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Myocardial revascularization and implantation of the automatic implantable cardioverter defibrillator (AICD) have individually been shown to improve survival in patients after sudden cardiac death. Their combined role has not been well defined. Twenty-three survivors of sudden death underwent revascularization and AICD implantation at an average age of 59 years. The initial arrest was caused by ventricular fibrillation in 15 and ventricular tachycardia in 8. Exercise stress tests, ambulatory ECGs, and electrophysiological monitoring with programmed electrical stimulation were done preoperatively and postoperatively. Follow-up averaged 24 months with a two-year survival of 91%. Eight patients (35%) required AICD resuscitation an average of 8 months postoperatively, and electrophysiological testing did not accurately predict arrhythmia recurrence. The addition of AICD implantation to revascularization substantially improves survival of patients with sudden cardiac death.

Survival, subsequent myocardial infarction and current anginal status were determined for 90 nearly consecutive patients who underwent coronary arteriography at the Johns Hopkins Hospital between 1960 and 1967. All patients had at least one coronary arterial narrowing equal to or greater than 70 percent; 78 of 90 patients would be candidates for coronary bypass surgery by present criteria. Twenty-nine of the 78 surgically "suitable" patients died of cardiac causes; 7 of 49 survivors sustained an acute myocardial infarction (mean follow-up period 9.9 years). Patients with a 70 percent or greater narrowing proximal to the first septal branch of the left anterior descending coronary artery had a significantly greater mortality compared with patients with equivalent narrowing distal to the first septal branch or with patients without 70 percent or greater narrowing of the left anterior descending artery. The patients with a 70 percent or greater narrowing of the left anterior descending artery who died were those with a significant narrowing in at least one other major coronary artery. Multivariate stepwise discriminate function analysis of all clinical, electrocardiographic (except stress electrocardiographic) and arteriographic variables identified three independent predictors of mortality: (1) the simultaneous occurrence of a narrowing in left anterior descending and right coronary arteries, (2) prior myocardial infarction; and (3) 70 percent or greater narrowing proximal to the first anterior descending septal branch. When stress electrocardiographic findings were included, a "positive" stress electrocardiographic test was also an independent predictor of mortality.

To investigate the accuracy of the 12-lead ECG in localizing the site of coronary artery narrowings, we reviewed abnormal ECGs obtained during myocardial infarction, spontaneous angina or exercise stress testing in 134 patients with angiographically documented one-vessel disease. The presence of Q waves, ST-segment elevation and T-wave inversion in leads I, aVL and V1--V4 were all highly correlated with the presence of left anterior descending coronary artery disease (p less than 0.001), and the same ECG findings in leads II, III and aVF were associated with right (RCA) or circumflex coronary artery (LCx) narrowings (p less than 0.001). In contrast, ST depression alone was not useful in predicting the site of coronary artery narrowing. Q waves correctly identified the location of the coronary disease in 98% of cases, ST elevation in 91%, T-wave inversion in 84%, and ST depression in 60%. No electrocardiographic criteria distinguished RCA from LCx disease, even in patients with a right-dominant circulation. These findings should lead to a better understanding of the value and limitations of the 12-lead ECG in localizing coronary artery disease.