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Table of Contents
Year : 2021  |  Volume : 11  |  Issue : 4  |  Page : 208-209

Post Myocardial Infarction sudden cardiac death within 90 days after coronary revascularization – therapeutically, a no-man's land

Department of Cardiology, Yashoda Hospitals, Hyderabad, Telangana, India

Date of Submission29-Sep-2020
Date of Acceptance01-Nov-2020
Date of Web Publication25-Oct-2021

Correspondence Address:
Dr. Pankaj Jariwala
Department of Cardiology, Yashoda Hospitals, Hyderabad - 500 082, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JICC.JICC_69_20

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How to cite this article:
Bhatia H, Jariwala P. Post Myocardial Infarction sudden cardiac death within 90 days after coronary revascularization – therapeutically, a no-man's land. J Indian coll cardiol 2021;11:208-9

How to cite this URL:
Bhatia H, Jariwala P. Post Myocardial Infarction sudden cardiac death within 90 days after coronary revascularization – therapeutically, a no-man's land. J Indian coll cardiol [serial online] 2021 [cited 2022 May 27];11:208-9. Available from: https://www.joicc.org/text.asp?2021/11/4/208/329149

Dear Editor,

Risk stratification for sudden cardiac death (SCD) among patients with coronary artery disease remains a difficult challenge, with the current guidelines being far from adequate in certain scenarios, as the following case serves to highlight.

A 47-year-male with risk factors in the form of type 2 diabetes, hypertension, chronic kidney disease, and alcohol abuse, presented to the emergency room with ongoing retrosternal chest pain, breathlessness NYHA Class IV, and a brief episode of syncope lasting for 2–3 min. Clinically, he was noted to be in acute decompensated heart failure. His electrocardiogram showed symmetrical deep T-wave inversions of >2 mm in pre-cordial leads (V1-4). Echocardiography showed moderate left ventricular (LV) systolic function with an ejection fraction (EF) of 37% with regional wall motion abnormality - akinesia in the left anterior descending (LAD) territory with preserved thickness, with hypokinesia of other territories. High sensitivity - troponin I was 3304 ng/L (normal range – 1.8–22.5 ng/L). A coronary angiogram revealed tandem 99% stenosis of the proximal segment of the LAD and 99% stenosis of the distal segment of the right coronary artery (RCA). He underwent successful percutaneous transluminal coronary angioplasty (PTCA) with the implantation of two drug-eluting stents to the proximal segment of LAD and distal RCA, with the establishment of TIMI III flow. The patient was discharged 2 days after the procedure, symptom free, in a stable condition on dual antiplatelet therapy, beta-blockers, diuretics, and insulin for type 2 diabetes. His LVEF at discharge was 39% and was asymptomatic 1st follow-up which was scheduled after 5 days post-discharge. Two weeks later, the patient was brought in an unresponsive state to the emergency room with a history of sudden collapse at home while he was taking a walk. No cardiac activity was discernible and he was declared brought dead, with a provisional diagnosis of SCD due to probable ventricular arrhythmia.

Patients with significant LV dysfunction are at increased risk of arrhythmic SCD. The implantable cardioverter-defibrillator (ICD) has emerged as an important treatment option for selected patients who are at risk of SCD. Persistence of severe LV systolic dysfunction following myocardial infarction (MI) is linked with enhanced mortality as well as being a class I indication for implantation of an ICD. Randomized trials have consistently shown that ICD implantation reduces mortality in patients with heart failure and reduced LV function, as well as in patients who have suffered a prior cardiac arrest.[1],[2],[3] However, current guidelines do not advocate ICD implantation within 30 days after an acute MI based on two separate randomized trials (defibrillator in acute MI) and (immediate risk stratification improves survival) which did not show a survival benefit.[4],[5] More relevant to our case, guidelines also suggest deferring ICD implantation for 3 months' post coronary revascularization. The above recommendations are based on the premise of a possible recovery of stunned or hibernating myocardium (aided by effective revascularization), with resultant improvement in LVEF and the attendant reduction in SCD risk.

PREDICTS - the prediction of ICD treatment study designed models and tested predictive factors of LV recovery in patients who present with acute MI and significant LV dysfunction to >35% and >50% after 90-day follow-up.[6],[7] EF at presentation, duration of stay, previous MI, lateral wall motion abnormality at presentation, and peak troponin were the parameters that better estimated EF improvement to >35%. 57% had EF improvement to >35% in patients with severe systolic dysfunction observed following MI with an EF of >35%. The estimation of EF improvement can be aided by a model utilizing clinical variables existing at the time of MI.

However, as clearly demonstrated by our tragic case, such a waiting period is not completely risk free and a certain proportion of patients may succumb to SCD during this period. At present, there is no clarity on which individuals would benefit from early ICD implantation in this scenario. Further compounding the problem, patients with LVEF >35% (such as our present case) are a completely unexplored subset with no randomized trials of ICD implantation. However, population-based studies have shown that the vast majority of SCD occurs among patients with LVEF >35%[8] and finally, the penetration of primary prevention ICDs in the general population is quite low.[9] Thus, a significant therapeutic dilemma exists when one is confronted with such a patient.

The external wearable cardiac defibrillator (WCD; life vest) has been proposed as a potential bridge device for temporary protection from SCD in patients who are not immediate candidates for an ICD. There are on-going trials involving the use of the WCD during the waiting period post-MI (Vest Prevention of Early Sudden Death Trial).[10] However, this is cumbersome to use and is very expensive, with limited experience in India at present.

In conclusion, there is an urgent need to evolve better SCD risk stratification and improved preventive strategies among patients who are in the vulnerable waiting period after an MI or post revascularization. Until then, these patients remain in a therapeutic no man's land.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Bardy GH, Lee KL, Mark DB, Jeanne E. Poole, Douglas L Packer, Robin Boineau. The sudden cardiac death in heart failure trial (SCD-HeFT) investigators. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005;352:225-37.  Back to cited text no. 1
Moss AJ, Zareba W, Hall WJ, Helmut Klein, David J Wilber, David S Cannom. The multi-centre automatic defibrillator implantation trial (MADIT) II investigators. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 2002;346:877-83.  Back to cited text no. 2
Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. N Engl J Med 1997;337:1576-83.  Back to cited text no. 3
Hohnloser SH, Kuck KH, Dorian P, Roberts RS, Hampton JR, Hatala R, et al. Prophylactic use of an implantable cardioverter-defibrillator after acute myocardial infarction. N Engl J Med 2004;351:2481-8.  Back to cited text no. 4
Steinbeck G, Andresen D, Seidl K, Johannes Brachmann, Ellen Hoffmann, Dariusz Wojciechowski. The IRIS investigators. Defibrillator implantation early after myocardial infarction. N Engl J Med 2009;361:1427-36.  Back to cited text no. 5
Brooks GC, Lee BK, Rao R, Lin F, Morin DP, Zweibel SL, et al. Predicting persistent left ventricular dysfunction following myocardial infarction: The predicts study. J Am Coll Cardiol 2016;67:1186-96.  Back to cited text no. 6
Lewis GF, Harless AC, Vazquez L, Abi-Samra FM, Bernard ML, Khatib S, et al. Natural history and implantable Cardioverter-defibrillator implantation after revascularization for stable coronary artery disease with depressed ejection fraction. Clin Cardiol 2015;38:715-9.  Back to cited text no. 7
Yancy CW, Jessup M, Bozkurt B, Javed Butler, Donald E Casey Jr, Mark H Drazner. 2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology Foundation/American heart association task force on practice guidelines. J Am Coll Cardiol 2013;62:e147.  Back to cited text no. 8
Olgin JE, Pletcher MJ, Lee BK. Vest Prevention of Early Sudden Death Trial and VEST Registry (ClinicalTrials.gov); 2016. Available from: https://clinicaltrials.gov/ct2/show/NCT01446965. [Last accessed on 2016 Sep 02].  Back to cited text no. 9
Stecker EC, Vickers C, Waltz J, Carmen Socoteanu, Benjamin T John, Ronald Mariani. Population-based analysis of sudden cardiac death with and without left ventricular systolic dysfunction: Two-year findings from the Oregon Sudden Unexpected Death Study. J Am Coll Cardiol 2006;47:1161-6.  Back to cited text no. 10


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