Is there a particular PVC/NSVT burden on inpatient telemetry in which you would consider discharging a patient with a LifeVest post-STEMI with newly reduced LVEF <35% while optimizing GDMT?

The PVC/NSVT burden is not part of the equation for post-STEMI LifeVest. The guidelines clearly state that if you have an EF of <35% and are within 40 days of an MI, or any revascularization within the past 90 days, the wearable defibrillator is a class IIb indication while optimizing GDMT. If the patient is having runs of NSVT, an EPS may be considered but my decision regarding a Lifevest would not be based on PVC or NSVT alone.

Patients with systolic LV dysfunction are at significantly elevated risk of SCD in the period immediately following MI. However, the ICD does not have an established benefit in this setting. The Defibrillator in Acute Myocardial Infarction Trial (DINAMIT) looked at ICD implantation in patients 6 to 40 days after a MI complicated by a reduced LVEF (≤ 35%) and impaired cardiac autonomic function. Follow-up at a mean of 30 months failed to identify an improvement in mortality with this treatment.

The evidence to support using any kind of defibrillator prophylactically after a STEMI is thin at best. Added to that is the psychological trauma inflicted on patients for a marginal gain in survival. Furthermore, there are absolutely not data to support using a ventricular arrhythmia burden to make this decision short of sustained VT/VF. 

These cases are becoming more common whereby our patients “do not fit the guidelines”. As care protocols evolve so to do guidelines in order to provide the most up to date advice based on the literature.