CHANGE OF ARRHYTHMIC EVENTS IN ACUTE MYOCARDIAL INFARCTION WITH ST-SEGMENT ELEVATION AFTER PHARMACOINVASIVE REVASCULARIZATION

Aim. To study changes in course of arrhythmias, depending on the efficacy of coronary blood flow restoration due to pharmacoinvasive revascularization in patients with ST segment elevation myocardial infarction (STEMI).

Material and methods. STEMI-patients (n=117) with an effective (according to ECG criteria) thrombolytic therapy (TLT) and the subsequent (after 3-24 hours) percutaneous coronary  intervention (PCI), were included into the study. Telemetry ECG was performed before  and after PCI with analysis of the arrhythmias and cardiac conduction disorders.

Results. Patients (n=84; 71.8%) with an effective TLT, confirmed by the coronary angiography (CAG), and with subsequent effective PCI were included into the group "without rethrombosis" (RT(–)). Patients (n=33; 28.2%) with CAG proven rethrombosis of the infarct-related coronary artery and subsequent effective PCI were included into the group "with rethrombosis" (RT(+)). Regardless of the stability of coronary blood flow restoration after the TLT, PCI was associated with an increased incidence of ventricular tachycardia (VT) (p<0.01), sinus tachycardia (p=0.01), paroxysmal supraventricular tachycardia (SVT) (p<0.05) and paired ventricular extrasystoles (p<0.01). Compared to the RT(–) group, in the RT(+) group after PCI VT were recorded more frequently (44% vs 63.6%, respectively; p<0.05) as well as AV-block 3 degree (3.6% vs 12.1%, respectively; p<0.05). Episodes of sinus tachycardia were detected significantly more frequently before PCI in RT(–) group compared with RT(+) group (67.9% vs 45.4% respectively; p<0.01). The number of patients with episodes of sinus bradycardia increased (from 19% to 32.1%; p=0.02) after PCI in RT(–) group.

Conclusion. The incidence of VT and SVT paroxysms, episodes of sinus tachycardia, atrioventricular conduction disturbances and ventricular extrasystoles increased in all patients after the effective PCI due to reperfusion. However, VT episodes and paroxysmal atrioventricular block grade 3 were more common in patients with previous re-thrombosis of the infarct-related coronary artery. Considering a high risk of arrhythmic events, continuous ECG mon itoring with automated alarm systems  about life-threatening arrhythmias should be applied in STEMI patients regardless of tactics of coronary  blood flow restoration and the reperfusion effectiveness.

1. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33(20):2569-619.

2. National guidelines on the diagnosis and treatment of patients with acute myocardial infarction with ST-segment elevation. Kardiovaskulyarnaya Terapiya i Profilaktika. 2007;6(8) suppl 1:415-500. (In Russ.) [Национальные рекомендации по диагностике и лечению больных острым инфарктом миокарда с подъемом сегмента ST ЭКГ. Кардиоваскулярная Терапия и Профилактика. 2007:6(8) приложение 1:415-500].

3. Heper G., Korkmaz M. E., Kilic A. Reperfusion arrhythmias: are they only a marker of epicardial reperfusion or continuing myocardial ischemia after acute myocardial infarction? Angiology. 2008;58(6):663-70.

4. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33(20):2569-619.

5. O'Gara P.T., Kushner F.G., Ascheim D.D. et al. 2013 ACCF/AHA Guideline for the Management of STElevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78-e140.

6. Syrkin A.L. Myocardial infarction. Moscow: Medicinskoe Informacionnoe Agentstvo Publishers; 2003. (In Russ.) [Сыркин А.Л. Инфаркт миокарда. М.: Медицинское информационное агентство; 2003].

7. Olejnikov V.Je., Shigotarova E.A., Kuljucin A.V., Evstigneev S.V. Improving the quality of diagnosis rethrombosis in patients with ACS ST-segment elevation in the implementation of the ECG telemonitoring. Rossiyskiy Kardiologicheskiy Zhurnal. 2014;113(9):37-42. (In Russ.) [Олейников В.Э., Шиготарова Е.А., Кулюцин А.В., Евстигнеев С.В. Повышение качества диагностики ретромбозов у больных ОКС с подъемом сегмента ST при внедрении телемониторинга ЭКГ. Российский Кардиологический Журнал. 2014:13(9):37-42].

8. Laun B. Ventricular premature beats in the detection and management of patients with risk of sudden death. In: Vihert A.M.; Laun B.; eds. Sudden death: Proceedings of the 1st Soviet-American symposium. Moscow: Medicine Publishers; 1980: 77-94. (In Russ.) [Лаун. Б. Желудочковые экстрасистолы в выявлении и тактике ведения больных с риском внезапной смерти. В: Вихерт А.М.; Лаун Б.; редакторы. Внезапная смерть: Материалы 1-го Советско-американского симпозиума. М.:Медицина; 1980: 77-94].

9. Pedersen C.T., Kay G.N., Kalman J. et al. EHRA/HRS/APHRS expert consensus on ventricular arrhythmias. Europace Sep. 2014;16(9):1257-83.

10. Armstrong P.W., Gershlick A.H., Goldstein P., et al. Fibrinolysis or Primary PCI in ST-Segment Elevation Myocardial Infarction. N Engl J Med. 2013;368:1379-87.

11. MacMahon S., Collins R., Peto R. Et al. Effects of prophylactic lidocaine in suspected acute myocardial infarction. An overview of results from the randomized, controlled trials. JAMA. 1988;260(13): 1910-6.

12. Bunin Ju.A. Treatment of arrhythmias and heart block in myocardial infarction with ST segment elevation. Consilium Medicum 2007;11:96-103. (In Russ.) [Бунин Ю.А. Лечение нарушений ритма и блокад сердца при инфаркте миокарда с подъемом сегмента SТ. Consilium Medicum 2007;11:96-103].

13. Ganz L.I., Antman E.M. Cardiac arrhythmias during acute myocardial infarction. In: Antman E.M., Rutherford J.D. et al. Coronary care medicine: a practical approach, 2nd ed. Boston: Martinus Nijhoff; 2004: 419-60.

14. Venetucci L.A., Trafford A.W., O’Neill S.C., Eisner D.A. The sarcoplasmic reticulum and arrhythmogenic calcium release. Cardiovasc Res. 2008;77(2):285-92.