European Journal of Preventive Cardiology (2024) 31, 2125–2126 INVITED EDITORIAL

https://doi.org/10.1093/eurjpc/zwae145

Ventricular arrhythmias during acute coronary

syndrome: a gateway to sudden cardiac death?
1
Pascal Bauer *, Philipp Bengel1, Samuel Tobias Sossalla1,2, and Borislav Dinov1
1
Department of Cardiology and Angiology, Justus-Liebig-University Giessen, Klinikstrasse 33, 35390 Giessen, Germany; and 2Department of Cardiology, Kerckhoff-Klinik GmbH, Benekestr.
2 - 8, 61231 Bad Nauheim, Germany

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Online publish-ahead-of-print 17 April 2024

This editorial refers to ‘Ventricular arrhythmias and haemo­ To put these results in the right context, it is important to under­
dynamic collapse during acute coronary syndrome: increased stand the characteristics of the studied population. It is noteworthy
risk for sudden cardiac death?’, by M. Järvensivu-Koivunen that the majority of the included 8062 ACS patients in this cohort
et al., https://doi.org/10.1093/eurjpc/zwae074. had STEMI, which confers a higher risk of monomorphic ventricular
tachycardia and SCD compared to ACS without ST elevation.
Acute coronary syndrome (ACS) remains a leading cause of mortality Furthermore, the VA subgroup was a high-risk cohort consisting of
worldwide,1 and its complications, including ventricular arrhythmias more male patients with lower left ventricular ejection fraction
(VA),2 contribute significantly to the burden of sudden cardiac death (LVEF) and more implantable cardioverter defibrillator (ICD) implanted
(SCD).1,2,3 However, it is unknown if VA during ACS predicts VA be­ in the acute stage. Therefore, it is not surprising that the risk for late
yond the acute phase and if VA increases the risk of SCD in patients VAs was higher in the subgroup presenting with VA, supposedly due
with ACS and only mildly impaired or preserved left ventricular ejection to larger scars, but also higher rates of ICD-detected VA.
fraction. The paper entitled ‘Ventricular arrhythmias and haemodynam­ Important criteria for ICD implantation are LVEF and the occurrence
ic collapse during acute coronary syndrome: increased risk for sudden of VA over time. Current guidelines do not recommend ICD implant­
cardiac death?’4 tackles these two important questions and provides ation in ACS patients with early (<48 h) VA, reversible ischaemia and
valuable insights into the association between VA during ACS and the during the first 40 days after STEMI.3 An important caveat of the
subsequent risk of SCD. ICD therapy is that VA are not the only cause of death in ACS, whereas
Acute coronary syndrome has a complex pathophysiology and the non-arrhythmic causes contribute significantly to mortality, especially in
risk of sudden cardiac death (SCD) varies along the spectrum of the the early stages of MI. This was an important lesion from the defibrilla­
ACS from unstable angina to segment elevation myocardial infarction tor in acute myocardial infarction (DINAMIT) and immediate risk-
(STEMI). Acute myocardial ischaemia can directly affect the character­ stratification improves survival (IRIS) trials, which failed to show a re­
istics of both the resting and action membrane potential, predisposing duction of all-cause mortality in patients with an acute MI and reduced
to afterdepolarization and phase 3 re-entry ventricular arrhythmias LVEF < 35%, despite a reduction of arrhythmic deaths.8,9 The more re­
(VA).5 These changes in myocardial electrophysiology are transient cent wearable cardioverter–defibrillator after myocardial infarction
and can be mitigated by coronary revascularization and use of beta (VEST) trial also failed to provide evidence of survival benefit of wear­
blockers. However, in addition to the reversible effects of acute ischae­ able defibrillators in individuals with LVEF < 35% in acute MI.10
mia, irreversible myocardial scarring occurs and provides substrate for Importantly, because all these studies systematically excluded patients
delayed re-entry VA, which is not affected by the elimination of the with LVEF > 35%, the risk of SCD in patients with ACS and mildly im­
acute trigger, and determines a higher long-term risk of SCD in patients paired or preserved LVEF is still unclear.
with ACS. This knowledge gap was addressed by Jä rvensivu-Koivunen et al.,4
Hence, timing and type of VA during ACS implies differences in the who included only patients with ACS and LVEF > 40% and report
pathophysiology and long-term prognosis and must be considered that the long-term risk for SCD remains high (incidence of 2.6% in
when evaluating the risk of SCD. Ventricular fibrillation (VF) in the first the study period) despite the elimination of the acute trigger.
48 h of myocardial infarction (MI) is related to acute transient changes Though, the reasons for this important observation remain unclear.
in myocardial electrophysiology and is not regarded as a risk factor On the one hand, obvious factors such as progression of coronary ar­
for future VA.5 However, studies consistently showed that early VA tery disease and worsening of heart failure may explain the elevated risk
occurrence in the setting of ACS, and MI in particular, is associated for SCD, which, on its own turn, highlights that the risk for SCD is not a
with increased intra-hospital and 90-days mortality, although an associ­ solitary estimate and should be periodically reassessed.
ation with long-term mortality can still not be proved.5,6,7 Notably, Furthermore, pathophysiology and SCD risk of ventricular tachycar­
these observations stand in contrast to the findings of the current dia (VT), VF, or asystole differ substantially. Hence, identifying the initial
study,4 which concludes that VA during ACS is associated with higher cause for SCD solely based on retrospective data of death certificates
rates of future VAs. may be inaccurate.

The opinions expressed in this article are not necessarily those of the Editors of the European Journal of Preventive Cardiology or of the European Society of Cardiology.
* Corresponding author. Tel: +49 641 985 56692, Fax: +49 641 985 42109, Email: pascal.bauer@innere.med.uni-giessen.de
© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for
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2126 Invited Editorial

In conclusion, the current study4 provides evidence supporting the 5. Kalarus Z, Svendsen JH, Capodanno D, Dan GA, De Maria E, Gorenek B, et al. Cardiac
notion that VA during ACS significantly increases the risk of SCD, arrhythmias in the emergency settings of acute coronary syndrome and revasculariza­
even in patients with normal or mildly impaired LVEF. The study chal­ tion: an European Heart Rhythm Association (EHRA) consensus document, endorsed
by the European Association of Percutaneous Cardiovascular Interventions (EAPCI),
lenges existing paradigms in risk stratification and highlights the import­
and European Acute Cardiovascular Care Association (ACCA). Europace 2019;21:
ance of vigilant monitoring and timely interventions to prevent 1603–1604.
life-threatening events. 6. Avezum A, Piegas LS, Goldberg RJ, Brieger D, Stiles MK, Paolini R, et al. Magnitude and
prognosis associated with ventricular arrhythmias in patients hospitalized with
Conflict of interest: none declared.
acute coronary syndromes (from the GRACE Registry). Am J Cardiol 2008;102:
1577–1582.
7. Mehta RH, Starr AZ, Lopes RD, Hochman JS, Widimsky P, Pieper KS, et al.
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