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Chrispin J, Merchant FM, Lakdawala NK, Wu KC, Tomaselli GF, Navara R, Torbey E, Ambardekar AV, Kabra R, Arbustini E, Narula J, Guglin M, Albert CM, Chugh SS, Trayanova N, Cheung JW. Risk of Arrhythmic Death in Patients With Nonischemic Cardiomyopathy: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:735-747. [PMID: 37587585 DOI: 10.1016/j.jacc.2023.05.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/21/2023] [Accepted: 05/30/2023] [Indexed: 08/18/2023]
Abstract
Nonischemic cardiomyopathy (NICM) is common and patients are at significant risk for early mortality secondary to ventricular arrhythmias. Current guidelines recommend implantable cardioverter-defibrillator (ICD) therapy to decrease sudden cardiac death (SCD) in patients with heart failure and reduced left ventricular ejection fraction. However, in randomized clinical trials comprised solely of patients with NICM, primary prevention ICDs did not confer significant mortality benefit. Moreover, left ventricular ejection fraction has limited sensitivity and specificity for predicting SCD. Therefore, precise risk stratification algorithms are needed to define those at the highest risk of SCD. This review examines mechanisms of sudden arrhythmic death in patients with NICM, discusses the role of ICD therapy and treatment of heart failure for prevention of SCD in patients with NICM, examines the role of cardiac magnetic resonance imaging and computational modeling for SCD risk stratification, and proposes new strategies to guide future clinical trials on SCD risk assessment in patients with NICM.
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Affiliation(s)
- Jonathan Chrispin
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | | | - Neal K Lakdawala
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine C Wu
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gordon F Tomaselli
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Rachita Navara
- Division of Cardiac Electrophysiology, University of California, San Fransisco, California, USA
| | - Estelle Torbey
- Division of Electrophysiology, Brown University, Providence, Rhode Island, USA
| | - Amrut V Ambardekar
- Department of Medicine, Division of Cardiology, University of Colorado, Aurora, Colorado, USA
| | - Rajesh Kabra
- Kansas City Heart Rhythm Institute, Overland Park, Kansas, USA
| | - Eloisa Arbustini
- Center for Inherited Cardiovascular Diseases, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
| | - Jagat Narula
- McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Maya Guglin
- Advanced Heart Failure and Transplant, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Christine M Albert
- Cardiac Electrohysiology, Cedars Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Sumeet S Chugh
- Cardiac Electrohysiology, Cedars Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jim W Cheung
- Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
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Duca ȘT, Roca M, Costache AD, Chetran A, Afrăsânie I, Miftode RȘ, Tudorancea I, Matei I, Ciorap RG, Mitu O, Bădescu MC, Iliescu-Halitchi D, Halițchi-Iliescu CO, Mitu F, Lionte C, Costache II. T-Wave Analysis on the 24 h Holter ECG Monitoring as a Predictive Assessment of Major Adverse Cardiovascular Events in Patients with Myocardial Infarction: A Literature Review and Future Perspectives. Life (Basel) 2023; 13:life13051155. [PMID: 37240799 DOI: 10.3390/life13051155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/01/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
Myocardial ischemia is a pathophysiological state characterized by inadequate perfusion of the myocardium, resulting in an imbalance between myocardial oxygen demand and supply. It is most commonly caused by coronary artery disease, in which atherosclerotic plaques lead to luminal narrowing and reduced blood flow to the heart. Myocardial ischemia can manifest as angina pectoris or silent myocardial ischemia and can progress to myocardial infarction or heart failure if left untreated. Diagnosis of myocardial ischemia typically involves a combination of clinical evaluation, electrocardiography and imaging studies. Electrocardiographic parameters, as assessed by 24 h Holter ECG monitoring, can predict the occurrence of major adverse cardiovascular events in patients with myocardial ischemia, independent of other risk factors. The T-waves in patients with myocardial ischemia have prognostic value for predicting major adverse cardiovascular events, and their electrophysiological heterogeneity can be visualized using various techniques. Combining the electrocardiographic findings with the assessment of myocardial substrate may offer a better picture of the factors that can contribute to cardiovascular death.
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Affiliation(s)
- Ștefania-Teodora Duca
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
| | - Mihai Roca
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiovascular Rehabilitation, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Alexandru-Dan Costache
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiovascular Rehabilitation, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Adriana Chetran
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
| | - Irina Afrăsânie
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
| | - Radu-Ștefan Miftode
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
| | - Ionuț Tudorancea
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
- Department of Morpho-Functional Science II-Physiology, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
| | - Iulian Matei
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
| | - Radu-George Ciorap
- Department of Biomedical Science, Faculty of Medical Bioengineering, University of Medicine and Pharmacy "Grigore T. Popa", 700145 Iasi, Romania
| | - Ovidiu Mitu
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
| | - Minerva Codruța Bădescu
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of III Internal Medicine Clinic, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
| | - Dan Iliescu-Halitchi
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiology, Arcadia Hospital, 700620 Iasi, Romania
| | - Codruța-Olimpiada Halițchi-Iliescu
- Department of Mother and Child Medicine-Pediatrics, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Pedriatics, Arcadia Hospital, 700620 Iasi, Romania
| | - Florin Mitu
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiovascular Rehabilitation, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Cătălina Lionte
- Department of Internal Medicine III, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700145 Iasi, Romania
- Department of Cardiology, Helicomed Hospital, 700115 Iasi, Romania
| | - Irina-Iuliana Costache
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
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Hammersley DJ, Halliday BP. Sudden Cardiac Death Prediction in Non-ischemic Dilated Cardiomyopathy: a Multiparametric and Dynamic Approach. Curr Cardiol Rep 2020; 22:85. [PMID: 32648053 PMCID: PMC7347683 DOI: 10.1007/s11886-020-01343-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Sudden cardiac death is recognised as a devastating consequence of non-ischaemic dilated cardiomyopathy. Although implantable cardiac defibrillators offer protection against some forms of sudden death, the identification of patients in this population most likely to benefit from this therapy remains challenging and controversial. In this review, we evaluate current guidelines and explore established and novel predictors of sudden cardiac death in patients with non-ischaemic dilated cardiomyopathy. RECENT FINDINGS Current international guidelines for primary prevention implantable defibrillator therapy do not result in improved longevity for many patients with non-ischemic cardiomyopathy and severe left ventricular dysfunction. More precise methods for identifying higher-risk patients that derive true prognostic benefit from this therapy are required. Dynamic and multi-parametric characterization of myocardial, electrical, serological and genetic substrate offers novel strategies for predicting major arrhythmic risk. Balancing the risk of non-sudden death offers an opportunity to personalize therapy and avoid unnecessary device implantation for those less likely to derive benefit.
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Affiliation(s)
- Daniel J. Hammersley
- Cardiovascular Research Centre, Royal Brompton Hospital, Sydney Street, London, SW3 6NP UK
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Brian P. Halliday
- Cardiovascular Research Centre, Royal Brompton Hospital, Sydney Street, London, SW3 6NP UK
- National Heart & Lung Institute, Imperial College London, London, UK
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4
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Kadakia RS, Link MS, Dominic P, Morin DP. Sudden cardiac death in nonischemic cardiomyopathy. Prog Cardiovasc Dis 2019; 62:235-241. [PMID: 31075279 DOI: 10.1016/j.pcad.2019.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 05/04/2019] [Indexed: 12/27/2022]
Abstract
Sudden cardiac death (SCD) is a major cause of mortality in patients with nonischemic cardiomyopathy (NICM). Identifying patients who are at highest risk for SCD is an ongoing challenge. At present, guidelines recommend the use of an implantable cardioverter-defibrillator (ICD) in patients with NICM with a reduced left ventricular ejection fraction (LVEF) and heart failure (HF) symptoms. Some recent data, however, suggest that ICDs may not increase longevity in this population. Conversely, community-based studies have demonstrated that many at-risk individuals who may benefit from ICD therapy remain unprotected. Current recommendations for ICD implantation are continually debated, justifying comprehensive individualized risk assessment. Various promising techniques for further risk stratification are under evaluation, including cardiac magnetic resonance imaging, electrocardiographic assessment of electrical instability, and genetic testing. However, none of these strategies has been fully adapted into guidelines. Hence, clinical risk stratification practice today depends on LVEF and HF symptoms, which have poor sensitivity and specificity for predicting SCD risk.
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Affiliation(s)
- Rikin S Kadakia
- Ochsner Medical Center, New Orleans, LA, United States of America
| | - Mark S Link
- University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Paari Dominic
- Ochsner Louisiana State University Shreveport, Shreveport, LA, United States of America
| | - Daniel P Morin
- Ochsner Medical Center, New Orleans, LA, United States of America; University of Queensland Ochsner Clinical School, New Orleans, LA, United States of America.
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5
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Risk Stratification of Sudden Cardiac Death in Patients with Heart Failure: An update. J Clin Med 2018; 7:jcm7110436. [PMID: 30423853 PMCID: PMC6262425 DOI: 10.3390/jcm7110436] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 10/29/2018] [Accepted: 11/06/2018] [Indexed: 12/15/2022] Open
Abstract
Heart failure (HF) is a complex clinical syndrome in which structural/functional myocardial abnormalities result in symptoms and signs of hypoperfusion and/or pulmonary or systemic congestion at rest or during exercise. More than 80% of deaths in patients with HF recognize a cardiovascular cause, with most being either sudden cardiac death (SCD) or death caused by progressive pump failure. Risk stratification of SCD in patients with HF and preserved (HFpEF) or reduced ejection fraction (HFrEF) represents a clinical challenge. This review will give an update of current strategies for SCD risk stratification in both HFrEF and HFpEF.
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6
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Almeida BCS, Carmo AALD, Barbosa MPT, Silva JLPD, Ribeiro ALP. Association between Microvolt T-Wave Alternans and Malignant Ventricular Arrhythmias in Chagas Disease. Arq Bras Cardiol 2018; 110:412-417. [PMID: 29641645 PMCID: PMC5967132 DOI: 10.5935/abc.20180056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 10/18/2017] [Indexed: 01/06/2023] Open
Abstract
Background Sudden cardiac death is the most frequent death mechanism in Chagas disease,
responsible for 55% to 65% of the deaths of patients with chronic Chagas
cardiomyopathy (CCC). The most often involved electrophysiological
mechanisms are ventricular tachycardia and ventricular fibrillation. The
implantable cardioverter defibrillator (ICD) has a beneficial role in
preventing sudden death due to malignant ventricular arrhythmias, and, thus
the correct identification of patients at risk is required. The association
of microvolt T-wave alternans (MTWA) with the appearance of ventricular
arrhythmias has been assessed in different heart diseases. The role of MTWA
is mostly unknown in patients with CCC. Objectives To evaluate the association between MTWA and the occurrence of malignant
ventricular arrhythmias in patients with CCC. Method This is a case-control study including patients with CCC and ICD, with
history of malignant ventricular arrhythmias (case group), and patients with
CCC and no history of those arrhythmias (control group). The MTWA test
results were classified as negative and non-negative (positive and
indeterminate). The significance level adopted was a = 0.05. Results We recruited 96 patients, 45 cases (46.8%) and 51 controls (53.1%). The MTWA
test was non-negative in 36/45 cases (80%) and 15/51 controls (29.4%)
[OR = 9.60 (95%CI: 3.41 - 27.93)]. After adjustment for known
confounding factors in a logistic regression model, the non-negative result
continued to be associated with malignant ventricular arrhythmias [OR
= 5.17 (95%CI: 1.05 - 25.51)]. Conclusion Patients with CCC and history of malignant ventricular arrhythmias more often
have a non-negative MTWA test as compared to patients with no history of
arrhythmia.
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Affiliation(s)
| | - André Assis Lopes do Carmo
- Hospital das Clínicas e Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG - Brasil
| | - Marco Paulo Tomaz Barbosa
- Hospital das Clínicas e Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG - Brasil
| | | | - Antonio Luiz Pinho Ribeiro
- Hospital das Clínicas e Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG - Brasil
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7
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Santangeli P, Epstein AE. Sudden Cardiac Death: Lessons Learned from Cardiac Implantable Rhythm Devices. Card Electrophysiol Clin 2017; 9:749-759. [PMID: 29173415 DOI: 10.1016/j.ccep.2017.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Trials have demonstrated that implantable-cardioverter defibrillators (ICDs) are effective in preventing sudden cardiac death (SCD). The degree of left ventricular dysfunction is the only parameter to identify primary prevention populations at higher risk of SCD in which ICDs may reduce longitudinal mortality risk. Clinical application of current stratification approaches based on left ventricular ejection fraction (LVEF) alone has failed to prevent most SCD in the general population. This lack of specificity has resulted in a significant number of potentially unnecessary ICDs. Future studies should focus on newer risk markers to improve the predictive value of LVEF and SCD prevention.
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Affiliation(s)
- Pasquale Santangeli
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Andrew E Epstein
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Halliday BP, Cleland JGF, Goldberger JJ, Prasad SK. Personalizing Risk Stratification for Sudden Death in Dilated Cardiomyopathy: The Past, Present, and Future. Circulation 2017; 136:215-231. [PMID: 28696268 PMCID: PMC5516909 DOI: 10.1161/circulationaha.116.027134] [Citation(s) in RCA: 150] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Results from the DANISH Study (Danish Study to Assess the Efficacy of ICDs in Patients With Non-Ischemic Systolic Heat Failure on Mortality) suggest that for many patients with dilated cardiomyopathy (DCM), implantable cardioverter-defibrillators do not increase longevity. Accurate identification of patients who are more likely to die of an arrhythmia and less likely to die of other causes is required to ensure improvement in outcomes and wise use of resources. Until now, left ventricular ejection fraction has been used as a key criterion for selecting patients with DCM for an implantable cardioverter-defibrillator for primary prevention purposes. However, registry data suggest that many patients with DCM and an out-of-hospital cardiac arrest do not have a markedly reduced left ventricular ejection fraction. In addition, many patients with reduced left ventricular ejection fraction die of nonsudden causes of death. Methods to predict a higher or lower risk of sudden death include the detection of myocardial fibrosis (a substrate for ventricular arrhythmia), microvolt T-wave alternans (a marker of electrophysiological vulnerability), and genetic testing. Midwall fibrosis is identified by late gadolinium enhancement cardiovascular magnetic resonance imaging in ≈30% of patients and provides incremental value in addition to left ventricular ejection fraction for the prediction of sudden cardiac death events. Microvolt T-wave alternans represents another promising predictor, supported by large meta-analyses that have highlighted the negative predictive value of this test. However, neither of these strategies have been routinely adopted for risk stratification in clinical practice. More convincing data from randomized trials are required to inform the management of patients with these features. Understanding of the genetics of DCM and how specific mutations affect arrhythmic risk is also rapidly increasing. The finding of a mutation in lamin A/C, the cause of ≈6% of idiopathic DCM, commonly underpins more aggressive management because of the malignant nature of the associated phenotype. With the expansion of genetic sequencing, the identification of further high-risk mutations appears likely, leading to better-informed clinical decision making and providing insight into disease mechanisms. Over the next 5 to 10 years, we expect these techniques to be integrated into the existing algorithm to form a more sensitive, specific, and cost-effective approach to the selection of patients with DCM for implantable cardioverter-defibrillator implantation.
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Affiliation(s)
- Brian P Halliday
- From CMR Unit and Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (B.P.H., S.K.P.), National Heart and Lung Institute Imperial College, London, United Kingdom (B.P.H., S.K.P., J.G.F.C.); Robertson Centre for Biostatistics, University of Glasgow, United Kingdom (J.G.F.C.); and Leonard M. Miller School of Medicine, University of Miami, FL (J.J.G.)
| | - John G F Cleland
- From CMR Unit and Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (B.P.H., S.K.P.), National Heart and Lung Institute Imperial College, London, United Kingdom (B.P.H., S.K.P., J.G.F.C.); Robertson Centre for Biostatistics, University of Glasgow, United Kingdom (J.G.F.C.); and Leonard M. Miller School of Medicine, University of Miami, FL (J.J.G.)
| | - Jeffrey J Goldberger
- From CMR Unit and Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (B.P.H., S.K.P.), National Heart and Lung Institute Imperial College, London, United Kingdom (B.P.H., S.K.P., J.G.F.C.); Robertson Centre for Biostatistics, University of Glasgow, United Kingdom (J.G.F.C.); and Leonard M. Miller School of Medicine, University of Miami, FL (J.J.G.)
| | - Sanjay K Prasad
- From CMR Unit and Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom (B.P.H., S.K.P.), National Heart and Lung Institute Imperial College, London, United Kingdom (B.P.H., S.K.P., J.G.F.C.); Robertson Centre for Biostatistics, University of Glasgow, United Kingdom (J.G.F.C.); and Leonard M. Miller School of Medicine, University of Miami, FL (J.J.G.).
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9
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Daniłowicz-Szymanowicz L, Szwoch M, Dąbrowska-Kugacka A, Dudziak M, Kozłowski D, Raczak G. Usefulness of microvolt T-wave alternans testing in the assessment of all-cause mortality and life-threatening ventricular arrhythmia risk in patients with left ventricular dysfunction. Arch Med Sci 2015; 11:945-51. [PMID: 26528334 PMCID: PMC4624729 DOI: 10.5114/aoms.2013.37936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 07/15/2013] [Accepted: 09/23/2013] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Patients with left ventricular ejection fraction (LVEF) ≤ 35% are eligible for implantable cardioverter-defibrillator (ICD) placement in the primary prevention of sudden cardiac death. Nevertheless, other risk factors facilitating the selection of individuals with highest mortality are still sought. The aim of the study was to verify the usefulness of microvolt T-wave alternans (MTWA) testing in the assessment of all-cause mortality and life-threatening ventricular arrhythmias (EVENTs) in these patients. Previous data from the literature are inconclusive. MATERIAL AND METHODS Patients with LVEF ≤ 35% were eligible if they did not have a history of sustained ventricular arrhythmias, and were treated with β-blockers. Participants underwent MTWA testing and were subsequently followed. RESULTS The group consisted of 139 patients. MTWA results were classified as non-negative (MTWA_non-neg) in 93 and negative (MTWA_neg) in 46 patients. During the 14.3 ±8.6 months of follow-up, EVENTs were observed in 21 patients. The 1-year EVENT rate was 16.4% among MTWA_non-neg patients, and 2.6% among MTWA_neg patients (p = 0.006). The sensitivity of the MTWA test was 95.24%, the specificity - 38.14%, the positive predictive value - 21.51% and the negative predictive value - 97.83%. CONCLUSIONS In the group of patients with left ventricular systolic dysfunction, with the exclusion of patients with the history of life-threatening ventricular arrhythmia and individuals not being on chronic β-adrenolytic therapy, the abnormal result of MTWA testing is associated with significantly increased risk of all-cause mortality and life-threatening ventricular arrhythmia during 1 year of follow-up, thus identifying the individuals at the highest risk.
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Affiliation(s)
| | - Małgorzata Szwoch
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Gdansk, Poland
| | | | - Maria Dudziak
- Department of Noninvasive Cardiac Diagnostics, Medical University of Gdansk, Gdansk, Poland
| | - Dariusz Kozłowski
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Gdansk, Poland
| | - Grzegorz Raczak
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Gdansk, Poland
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10
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Borgquist R, Singh JP. An Electrophysiologist Perspective on Risk Stratification in Heart Failure: Can Better Understanding of the Condition of the Cardiac Sympathetic Nervous System Help? J Nucl Med 2015; 56 Suppl 4:59S-64S. [DOI: 10.2967/jnumed.114.148452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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11
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Klingenheben T. [Microvolt T-wave alternans. Ischemic vs. nonischemic dilated cardiomyopathy]. Herzschrittmacherther Elektrophysiol 2015; 26:22-26. [PMID: 25693483 DOI: 10.1007/s00399-015-0353-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 01/26/2015] [Indexed: 06/04/2023]
Abstract
The use of implantable cardioverter defibrillators (ICD) for primary preventive therapy of sudden arrhythmogenic death has become a mainstay in selected patients with systolic congestive heart failure, particularly in the setting of ischemic and nonischemic cardiomyopathy (Moss et al., N Engl J Med 346:877–883, 2002; Bardy et al., N Engl J Med 352:225–237, 2005). However, more accurate identification of high-risk patients is desirable in order to avoid unnecessary ICD implants. Since currently available risk stratification methods have limited predictive accuracy, development of new techniques is important in order to noninvasively assess arrhythmogenic risk in patients prone to sudden death.Microvolt level T-wave alternans (mTWA) has recently been proposed to assess abnormalities in ventricular repolarization favoring the occurrence of reentrant arrhythmias (Adam et al., J Electrocardiol 17:209–218, 1984; Pastore et al., Circulation 99:1385–1394, 1999). In 1994, a preliminary clinical study by Rosenbaum et al. convincingly demonstrated that mTWA is closely related to arrhythmia induction in the electrophysiology laboratory as well as to the occurrence of spontaneous ventricular tachyarrhythmias during follow-up (Rosenbaum et al., N Engl J Med 330:235–241,1994). More recently, a number of clinical studies have examined its clinical applicability in ischemic and nonischemic cardiomyopathy.
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Affiliation(s)
- Thomas Klingenheben
- Praxis für Kardiologie & Ambulante Herzkatheterkooperation Bonn, Im Mühlenbach 2 B, 53127, Bonn, Deutschland,
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12
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Pimentel M, Zimerman LI, Rohde LE. Stratification of the risk of sudden death in nonischemic heart failure. Arq Bras Cardiol 2014; 103:348-57. [PMID: 25352509 PMCID: PMC4206366 DOI: 10.5935/abc.20140125] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 04/03/2014] [Indexed: 12/20/2022] Open
Abstract
Despite significant therapeutic advancements, heart failure remains a highly
prevalent clinical condition associated with significant morbidity and mortality. In
30%-40% patients, the etiology of heart failure is nonischemic. The implantable
cardioverter-defibrillator (ICD) is capable of preventing sudden death and decreasing
total mortality in patients with nonischemic heart failure. However, a significant
number of patients receiving ICD do not receive any kind of therapy during follow-up.
Moreover, considering the situation in Brazil and several other countries, ICD cannot
be implanted in all patients with nonischemic heart failure. Therefore, there is an
urgent need to identify patients at an increased risk of sudden death because these
would benefit more than patients at a lower risk, despite the presence of heart
failure in both risk groups. In this study, the authors review the primary available
methods for the stratification of the risk of sudden death in patients with
nonischemic heart failure.
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Affiliation(s)
- Maurício Pimentel
- Curso de Pós-graduação em Ciências Cardiovasculares, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Leandro Ioschpe Zimerman
- Curso de Pós-graduação em Ciências Cardiovasculares, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Luis Eduardo Rohde
- Curso de Pós-graduação em Ciências Cardiovasculares, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Disertori M, Quintarelli S, Mazzola S, Favalli V, Narula N, Arbustini E. The need to modify patient selection to improve the benefits of implantable cardioverter-defibrillator for primary prevention of sudden death in non-ischaemic dilated cardiomyopathy. Europace 2013; 15:1693-701. [PMID: 23946316 DOI: 10.1093/europace/eut228] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Left ventricular ejection fraction (LVEF) ≤35% is a major determinant for implantable cardioverter-defibrillator (ICD) therapy for primary prevention of sudden death (SD) in patients with non-ischaemic dilated cardiomyopathy (DCM). However, as a risk marker for SD, low LVEF has limited sensibility and specificity. Selecting patients according to the current guidelines shows that most DCM patients do not actually benefit from ICD implantation and may suffer collateral effects and that many patients who are at risk of SD are not identified because a large proportion of SD patients exhibit only mildly depressed LVEF. Identifying patients who are at risk of SD on the sole basis of LVEF appears to be an over-simplification which does not maximize the benefit of ICD therapy. Owing to the complexity of the substrates underlying SD, multiple risk factors used in combination could probably predict the risk of SD better than any individual risk marker. Among non-invasive tests, microvolt T-wave alternans and cardiac magnetic resonance with late gadolinium enhancement may contribute to a better SD risk stratification by their high negative predictive value. Genetics may further contribute because approximately one-third of DCM patients have evidence of familial disease, and mutations in some known disease genes, including LMNA, have been associated with a high risk of SD. In this review, we critically analyse the current indications for ICD implantation and we explore existing knowledge about potentially predicting markers for selecting DCM patients who are at high and low risk of SD.
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Affiliation(s)
- Marcello Disertori
- Healthcare Research and Innovation Program, IRCS-FBK, 38123, Trento, Italy
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Shuster JJ, Guo JD, Skyler JS. Meta-analysis of safety for low event-rate binomial trials. Res Synth Methods 2012; 3:30-50. [PMID: 24339834 PMCID: PMC3856441 DOI: 10.1002/jrsm.1039] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 03/20/2012] [Accepted: 03/21/2012] [Indexed: 01/06/2023]
Abstract
This article focuses on meta-analysis of low event-rate binomial trials. We introduce two forms of random effects: (1) 'studies at random' (SR), where we assume no more than independence between studies; and (2) 'effects at random' (ER), which forces the effect size distribution to be independent of the study design. On the basis of the summary estimates of proportions, we present both unweighted and study-size weighted methods, which, under SR, target different population parameters. We demonstrate mechanistically that the popular DerSimonian-Laird (DL) method, as DL actually warned in their paper, should never be used in this setting. We conducted a survey of the major cardiovascular literature on low event-rate studies and found that DL using odds ratios or relative risks to be the clear method of choice. We looked at two high profile examples from diabetes and cancer, respectively, where the choice of weighted versus unweighted methods makes a large difference. A large simulation study supports the accuracy of the coverage of our approximate confidence intervals. We recommend that before looking at their data, users should prespecify which target parameter they intend to estimate (weighted vs. unweighted) but estimate the other as a secondary analysis. Copyright © 2012 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jonathan J Shuster
- Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, FL, 32610, U.S.A..
| | - Jennifer D Guo
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, 32610, U.S.A
| | - Jay S Skyler
- Diabetes Research Institute and Division of Endocrinology Diabetes and Metabolism, University of Miami Miller School of Medicine, Miami, FL, 33136, U.S.A
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Calò L, De Santo T, Nuccio F, Sciarra L, De Luca L, Stefano LMDS, Piroli E, Zuccaro L, Rebecchi M, de Ruvo E, Lioy E. Predictive value of microvolt T-wave alternans for cardiac death or ventricular tachyarrhythmic events in ischemic and nonischemic cardiomyopathy patients: a meta-analysis. Ann Noninvasive Electrocardiol 2012; 16:388-402. [PMID: 22008495 DOI: 10.1111/j.1542-474x.2011.00467.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Microvolt T-wave alternans (MTWA) has been proposed as a predictor of the risk of ventricular tachyarrhythmias (VT) and sudden cardiac death (SCD). Aim of this study was to perform a systematic review of the literature and a meta-analysis of MTWA in primary prevention patients with ischemic and nonischemic cardiomyopathy. METHODS The positive predictive value (PPV), negative predictive value (NPV), and relative risk (RR) of MTWA in predicting death, cardiac death, and SCD during follow-up were reported. RESULTS Fifteen studies involving 5681 patients (mean age 62 years, mean ejection fraction 32%) were included. The summary PPV during the average 26-month follow-up was 14% (95% CI: 13-15); NPV was 95% (95% CI: 94-96), and the univariate RR was 2.35 (95% CI: 1.68-3.28). The predictive value of MTWA was similar in patients with ischemic and nonischemic cardiomyopathy. The average RR for SCD or VT events of an abnormal MTWA was 2.40, similar to that for cardiac death. When we grouped the studies together depending upon whether beta-blockers were withheld prior to MTWA screening, the beta-blockers group showed an RR of 5.88. By contrast, the group in which beta-blocker therapy was withheld had an RR of 1.63. CONCLUSION A positive MTWA determined an approximately 2.5-fold higher risk of cardiac death and life-threatening arrhythmia and showed a very high NPV both in ischemic and nonischemic patients. An abnormal MTWA test was associated with a 5-fold increased risk for cardiac mortality in the low-indeterminate group and about a 6-fold increased risk in beta-blockers group.
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Affiliation(s)
- Leonardo Calò
- Division of Cardiology, Policlinico Casilino, ASL Roma B, Via Buonarroti 16, Marino, Rome, Italy.
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Morita H. How can we stabilize QT variability? Heart Rhythm 2011; 8:1243-4. [DOI: 10.1016/j.hrthm.2011.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Indexed: 10/18/2022]
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Zhang X, Ma LL, Yao DK, Wang LX. Prediction values of T wave alternans for sudden cardiac death in patients with chronic heart failure: a brief review. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2011; 17:152-156. [PMID: 21609390 DOI: 10.1111/j.1751-7133.2011.00223.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
More than 50% of patients with heart failure die from sudden cardiac death as a result of malignant arrhythmia. T wave alternans (TWA) is a convenient, noninvasive, and inexpensive testing modality, with a higher sensitivity and specificity for sudden cardiac death. Its prediction value for malignant arrhythmia may even exceed electrophysiologic study. Generally, the algorithms of TWA can be divided into frequency-domain and time-domain methods, and the latter has a stronger anti-interference ability. So far, a unified measuring formula and diagnostic criteria about TWA measurements have been created. Large clinical studies in recent years strongly suggest that TWA can predict sudden cardiac death, which can be used as a guide for the implanting of implantable cardioverter-defibrillator. This article reviews the current literature on recording techniques and clinical implications of TWA.
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Affiliation(s)
- Xian Zhang
- Department of Cardiology, Liaocheng People's Hospital and Liaocheng Clinical School of Taishan Medical University, Liaocheng City, Shandong Province, China
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Santangeli P, Dello Russo A, Casella M, Pelargonio G, Di Biase L, Natale A. Left ventricular ejection fraction for the risk stratification of sudden cardiac death: friend or foe? Intern Med J 2011; 41:55-60. [DOI: 10.1111/j.1445-5994.2010.02371.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Verrier RL, Kumar K, Nearing BD. Basis for sudden cardiac death prediction by T-wave alternans from an integrative physiology perspective. Heart Rhythm 2009; 6:416-22. [PMID: 19251221 PMCID: PMC2672309 DOI: 10.1016/j.hrthm.2008.11.019] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Accepted: 11/18/2008] [Indexed: 10/21/2022]
Abstract
Detection of microvolt levels of T-wave alternans (TWA) has been shown to be useful in identifying individuals at heightened risk for sudden cardiac death. The mechanistic bases for TWA are complex, at the cellular level involving multiple mechanisms, particularly instabilities in membrane voltage (i.e., steep action potential duration restitution slope) and disruptions in intracellular calcium cycling dynamics. The integrative factors influencing TWA at the systemic level are also multifold. We focus on three main variables: heart rate, autonomic nervous system activity, and myocardial ischemia. Clinically, there is growing interest in extending TWA testing to include ambulatory ECG monitoring as well as exercise. The former modality permits assessment of the influence of diverse provocative stimuli of daily life, including physical activity, circadian factors, mental stress, and sleep-state related disturbances in respiratory and cardiovascular function. Two major emerging concepts in clinical TWA testing are discussed: quantitative analysis of TWA level to complement the current binary classification scheme, and risk stratification of patients with preserved left ventricular function, the population with the largest absolute number of sudden cardiac deaths.
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Affiliation(s)
- Richard L Verrier
- Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Cardiovascular Institute, Boston, Massachusetts 02115, USA.
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