Significance of Repeat Programmed Ventricular Stimulation at Electrophysiology Study for Arrhythmia Prediction after Acute Myocardial Infarction

BACKGROUND: The prognostic significance of a second programmed ventricular stimulation (PVS) at electrophysiology study (EPS), when the first PVS is negative for inducible ventricular tachycardia (VT), in patients following myocardial infarction (MI) is unknown. METHODS: Consecutive ST-elevation MI patients with left ventricular ejection fraction ≤ 40% following revascularization underwent early EPS. An implantable cardioverter defibrillator (ICD) was implanted for a positive (inducible monomorphic VT) but not a negative (no arrhythmia or inducible ventricular fibrillation [VF]/flutter) EPS. The combined primary end point of death or arrhythmia (sudden death, resuscitated cardiac arrest, and spontaneous VT/VF) was assessed in EPS-positive patients grouped according to if VT was induced on the first PVS application, or the second PVS application, when the first was negative. RESULTS: EPS performed a median 8 days post-MI in 290 patients was negative in 70% (n = 203) and positive in 30% (n = 87). In patients with a positive EPS, VT was induced on the first PVS in 67% (n = 58) and the second PVS, after the first was negative, in 33% (n = 29). Predischarge ICD was implanted in 79 of 87 patients with a positive EPS. Three-year primary end point occurred in 20.9 ± 5.6% and 38.3 ± 9.7% of patients with VT induced by the first and second PVS, respectively (P = 0.042) and in 6.3 ± 1.9% of electrophysiology-negative patients (P < 0.001). CONCLUSIONS: In patients with post-MI left ventricular dysfunction, VT can be induced in a significant proportion with a second PVS when negative on the first. These patients have a similar higher risk of death or arrhythmia compared to patients with VT induced on the first PVS.