How to manage SCD in

post MI patients
Rerdin Julario
Electrophysiology and Pacing Division
Dr Soetomo General Hospital
Surabaya
Etiology of SCD

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 Sudden Cardiac Death

50% of cardiac arrest occur in individuals

without known heart disease, but most
suffer from ischemic heart disease
 Majority of sudden cardiac arrest occur
in individuals that have not been indentified as being a high
risk of experiencing sudden cardiac arrest

Atherosclerotic coronary artery disease

remain the most important underlying
substrate for sudden cardiac death
 Management SCD of Post MI

Medical Revascularization ICD

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 Mechanism
Substrate for Reentrant Tachycardia

The scar related to the MI provides the underlying substrate

◦ Abnormalities in cardiac conduction , repolarization and
autonomic modulation
Ischemia and infarction of the underlying perfused myocardium
pro to remodelling, a complex process leading to ventricular
wall dilatation
In the acute phase after infarct, ventricular arrhythmias can
develop as a result of changes in cellular electric activity,
particularly repolarization problem

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 Substrate for Reentrant Tachycardia

First 24 to 48 h, ventricular tachyarrhythmias during this

period do not carry an increased risk of long term
arrhythmia
After day 5, leaving a subendocardial layer or border zone
of surviving myocytes.
Prolonged refractory periods, allows reentrant circuits to
develop
Remodelling LV in patients with heart failure and
neurohormonal mechanism increase arrhytmia risk

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Substrate for Reentrant Tachycardia

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Coronary artery disease and Sudden cardiac death
cascade

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Major Risk Stratification Assessment of
Sudden Cardiac Death in Post MI

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 Non Sustained VT

Independent risk factor for mortality and SCD after MI

in pre PPCI area.
Analysis of 36 trial in 2010 (MERLIN-TIMI) found that
NSVT in the 7 days after acute non STEMI predicted 1
year SCD
IRIS trial, no survival benefit was seen with the use
NSVT (33% of study cohort) as one of the inclusion
criteria to select early ICD implantation

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LVEF/ LV dysfunction

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LVEF/ LV dysfunction

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 Risk of SCD post MI

Data from VALIANT trial

showed the SCD risk is the
highest in the first 30 days
post MI

5% decrease in LVEF, there

was increase 21% RR of SCD

LVEF alone had low

specificity

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Electrophysiology Study

EP testing considered primary for risk stratification for

malignant ventricular arrythmia
EPS combine with impaired LVEF (MADIT trial)
◦ resulted absolute mortality reduction of 22.8%
◦ > 4 fold the 5.6% reduction seen in MADIT II trial with
LVEF alone
MUSTT demonstrated 31% absolute mortality reduction in
patients who received EPS-guided defibrillator

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Risk Stratification of Sudden Cardiac Death

Non Invasive Assesment Risk SCD

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Risk Stratification of Sudden Cardiac Death

Non Invasive Assesment Risk SCD

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 Non Invasive Assesment Risk SCD

Ambulatory ECG Monitoring or Loop Recorders or

Implantable Loop Recorders (Class IA/IIB)
◦ Useful for symptomatic and asymptomatic arrythmias
including NSVT
Signal Averaged ECG (SAECG) (Class IIB)
Microvolt T Wave Alternans (MTWA) (Class IIA)
Heart Rate Variability (HRV) (Class IIA)
ACC/AHA/ESC 2006 Guidelines Ventricular Arrhythmia and the Prevention of SCD

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 Signal Averaged Electrocardiogram

Signal Averaged ECG (SAECG) was developed in early 1980s

to identify existance of substrate for reentrant VT assosiated
with CAD

Detect late potentials (independent predictor)

which represent low amplitude and high frequency electrical activity
of the QRS

This caused by slow conduction of the tissue

and identify presence of substrate

Reentrant Ventricular Arrythmias

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Signal Averaged Electrocardiogram

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 Microvolt T Wave Alternans (MTWA)

Electrical alternans is variability of the ECG T wave form on

alternate beats

Repolarization alternans showed risk stratifier for ventricular

arrythmias

Rosenbaum et al showed that TWA was predictive inducibility

VT at EP study, and independent risk factor for spontaneous
VT, VF or SCD during 20 months follow up

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Microvolt T Wave Alternans (MTWA)

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Recent Studies

In MUSTT Trial showed SAECG better independent predictor than EPS

Recent Studies of 102 post MI patients who underwent evaluation of LV

function, TWA and SAECG
Positive predictive accuracy of TWA was 28%
TWA combine SAECG resulted 50%

This may concluded that this Non invasive test may serve for screening
high risk SCD

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 ICD
Guidelines and Recommendation

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 Pedoman Terapi Memakai Alat Elektronik
Kardiovaskular Implan (ALEKA)

Pasien dengan FEVKi ≤35% dan kelas fungsional II atau III

NYHA, yang disebabkan IM, paling cepat 40 hari setelah
kejadian serangan jantung.

Pasien dengan FEVKi ≤30% dan kelas fungsional I NYHA, yang

disebabkan IM, paling cepat 40 hari setelah kejadian serangan
jantung.

Pasien yang selamat dari kejadian henti jantung karena FV atau

TV yang menetap dengan hemodinamik tidak stabil, dan tidak
ditemukan penyebabnya yang reversibe

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 Summary

For Post MI patients the management is to maximize

optimal medical theraphy and revascularization
Reevaluate LVEF in important for indication of ICD
Some risk stratification parameters of SCD have been
shown to guide the need for ICD implantation

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Thank you

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POST MI

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Early after MI : Mechanical problem caused
SCD or Arrhythmia induced SCD
VALIANT trial : autopsy of 444 died patient 15%
of total 2878 after MI
with 105 patients defined as SCD

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