Akut koronart syndrom: tidiga och sena ventrikulära arytmier

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1 Akut koronart syndrom: tidiga och sena ventrikulära arytmier Anders Jönsson/ Lennart Bergfeldt Stockholm & Umeå & 22

2 Disposition 1. VF i den akuta fasen och prognos i PCI-eran. 2. Underliggande arytmisubstrat för VF i akutfasen. 3. Kammararytmi och TnT-stegring ischemi ja, men infarkt? 4. Subakut eko vad händer med EF under första månaden post AKS? 5. QRS-T vinkeln och/eller EF 35% - subakuta prediktorer för SCD?

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4 Ad 1. Ur STEMI-guidelines 2012; sid. 2603

5 Ad 1. Prognos efter primärt VF - i PCI eran GISSI, Italien. Circulation 1990;82: : When VF complicates the course of infarction (secondary VF), it is associated with an Adverse short-term outcome, whereas the long-term prognosis is not influneced. Heidbüchel Van de Werf, Belgien. Circulation 1994;89: We could not detect a relation between malignant arrhythmias on day 1 and recurrences within the following 2 weeks. Sayer Timmis, London, UK. Heart 2000;84:258-61: Patients successfully resuscitated from early ventricular fibrillation have the same prognosis as those without ventricular fibrillation after acute myocardial infarction. Khairy Nattel, Canada. Can J Cardiol 2003;19: : Inhospital mortality is higher when ventricular fibrillation presents in the acute phase but long term prognosis is not adversely affected. de jong.dekker, Holland. Am Heart J 2009;158:467-72: In conclusion, patients who survive the first month after primary VF have a similar prognosis as patients with STEMI without VF.

6 Ad 1.

7 Ad 1. Slutsats 1: Primärt VF vid AKS påverkar sjukhusmortalitet men inte långtidsprognos gammal sanning håller också idag.

8 Ad 2. Underliggande arytmisubstrat för VF i akutfasen Transient repolarization alterations dominate the initial phase of an acute anterior infarction a vectorcardiography study Lingman Bergfeldt J Electrocardiol 2014;47: Fig. 2 Selected electrophysiological parameters in 51 patients with complete data from all 7 predefined sampling periods during acute ischemia and reperfusion: ST vector magnitude 60 ms after the J-point (STVM60), Tarea, ventricular gradient (VG), Tavplan,...

9 Ad 2. Underliggande arytmisubstrat för VF i akutfasen Transient repolarization alterations dominate the initial phase of an acute anterior infarction a vectorcardiography study Lingman Bergfeldt J Electrocardiol 2014;47: Slutsats 2: VF risk vid AKS är starkare kopplad till Conclusions Ischemia-reperfusion during myocardial infarction was accompanied by modest and delayed repolarisation changes in depolarization än but till profound depolarisation. and transient changes in repolarization, including greatly increased VR dispersion. The time frame of repolarization För monomorf changes coincides VT with the gäller period during sannolikt which properly treated VF has no impact on long-term prognosis. motsatsen (ärr- o/e Purkinjeursprung).

10 Ad 3. Kammararytmi och TnT-stegring ischemi ja, men infarkt?

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13 Myocardial Injury After Electrical Therapy for Cardiac Arrhythmias Assessed by Troponin-T Release Runsiö Bergfeldt. Am J Cardiol 1997;79,: Från cytosolen? Fig. 1 S-Troponin T in patients receiving an implantable cardioverter defibrillator. The thick line denotes median values and dotted lines the corresponding 95% confidence limits. B = before intervention; IA = immediately after intervention; 1h-20h = 1...

14 Ad 3. Kammararytmi och TnT-stegring ischemi ja, myocytdysfunktion ja, men infarkt? Slutsats 3: Takykardi kan ge blodtrycksfall, myocardischemi/-dysfunktion och /kortvarigt/ TnT utsläpp infarkt. Handlägg som takykardi utan TnT utsläpp!

15 Ad 4. Subakut eko vad händer med EF under första månaden post AKS? Evolution of Left Ventricular Ejection Fraction After Acute Myocardial Infarction Implications for Implantable Cardioverter-Defibrillator Eligibility Sjöblom Frykman-Kull Circulation 2014;130:743-8

16 Ad 4& 5. men först måste vi fråga oss

17 Ad 4 & 5. är det inga problem att identifiera de patienter som ska resp. inte ska ha primärprofylaktisk ICD?

18 Ad 4. Sjöblom Frykman-Kull. Circulation. 2014;130:743-8 A, Left ventricular ejection fraction (LVEF) at inclusion, 1 month, and 3 months after acute myocardial infarction (AMI) among the patients who did not meet the criteria for implantable cardioverter-defibrillator (ICD) after 3 months (n=51). B, LVEF at inclusion, 1 month, and 3 months after AMI among the patients who did meet the criteria for ICD after 3 months (n=35).

19 Evolution of Left Ventricular Ejection Fraction After Acute Myocardial Infarction Implications for Implantable Cardioverter-Defibrillator Eligibility Ad 4. Sjöblom Frykman-Kull Circulation 2014;130:743-8 Slutsats 4: Methods and Results Patients admitted for AMI with reduced LVEF ( 40%) were eligible for inclusion. Repeat echocardiographic examinations were performed 5 days, 1 month, and Första 3 months after månaden the AMI. We prospectively efter infarkt included händer 100 patients with LVEF of 31±5.8% after AMI. mycket med initialt nedsatt LVEF. At the 1-month follow-up, 55% had an LVEF >35%. The main improvement in LVEF had occurred Om by 1 month. man The väntar mean difference minst LVEF 40 over dagar the next 2 months was small, 1.9 percentage units. During the first med 9 weeks, riskbedömning 10% of the patients suffered hinner from life-threatening patienter arrhythmias. dö SCD. Vi måste hitta subakuta riskmarkörer. Conclusions Most patients have improved LVEF after AMI, and in the majority, the improvement can be confirmed after 1 month, implying that further delay of implantable cardioverter-defibrillator implantation may not be warranted. Lifethreatening arrhythmias occurred in 10% of the patients, illustrating the high risk for sudden cardiac death in this population.

20 Ad 5. QRS-T vinkeln och/eller EF 35% - subakuta prediktorer för SCD? Prediction of sudden cardiac death after myocardial infarction in the beta-blocking era. Huikuri Myerburg JACC 2003;42:652-8 METHODS: A consecutive series of 700 patients with AMI was studied. The end points were total mortality, SCD, and nonsudden cardiac death (non-scd). Nonsustained ventricular tachycardia (nsvt), ejection fraction (EF), heart rate variability, baroreflex sensitivity, signal-averaged electrocardiogram (SAECG), QT dispersion, and QRS duration were analyzed (n = 675). Beta-blocking therapy was used by 97% of the patients at discharge and by 95% at one and two years after AMI. RESULTS: Sudden cardiac death was weakly predicted only by reduced EF (<0.40; p < 0.05), nsvt (p < 0.05), and abnormal SAECG (p < 0.05), but not by autonomic markers or standard ECG variables. The positive predictive accuracy of EF, nsvt, and abnormal SAECG as predictors of SCD was relatively low (8%, 12%, and 13%, respectively). CONCLUSIONS: The common arrhythmia risk variables, particularly the autonomic and standard ECG markers, have limited predictive power in identifying patients at risk of SCD after AMI in the beta-blocking era.

21 Ad 5. Två icke-publicerade bilder visas.

22 Ad 5. Slutsats 5: Depolarisations-repolarisations vinkeln är en prognostisk markör också efter AKS. Den är väl så bra som LVEF 35% och ger additivt /NPV/ prognostiskt värde. Dags att byta fokus från PPV till NPV?

23 Tack för uppmärksamheten!