Implantable defibrillator therapy and mortality in patients with non-ischaemic dilated cardiomyopathy : An updated meta-analysis and effect on Dutch clinical practice by the Task Force of the Dutch Society of Cardiology

Primary prevention ICD in non-ischaemic cardiomyopathy: an ongoing search for improvement of current indications : A retrospective study analysing the impact of the new Dutch guideline on the use of ICDs

INTRODUCTION

Patients with non-ischaemic cardiomyopathy (NICMP) have a class IIa primary prevention indication for an implantable cardioverter-defibrillator (ICD). Recent studies have shown that the evidence for a survival benefit following ICD implantation in this patient group is not particularly robust. In 2023, the Dutch Society of Cardiology published an update of the ESC guideline to better select patients with NICMP for ICD implantation. The objective of this study was to analyse the impact of this guideline on the number of indications in a retrospective cohort of patients who had received an ICD and whether the patients without an indication were also without appropriate ICD therapy.

METHODS

A single-centre, retrospective observational study was performed in 134 patients with NICMP who underwent ICD implantation for primary prevention between 2015 and 2020.

RESULTS

After applying the new Dutch guideline, 74 out of 134 patients with NICMP without a high-risk phenotype (35 patients) had no ICD indication (group 2). The remaining 25 patients were considered to have an ICD indication (group 1). During a median follow-up of 66 months (interquartile range 52-81) the incidence of appropriate ICD therapy (antitachycardia pacing and shock) was comparable in both groups: 4 patients in group 1 (16%) and 9 in group 2 (12%), p = 0.623.

CONCLUSION

The new 2023 guideline for ICD implantation in NICMP patients does indeed rule out a significant group of patients from ICD implantation. Nevertheless, our data show that patients without an indication still had comparable rates of appropriate ICD therapy.

Prognostic value of late gadolinium enhancement cardiac MRI for ICD therapy in non-ischaemic cardiomyopathy : A 5-year cohort study

AIM

To evaluate the impact of the 2023 Dutch national guidelines for primary prevention implantable cardioverter-defibrillator (ICD) implantation on outcomes in non-ischaemic cardiomyopathy (NICM) patients and to assess the role of late gadolinium enhancement cardiac magnetic resonance imaging (LGE-CMR) in predicting ICD therapy.

METHODS

This retrospective, single-centre observational exploratory cohort study included patients with NICM who received a primary prevention single-chamber, dual-chamber or subcutaneous ICD between January 2008 and April 2022 and underwent LGE-CMR prior to implantation. Patients were classified into LGE+ and LGE- groups based on the presence of late enhancement detected by CMR. The primary endpoint was time to first appropriate ICD therapy. The secondary endpoint was all-cause mortality.

RESULTS

Of the 258 NICM patients in the database, a total of 85 patients were included, of whom 41 had LGE on CMR. After a 5-year follow-up period, appropriate ICD therapy occurred in 20% of the patients in the LGE+ group and 14% of patients in the LGE- group (p = 0.37). All-cause mortality was 7% in the LGE+ group and 14% in the LGE- group (p = 0.46). Multivariable analysis showed no parameters significantly associated with appropriate ICD therapy.

CONCLUSION

Applying the 2023 national guidelines retrospectively on a population of NICM patients with a primary prevention ICD indication demonstrated no significant association between LGE on CMR and appropriate ICD therapy over a follow-up period of 5 years. These findings underscore the need for further research and randomised trials to refine risk stratification and ICD implantation guidelines in NICM, ideally leveraging a multicentre approach to address current limitations in sample size and enhance the generalisability of the results.

CRO-INSIGHT: Utilization of Implantable Cardioverter Defibrillators in Non-ischemic and Ischemic Cardiomyopathy in a Single Croatian Tertiary Hospital Centre

Background

Implantable cardioverter defibrillators (ICDs) have significantly reduced the incidence of sudden cardiac death in patients with heart failure, particularly those with ischemic heart disease. However, the impact on overall mortality remains controversial, especially in non-ischemic heart failure patients. The Danish Study to Assess the Efficacy of ICDs in Patients with Non-Ischemic Systolic Heart Failure (DANISH) trial and subsequent studies have questioned the efficacy of ICDs in this population, particularly among older patients. The present study aimed to evaluate survival outcomes and predictors in a Croatian cohort of patients with an ICD or cardiac resynchronization therapy defibrillator (CRT-D) device.

Methods

This retrospective cohort study analyzed data from 614 patients who received an ICD or CRT-D device at KBC Zagreb between 2009 and 2018. Patient data, including demographic information, device indication, and clinical parameters, were collected at the time of implantation. Follow-up data were systematically recorded to assess device activation and survival outcomes. Statistical analyses included a detailed descriptive analysis, Kaplan-Meier survival estimates, and Cox regression models.

Results

The cohort consisted predominantly of males (83.4%), with a mean age of 58.7 years. Most had reduced left ventricular ejection fraction (mean 31.4%) and were classified as New York Heart Association (NYHA) class II or III. Over a median follow-up of 48.4 months, 36.6% of patients died. Device activation occurred in 30.3% of patients, with appropriate activation observed in 88.2% of these cases. Cox regression identified age, non-sustained ventricular tachycardia (NSVT), and decompensation history as significant survival predictors.

Conclusions

This study confirmed that appropriate device activation improved survival in patients with an ICD/CRT-D. Age, NSVT, and history of decompensation were key predictors of device activation and survival outcomes. These findings underscore the need for individualized patient assessment when considering inserting ICDs, particularly in non-ischemic heart failure patients. Further research is needed to refine clinical guidelines and optimize patient selection for ICD therapy.

2021 European Society of Cardiology guidelines on cardiac pacing and cardiac resynchronisation therapy : Statement of endorsement by the NVVC

The European Society of Cardiology (ESC) has updated its guidelines on cardiac pacing and cardiac resynchronisation. As the majority are class II recommendations (61%) and based on expert opinion (59%), a critical appraisal for the Dutch situation was warranted. A working group has been established, consisting of specialists in cardiology, cardiothoracic surgery, geriatrics, allied professionals in cardiac pacing, and patient organisations with support from the Knowledge Institute of the Dutch Association of Medical Specialists. They assessed the evidence leading to the recommendations and the suitability for daily Dutch practice. Several recommendations have been amended or omitted altogether if a conflicting Dutch guideline has recently been published, such as a guideline on performing magnetic resonance imaging in patients with cardiac implantable electronic devices. The recent Dutch guideline on implantable cardioverter defibrillator implantation in patients with non-ischaemic cardiomyopathy has recommended implanting cardiac resynchronisation therapy devices without a defibrillator function. Shared decision making has received a more prominent role in the ESC guidelines and is discussed in more detail in this document. The recommendations given in this document are intended for health care professionals involved in the care of patients with an indication for cardiac pacing and are approved by the participating professional societies and the patient organisation Harteraad.

Assessment of ICD eligibility in non-ischaemic cardiomyopathy patients: a position statement by the Task Force of the Dutch Society of Cardiology

International guidelines recommend implantation of an implantable cardioverter-defibrillator (ICD) in non-ischaemic cardiomyopathy (NICM) patients with a left ventricular ejection fraction (LVEF) below 35% despite optimal medical therapy and a life expectancy of more than 1 year with good functional status. We propose refinement of these recommendations in patients with NICM, with careful consideration of additional risk parameters for both arrhythmic and non-arrhythmic death. These additional parameters include late gadolinium enhancement on cardiac magnetic resonance imaging and genetic testing for high-risk genetic variants to further assess arrhythmic risk, and age, comorbidities and sex for assessment of non-arrhythmic mortality risk. Moreover, several risk modifiers should be taken into account, such as concomitant arrhythmias that may affect LVEF (atrial fibrillation, premature ventricular beats) and resynchronisation therapy. Even though currently no valid cut-off values have been established, the proposed approach provides a more careful consideration of risks that may result in withholding ICD implantation in patients with low arrhythmic risk and substantial non-arrhythmic mortality risk.

Special Issue: Latest Advances in Delivery and Outcomes of Cardiac Resynchronization Therapy and Conduction System Pacing

Cardiac Resynchronization Therapy (CRT) is an established technique to improve morbidity and mortality in selected heart failure patients [...].