Risk of Arrhythmia and Sudden Death Edited by Marek Malik BMJ Books Risk of Arrhythmia and Sudden Death To my parents Risk of Arrhythmia and Sudden Death Edited by Marek Malik Professor of Cardiac Electrophysiology St George’s Hospital Medical School, London, UK ©BMJ Books 2001 BMJ Books is an imprint of the BMJ Publishing Group All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. First published in 2001 by BMJ Books, BMA House, Tavistock Square, London WC1H 9JR www.bmjbooks.com British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0-7279-1581-9 Typeset by Phoenix Photosetting, Chatham, Kent Printed and bound by Creative Print and Design Ltd Contents Contributors ix Preface xiii Abbreviations xv Part I: Problem and methodology 1 Clinical goals of risk stratification 3 Roberto Elosua, Josep Guindo, Xavier Viñolas, Antonio Martinez-Rubio, Toni Bayés-Genis and Antoni Bayés de Luna 2 Definition of arrhythmic risk 10 Steen Z Abildstrom, Christian Torp-Pedersen and Lars Køber 3 Statistical methods for risk-stratification studies 19 Timothy R Church 4 Step-wise risk-stratification strategies 29 Stefan H Hohnloser 5 Risk-stratification studies for prospective trial design 37 Marek Malik Part II: Techniques of risk assessment 6 Basic clinical assessment 49 Branco Mautner 7 Left ventricular ejection fraction and wall motion score 57 Steen Z Abildstrom, Christian Torp-Pedersen and Lars Køber 8 Risk assessment: the 12-lead electrocardiogram 65 Rory Childers 9 Electrophysiological study for risk stratification of cardiac patients 98 Velislav Batchvarov 10 QT dispersion 117 Velislav Batchvarov and Marek Malik v Risk of Arrhythmia and Sudden Death 11 Electrocardiographic assessment of myocardial ischaemia (with a note on the ischaemia–arrhythmia connection) 135 Shlomo Stern 12 Exercise electrocardiography for the assessment of arrhythmias 144 Michael Cusack and Simon Redwood 13 Analysis of monophasic action potentials 155 Peter Taggart and Peter Sutton 14 Ventricular signal averaged electrocardiography 167 Piotr Kulakowski 15 Signal averaged P wave 180 Antonio Michelucci, Luigi Padeletti, Andrea Colella, Maria Cristina Porciani, Paolo Pieragnoli, Alessandro Costoli and Gian Franco Gensini 16 Non-invasive investigation of Wedensky modulation 187 Katerina Hnatkova and Marek Malik 17 Ambulatory electrocardiography: use in arrhythmia risk assessment 194 Morrison Hodges and James J Bailey 18 Event loop recorders and implantable monitors 202 Mark L Brown 19 Basic autonomic tests 209 Federico Lombardi 20 Heart rate assessment and monitoring 213 Xavier Copie, Olivier Piot, Thomas Lavergne, Louis Guize and Jean-Yves Le Heuzey 21 Heart rate variability 221 Robert E Kleiger and Phyllis K Stein 22 Baroreflex sensitivity 234 Maria Teresa La Rovere, Andrea Mortara and Gian Domenico Pinna 23 Heart rate turbulence 242 Georg Schmidt 24 T wave dynamicity 249 Pierre Maison Blanche and Philippe Coumel 25 Repolarisation alternans 256 Daniel M Bloomfield and Richard J Cohen 26 Social and psychosocial influences on sudden cardiac death, ventricular arrhythmia and cardiac autonomic function 266 Harry Hemingway vi Contents Part III: Clinical studies of risk assessment 27 Risk stratification after myocardial infarction 287 Yee Guan Yap 28 Ventricular arrhythmias in chronic heart failure 297 Steven Lindsay and Jim Nolan 29 Ventricular arrhythmias in hypertrophic cardiomyopathy 309 Gang Yi and William J McKenna 30 Ventricular arrhythmias in apparently healthy athletes 316 Francesco Furlanello, Fredrick Fernando, Amedeo Galassi and Annalisa Bertoldi 31 Paroxysmal atrial fibrillation 325 Johan EP Waktare 32 Persistent atrial fibrillation 336 Joseph T Dell’Orfano and Gerald V Naccarelli 33 Permanent atrial fibrillation 348 Isabelle C Van Gelder and Harry JGM Crijns 34 Arrhythmias associated with the long QT syndrome 353 Peter J Schwartz 35 Arrhythmia associated with other cardiac diseases 360 Patrick Lam and Paul Schweitzer 36 Arrhythmias associated with non-cardiac disease 365 Josef Kautzner Part IV: Antiarrhythmic trials 37 Antiarrhythmic device trials 379 Arthur J Moss 38 Recent antiarrhythmic drug trials 389 Michiel J Janse Index 395 vii Contributors Steen Z Abildstrom Richard J Cohen Department of Cardiology, Gentofte University Hospital, Whitaker Professor, Harvard University–Massachusetts Copenhagen, Denmark Institute of Technology, Division of Health Sciences and Technology, Massachusetts, USA James J Bailey Center for Information Technology, National Institutes of Andrea Colella Health, Bethesda, Maryland, USA Istituto di Clinica Medica e Cardiologia, Università di Firenze, Florence, Italy Velislav Batchvarov Xavier Copie Department of Cardiological Sciences, St George’s Department of Cardiology, Broussais Hospital, Paris, Hospital Medical School, London, UK France Antoni Bayés de Luna Alessandro Costoli Departamento de Cardiología, Hospital de la Santa Creu i Istituto di Clinica Medica e Cardiologia, Università di Sant Pau, Barcelona, Spain Firenze, Florence, Italy Toni Bayés-Genis Philippe Coumel Fellow, Mayo Clinic, Rochester, Minnesota, USA Hôpital Lariboisière, Paris, France Annalisa Bertoldi Harry JGM Crijns Department of Cardiology, S. Chiara Hospital, Trento, Italy Department of Cardiology, Thoraxcenter, University Hospital Groningen, Groningen, The Netherlands Daniel M Bloomfield Assistant Professor of Medicine, Division of Cardiology, Michael Cusack College of Physicians and Surgeons, Columbia University, Clinical Research Fellow, Department of Cardiology, USA Rayne Institute, St Thomas’ Hospital, London, UK Mark L Brown Joseph T Dell’Orfano Staff Scientist, Tachyarrhythmia Research Department, Department of Medicine, Division of Cardiology, The Atrial Fibrillation Research Group, Medtronic, State University of New York at Stony Brook, Stony Minneapolis, Minnesota, USA Brook, New York, USA Rory Childers Roberto Elosua Professor of Medicine, Section of Cardiology, University Unidad de Lípidos y Epidemiología Cardiovascular, of Chicago Medical Centre, Chicago, USA Instituto Municipal de Investigación Médica, Barcelona, Spain Timothy R Church Division of Environmental and Occupational Health, Fredrick Fernando School of Public Health, University of Minnesota, Sports Science Institute, Italian National Olympic Minneapolis, Minnesota, USA Committee, Rome, Italy ix