|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 4 | Page : 208-209
Post Myocardial Infarction sudden cardiac death within 90 days after coronary revascularization – therapeutically, a no-man's land
Hemanshu Bhatia, Pankaj Jariwala
Department of Cardiology, Yashoda Hospitals, Hyderabad, Telangana, India
|Date of Submission||29-Sep-2020|
|Date of Acceptance||01-Nov-2020|
|Date of Web Publication||25-Oct-2021|
Dr. Pankaj Jariwala
Department of Cardiology, Yashoda Hospitals, Hyderabad - 500 082, Telangana
Source of Support: None, Conflict of Interest: None
|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 2021 Dec 5];11:208-9. Available from: https://www.joicc.org/text.asp?2021/11/4/208/329149
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.,, 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., 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., 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% and finally, the penetration of primary prevention ICDs in the general population is quite low. 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). 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.
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