Ventricular flutter induced during electrophysiologic studies in patients with old myocardial infarction: Clinical and electrophysiologic predictors, and prognostic significance

Introduction: Induction of ventricular flutter during electrophysiologic (EP) studies (similar to that of ventricular fibrillation [VF]) often is viewed as a nonspecific response with limited prognostic significance. However, data supporting this dogma originate from patients without previously documented ventricular tachyarrhythmias. We examined the significance of ventricular flutter in patients with and without spontaneous ventricular arrhythmias. Methods and Results: We conducted a cohort study of all patients with myocardial infarction (MI) undergoing EP studies at our institution. Of 344 consecutive patients, 181 had previously documented spontaneous sustained ventricular arrhythmias, 61 had suspected ventricular arrhythmias, and 102 had neither. Ventricular flutter was induced in 65 (19%) of the patients. Left ventricular ejection fraction was highest among patients with inducible VF (35 ± 13), lowest for patients with inducible sustained monomorphic ventricular tachycardia (SMVT; 27 ± 9), and intermediate for patients with inducible ventricular flutter (30 ± 10). Similarly, the coupling intervals needed to induce the arrhythmia were shortest for VF (200 ± 28 msec), intermediate for ventricular flutter (209 ± 27 msec), and longest for SMVT (230 5:35 msec). During 5 ± 8 years of follow-up, the risk for ventricular tachycardia/VF was high for patients with SMVT and ventricular flutter and low for patients with inducible VF and noninducible patients (46%, 34%, 17%, and 14%, P < 0.005). Conclusion: Patients with inducible ventricular flutter appear to be "intermediate" between patients with inducible VF and patients with SMVT in terms of clinical and electrophysiologic correlates. However, the prognostic value of inducible ventricular flutter is comparable to that of SMVT.