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European Heart Journal Advance Access published online on December 23, 2008
European Heart Journal, doi:10.1093/eurheartj/ehn540
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that the original authorship is properly and fully attributed; the Journal, Learned Society and Oxford University Press are attributed as the original place of publication with correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact journals.permissions@oxfordjournals.org

Improved Stratification of Autonomic Regulation for risk prediction in post-infarction patients with preserved left ventricular function (ISAR-Risk)

Axel Bauer1,{dagger}, Petra Barthel1,{dagger}, Raphael Schneider1, Kurt Ulm2, Alexander Müller1, Anke Joeinig1, Raphael Stich1, Antti Kiviniemi3, Katerina Hnatkova4, Heikki Huikuri3, Albert Schömig1, Marek Malik4 and Georg Schmidt1,*

1 Medizinische Klinik und Deutsches Herzzentrum München der Technischen Universität München, Ismaninger Straße 22, 81675 München, Germany
2 Institut für Medizinische Statistik und Epidemiologie der Technischen Universität München, München, Germany
3 Department of Medicine, University of Oulu, Oulu, Finland
4 Division of Cardiac and Vascular Sciences, St George’s, University of London, London, UK

Received 3 June 2008; revised 10 November 2008; accepted 18 November 2008.

* Corresponding author. Tel: +49 89 4140 2352, Fax: +49 89 4140 4862, Email: gschmidt{at}tum.de

Aims: To investigate the combination of heart rate turbulence (HRT) and deceleration capacity (DC) as risk predictors in post-infarction patients with left ventricular ejection fraction (LVEF) > 30%.

Methods and results: We enrolled 2343 consecutive survivors of acute myocardial infarction (MI) (<76 years) in sinus rhythm. HRT and DC were obtained from 24 h Holter recordings. Patients with both abnormal HRT (slope ≤ 2.5 ms/RR and onset ≥ 0%) and abnormal DC (≤4.5 ms) were considered suffering from severe autonomic failure (SAF) and prospectively classified as high risk. Primary and secondary endpoints were all-cause, cardiac, and sudden cardiac mortality within the first 5 years of follow-up. During follow-up, 181 patients died; 39 deaths occurred in 120 patients with LVEF ≤ 30%, and 142 in 2223 patients with LVEF>30% (cumulative 5-year mortality rates of 37.9% and 7.8%, respectively). Among patients with LVEF > 30%, SAF identified another high-risk group of 117 patients with 37 deaths (cumulative 5-year mortality rates of 38.6% and 6.1%, respectively). Merging both high-risk groups (i.e. LVEF ≤ 30% and/or SAF) doubled the sensitivity of mortality prediction compared with LVEF ≤ 30% alone (21.1% vs. 42.1%, P < 0.001) while preserving 5-year mortality rate (38.2%).

Conclusion: In post-MI patients with LVEF>30%, SAF identifies a high-risk group equivalent in size and mortality risk to patients with LVEF ≤ 30%.

Key Words: Autonomic function • Myocardial infarction • Risk stratification • Sudden death

{dagger} A.B. and P.B. contributed equally to this study.


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