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I would like to thank Professor NikolicHeitzler and Dr Babic for their interest in our study. They share their experience, indicating a decreasing rate of malignant arrhythmia in patients with ST-segment elevation myocardial infarction—a fact that they attribute to the wider use of invasive treatment. Indeed, the incidence of malignant arrhythmias seems to have decreased across the whole spectrum of acute coronary syndromes during recent years. This trend is likely to be multifactorial in origin. Although the wide use of invasive strategy and early reperfusion is a plausible explanation, equally, effective medical care such as the use of b-blockers is an important determinant. Moreover, the shift in epidemiology due to the redefinition of myocardial infarction is unlikely to leave the incidence of early malignant arrhythmias unaffected. I fully agree with the authors that the prediction of such events, albeit of major scientific and health economic interest, still remains a challenge. As our data suggest, the susceptibility of patients with non-STsegment elevation myocardial infarction for such events is not explained by factors which have been shown to have good discriminatory power for other acute adverse events. Similarly, a recent metaanalysis could not elicit any risk factors for primary ventricular fibrillation other than ST-elevation and time from onset of symptoms, with the latter being a major confounder for other previously reported risk factors. In agreement with the authors, I hope that future studies with inclusion of ‘novel’ biomarkers will help us to understand this complex and life-threatening complication.

european heart journal

Incidence, time course, and predictors of early malignant ventricular arrhythmias after non-ST-segment elevation infarction in patients with early invasive treatment: reply