Risk Stratification for Sudden Cardiac Death
2017; Lippincott Williams & Wilkins; Volume: 135; Issue: 22 Linguagem: Inglês
10.1161/circulationaha.117.027958
ISSN1524-4539
AutoresTimothy M. Markman, Saman Nazarian,
Tópico(s)Cardiac Arrhythmias and Treatments
ResumoHomeCirculationVol. 135, No. 22Risk Stratification for Sudden Cardiac Death Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBRisk Stratification for Sudden Cardiac DeathIs It Too Late to Establish a Role for Cardiac MRI? Timothy M. Markman, MD and Saman Nazarian, MD, PhD Timothy M. MarkmanTimothy M. Markman From Department of Medicine, The Johns Hopkins University, Baltimore, MD (T.M.M.); and Division of Cardiology, Section for Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia (S.N.). and Saman NazarianSaman Nazarian From Department of Medicine, The Johns Hopkins University, Baltimore, MD (T.M.M.); and Division of Cardiology, Section for Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia (S.N.). Originally published28 Mar 2017https://doi.org/10.1161/CIRCULATIONAHA.117.027958Circulation. 2017;135:2116–2118Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2017: Previous Version 1 Article, see p 2106Automatic detection and transvenous or subcutaneous defibrillation of malignant ventricular arrhythmias by implantable cardioverter defibrillators are vital for management of patients at high risk for sudden cardiac death. Guidelines and appropriate use criteria based on data from several clinical trials support prophylactic defibrillator implantation in patients with symptoms of heart failure and left ventricular ejection fraction ≤35%.1,2 Yet, existing guidelines direct defibrillator implantation to a small subset of the overall population at risk for sudden death, and with an average annual appropriate shock rate of 5.1%, many patients that receive an implantable defibrillator never require appropriate therapies and are exposed to device-related risks.3,4 The recent DANISH trial (Defibrillator Implantation in Patients with Non-Ischemic Systolic Heart Failure) found no mortality benefit with prophylactic defibrillator implantation in patients with symptomatic heart failure and nonischemic cardiomyopathy.5 Thus, additional data are necessary to refine patient selection among patients with nonischemic cardiomyopathy that currently meet defibrillator implantation criteria. At the same time, criteria to identify high risk of sudden cardiac death among patients that are currently excluded must evolve. As many as 80% of those who experience out-of-hospital cardiac arrests would not meet current criteria for primary prevention defibrillator implantation before the event.6–9 These patients, who generally have preserved or nearly preserved cardiac function, have lower mortality risks competing with sudden cardiac death and stand to derive significant benefit from defibrillator implantation. Currently used measures of sudden cardiac death risk, however, are based on cardiac function rather than identification of the substrate for malignant arrhythmia. The left ventricular ejection fraction is readily quantifiable by echocardiography and has been used as the primary stratification tool in all major trials, but it is highly dependent on loading conditions, and is only an effective predictor of sudden cardiac death in subgroups of patients with direct association between scar extent and cardiac function.In this issue of Circulation, Halliday et al10 report findings from a prospective registry of 399 patients with nonischemic cardiomyopathy and left ventricular ejection fraction ≥40% not meeting current guidelines for defibrillator implantation. All patients underwent baseline cardiovascular MRI and were followed for a prespecified composite end point of sudden death or successful resuscitation from ventricular arrhythmia. Over nearly 5 years of follow-up, patients with midmyocardial late gadolinium enhancement on baseline cardiovascular magnetic resonance were more likely to have sudden cardiac death or aborted sudden cardiac death in comparison with those without late gadolinium enhancement (17.8% versus 2.3%, P<0.001). After adjustment for age, New York Heart Association class of heart failure, and left ventricular ejection fraction, the presence of late gadolinium enhancement predicted actual (hazard ratio, 4.8; P=0.003) and aborted (hazard ratio, 35.9; P 35%. The findings may enhance guidelines to include more patients at high risk for sudden cardiac death. In the long run, however, we must also identify the subset of patients that currently undergo defibrillator implantation without deriving benefit. This is necessary, not only to reduce costs to society, but also to eliminate unnecessary device-related risks. Ultimately, future studies must examine the paradigm of risk stratification based only on late gadolinium enhancement and regardless of the left ventricular ejection fraction.DisclosuresDr Nazarian serves as a scientific advisor for Biosense Webster, St. Jude Medical, and CardioSolv. He is a principal investigator for research grants from Biosense Webster and the National Institutes of Health.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circulation is available at http://circ.ahajournals.org.Correspondence to: Saman Nazarian, MD, PhD, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9118, Philadelphia, PA 19104. E-mail [email protected]References1. Kusumoto FM, Calkins H, Boehmer J, Buxton AE, Chung MK, Gold MR, Hohnloser SH, Indik J, Lee R, Mehra MR, Menon V, Page RL, Shen WK, Slotwiner DJ, Stevenson LW, Varosy PD, Welikovitch L. 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Markman T, Bluemke D, Soliman E, Wu C, Kawel-Boehm N, Lima J and Nazarian S (2019) Baseline ST elevation and myocardial scar: Results from the multi-ethnic study of atherosclerosis, Journal of Electrocardiology, 10.1016/j.jelectrocard.2019.06.013, 56, (29-33), Online publication date: 1-Sep-2019. Markman T, McBride D and Liang J (2018) Catheter Ablation for Ventricular Tachycardia in Patients with Structural Heart Disease, US Cardiology Review, 10.15420/usc.2017:28:3, 12:1, (51-56), Online publication date: 15-Mar-2018. Markman T and Nazarian S (2017) Cardiac Magnetic Resonance for Lesion Assessment in the Electrophysiology Laboratory, Circulation: Arrhythmia and Electrophysiology, 10:11, Online publication date: 1-Nov-2017. May 30, 2017Vol 135, Issue 22 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.027958PMID: 28351902 Originally publishedMarch 28, 2017 Keywordsdeath, sudden, cardiacEditorialsgadolinium DTPAventricular ejection fractiondefibrillators, implantablecardiomyopathiestachycardia, ventricularPDF download Advertisement
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