Significance of Repeat Programmed Ventricular Stimulation at Electrophysiology Study for Arrhythmia Prediction After Acute Myocardial Infarction

Sarah Zaman, M.B.B.S.; Arun Narayan, R.N.; Aravinda Thiagalingam, PH.D.; Gopal Sivagangabalan, PH.D.; Stuart Thomas, PH.D.; David L. Ross, PH.D.; Pramesh Kovoor, PH.D.


Pacing Clin Electrophysiol. 2014;37(7):795-802. 

In This Article

Abstract and Introduction


Background. The prognostic significance of a second programmed ventricular stimulation (PVS) at electrophysiology study (EPS), when the first PVS is negative for inducible ventricular tachycardia (VT), in patients following myocardial infarction (MI) is unknown.

Methods. Consecutive ST-elevation MI patients with left ventricular ejection fraction ≤40% following revascularization underwent early EPS. An implantable cardioverter defibrillator (ICD) was implanted for a positive (inducible monomorphic VT) but not a negative (no arrhythmia or inducible ventricular fibrillation [VF]/flutter) EPS. The combined primary end point of death or arrhythmia (sudden death, resuscitated cardiac arrest, and spontaneous VT/VF) was assessed in EPS-positive patients grouped according to if VT was induced on the first PVS application, or the second PVS application, when the first was negative.

Results. EPS performed a median 8 days post-MI in 290 patients was negative in 70% (n = 203) and positive in 30% (n = 87). In patients with a positive EPS, VT was induced on the first PVS in 67% (n = 58) and the second PVS, after the first was negative, in 33% (n = 29). Predischarge ICD was implanted in 79 of 87 patients with a positive EPS. Three-year primary end point occurred in 20.9 ± 5.6% and 38.3 ± 9.7% of patients with VT induced by the first and second PVS, respectively (P = 0.042) and in 6.3 ± 1.9% of electrophysiology-negative patients (P < 0.001).

Conclusions. In patients with post-MI left ventricular dysfunction, VT can be induced in a significant proportion with a second PVS when negative on the first. These patients have a similar higher risk of death or arrhythmia compared to patients with VT induced on the first PVS.


Electrophysiology study (EPS) demonstrates the presence of an electrical substrate for reentrant ventricular tachyarrhythmia and, while invasive, has been shown to be safe even in the acute period post-myocardial infarction (MI),[1] including those treated with primary percutaneous coronary intervention (PPCI).[2] It remains a risk stratifier that consistently predicts arrhythmic risk both in observational studies and randomized defibrillator trials.[3–8] The prognostic value of EPS is critically dependent on the protocol used to induce ventricular tachycardia (VT).[9] Common practice usually involves one, two, or three programmed ventricular stimulation (PVS) attempts each using up to three or four extrastimuli (ES).[9,10] However, the predictive value of using more than one PVS in a contemporary population of revascularized MI patients without a history of sustained VT is largely unknown. The aim of this study was to assess the long-term outcomes of patients with VT induced only by the second PVS at EPS (i.e., negative EPS with no arrhythmia after a single PVS) compared to patients with VT induced on the first PVS protocol.