article via Infotrieve]
    

This article has been cited by other articles:

				M. Majidi, A. S. Kosinski, S. M. Al-Khatib, M. E. Lemmert, L. Smolders, A. van Weert, J. H.C. Reiber, D. Tzivoni, F. W.H.M. Bar, H. J.J. Wellens, et al. Reperfusion ventricular arrhythmia 'bursts' in TIMI 3 flow restoration with primary angioplasty for anterior ST-elevation myocardial infarction: a more precise definition of reperfusion arrhythmias Europace, May 14, 2008; (2008) eun123v1. [Abstract] [Full Text] [PDF]

				Developed in Collaboration With the European Heart, D. P. Zipes, A. J. Camm, M. Borggrefe, A. E. Buxton, B. Chaitman, M. Fromer, G. Gregoratos, G. Klein, A. J. Moss, et al. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death) J. Am. Coll. Cardiol., September 5, 2006; 48(5): e247 - e346. [Full Text] [PDF]

				U. Schaefer, T. Machida, S. Vorlova, S. Strickland, and R. Levi The plasminogen activator system modulates sympathetic nerve function J. Exp. Med., September 4, 2006; 203(9): 2191 - 2200. [Abstract] [Full Text] [PDF]

				Writing Committee Members, D. P. Zipes, A. J. Camm, M. Borggrefe, A. E. Buxton, B. Chaitman, M. Fromer, G. Gregoratos, G. Klein, A. J. Moss, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: A report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society Europace, September 1, 2006; 8(9): 746 - 837. [Full Text] [PDF]

				B. K. Nallamothu, M. Saint, S. Saint, and D. Mukherjee Double Jeopardy N. Engl. J. Med., July 7, 2005; 353(1): 75 - 80. [Full Text] [PDF]

				R. H. Mehta, K. J. Harjai, L. Grines, G. W. Stone, J. Boura, D. Cox, W. O'Neill, C. L. Grines, and Primary Angioplasty in Myocardial Infarction (PAMI Sustained ventricular tachycardia or fibrillation in the cardiac catheterization laboratory among patients receiving primary percutaneous coronary intervention: Incidence, predictors, and outcomes J. Am. Coll. Cardiol., May 19, 2004; 43(10): 1765 - 1772. [Abstract] [Full Text] [PDF]

				R. Ascione, B. C. Reeves, K. Santo, N. Khan, and G. D. Angelini Predictors of new malignant ventricular arrhythmias after coronary surgery: A case-control study J. Am. Coll. Cardiol., May 5, 2004; 43(9): 1630 - 1638. [Abstract] [Full Text] [PDF]

				H. F.J Mannaerts, J. A van der Heide, O. Kamp, M. G Stoel, J. Twisk, and C. A Visser Early identification of left ventricular remodelling after myocardial infarction, assessed by transthoracic 3D echocardiography Eur. Heart J., April 2, 2004; 25(8): 680 - 687. [Abstract] [Full Text] [PDF]

				S. M. Al-Khatib, C. B. Granger, Y. Huang, K. L. Lee, R. M. Califf, M. L. Simoons, P. W. Armstrong, F. Van de Werf, H. D. White, R. J. Simes, et al. Sustained Ventricular Arrhythmias Among Patients With Acute Coronary Syndromes With No ST-Segment Elevation: Incidence, Predictors, and Outcomes Circulation, July 16, 2002; 106(3): 309 - 312. [Abstract] [Full Text] [PDF]

				D. J. Callans Management of the Patient Who Has Been Resuscitated From Sudden Cardiac Death Circulation, June 11, 2002; 105(23): 2704 - 2707. [Full Text] [PDF]

				S. Windecker, C. Seiler, K. H. Newby, T. Thompson, A. Stebbins, R. M. Califf, E. J. Topol, and A. Natale Sustained Ventricular Arrhythmias in Patients Receiving Thrombolytic Therapy Response Circulation, June 27, 2000; 101 (25): e237 - e238. [Full Text] [PDF]

				R. M. Califf, K. S. Pieper, K. L. Lee, F. Van de Werf, R. J. Simes, P. W. Armstrong, and E. J. Topol Prediction of 1-Year Survival After Thrombolysis for Acute Myocardial Infarction in the Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries Trial Circulation, May 16, 2000; 101(19): 2231 - 2238. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Newby, K. H. Articles by Natale, A. Search for Related Content PubMed PubMed Citation Articles by Newby, K. H. Articles by Natale, A.