The MADIT II study results suggest the following at-risk profile for sudden cardiac death:
The patient is a 55-year-old male construction supervisor who sustained an acute anterior wall myocardial infarction in 1999. Coronary angioplasty was performed with stenting of the left anterior descending coronary artery. Nearly 1 month later, coronary sinus angiography revealed the left anterior descending coronary artery was widely patent and a 30% obstruction of the distal right coronary artery existed. The left ventricular EF was 26% with apical anterior hypokinesis.
Treatment included digoxin 0.25 mg daily, lisinopril 20 mg daily, and metoprolol 50 mg bid. He had no further problems. However, at his first office visit 3 months after the infarction, he had a repeat echocardiogram that showed an EF of 22%. He was enrolled into the MADIT II study and received an implantable cardioverter defibrillator (ICD). Two months after implantation, he had an ICD discharge for ventricular tachycardia at 190 beats/minute. He was successfully converted to sinus rhythm. Amiodarone 200 mg daily was added after a total of 12.0 g loading dose. He has done well since.
Comment: The patient had a prior myocardial infarction and significantly depressed left ventricular function. Two echocardiograms showed a markedly reduced EF. The EF following a myocardial infarction is often unchanged despite conventional medical therapy.
Case study provided by Barry W. Ramo, MD, cardiac electrophysiologist, New Mexico Heart Institute, Albuquerque, New Mexico.