Choice of ventricular arrhythmia therapy in coronary artery disease

Aim. To study trigger factors of ventricular arrhythmias (VA) in patients with stable coronary artery disease (CAD) and evaluate the effectiveness of individualized treatment.

Material and methods. The study included 155 patients with CAD aged 36 to 83 years (61,5±9,8 years); 73,5% were men with frequent single and coupled ventricular ectopic complexes (VEC) and the left ventricle ejection fraction (LVEF) of 56,4±8,5%. Exclusion criteria were class IV angina, acute coronary syndrome, LV aneurysm, LVEF ≤45%. Treatment and examination of patients was carried out according to the algorithm we proposed in 2017 for managing patients with CAD and high-grade VA.

Results. Depending on association between ventricular ectopy and transient myocardial ischemia (TMI) during an exercise tolerance test, patients were divided into 2 groups. Group I included 84 patients (54,2%) with ischemic VA. According to noninvasive topical diagnostics, the arrhythmogenic focus in all patients with ischemic VA was located in the left ventricle. Group II consisted of 71 (45,8%) patients with nonischemic VA, and two subgroups were distinguished depending on presence/absence of TMI: 2A and 2B. During the exercise test, several types of VA were identified.

Myocardial revascularization (MR) was indicated in 84,5% of cases in both groups. Six months after MR in group I, the antiarrhythmic effect (AAE) was observed in 55 (77,5%) patients. In group IIA, AAE was significantly lower at 61,7% (p=0,048). We also revealed anxiety in 15 patients of group II. Anxiolytic therapy showed AAE in 75% of group IIA patients and in 63,6% of group IIB patients. Nine patients of group II were referred to radiofrequency ablation of VA with a positive effect of 55,5%. Antiarrhythmic drugs (amiodarone, sotalol) were taken by 5 people of group I.

Conclusion. The search for trigger factors and their elimination provides a high AAE for VA therapy in patients with CAD.

1. Myerburg RJ, Junttila MJ. Sudden Cardiac Death Caused by Coronary Heart Disease. Circulation. 2012;125:1043-52. doi:10.1161/CIRCULATIONAHA.111.023846.

2. Al-Khatib SM, Stevenson WG, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. Circulation. 2018;138:272-391. doi:10.1161/CIR.0000000000000549.

3. Ryngach EA, Treshkur TV, Tatarinova AA, et al. Algorithm for the management of patients with stable coronary artery disease and high-grade ventricular arrhythmias. Therapeutic archive. 2017;89(1):94-102. (In Russ.) doi:10.17116/terarkh201789194-102.

4. Treshkur TV. Clinical and electrocardiographic characteristics of ischemic ventricular arrhythmias. Journal of arrhythmology. 2002;30:31-9. (In Russ.)

5. Makarov LM, Komolyatova VN, Kupriyanova OO, et al. Russian National recommendations on the use of techniques Holter monitoring in clinical practice. Russian Journal of Cardiology. 2014;(2):6-71. (In Russ.) doi:10.15829/1560-4071-2014-2-6-71.

6. Priori SG, Blomstrom-Lundqvist C, Mazzanti A, et al. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. European Heart Journal. 2015;36(41):2793-867 doi:101093/eurheartj/ehv316.

7. Shlyakhto EV, Arutyunov GP, Belenkov YN, et al. National Guidelines for sudden cardiac death risk assessment and prevention (second edition). Moscow: MeDpraktIka-M, 2018. p.247 (In Russ.) ISBN: 978-5-98803-397-4.

8. Lupanov VP, Nuraliev EV, Sergienko IV. Functional stress tests in the diagnosis of coronary heart disease, risk assessment of complications and prognosis. Moscow: PatiSS, 2016. p.68. (In Russ.) ISBN: 978-5-9907885-1-0.

9. Sumarokov AB. The risk stratification of patients with coronary artery disease. Russ J Med. 1998;6(14):896-907. (In Russ.)

10. Tatarinova AA, Ryngach EA, Treshkur TV, et al. Ventricular Tachycardia Induced by Exercise Test as a Predictor of Coronary Artery Disease Development. Rational Pharmacotherapy in Cardiology. 2019;15(2):198-203. (In Russ.) doi:10.20996/1819-6446-2019-15-2-198-203.

11. Karpov YuA, Kukharchuk VV, Lyakishev AA, et al. Diagnosis and treatment of chronic ischemic heart disease. Kardiologicheskii Vestnik. 2015;10(3):3-33. (In Russ.)

12. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology. European Heart Journal. 2019;00:1-71. doi:10.1093/eurheartj/ehz425.

13. Fitzgibbon GM, Burggraf GW, Groves TD, et al. A double Master's two-step test: clinical, angiographic and hemodynamic correlation. Ann. Int. Med. 1971;74(4):509-17 doi:10.7326/0003-4819-74-4-509.