[Limits and scopes of invasive risk stratification. Do we still need programmed ventricular stimulation?]
Sascha Rolf1, Wilhelm Haverkamp
1Medizinische Klinik mit Schwerpunkt Kardiologie, Charité - Campus Virchow-Klinikum, Berlin, Germany. sascha.rolf@charite.de
Insights
Patients with heart conditions face sudden cardiac death (SCD) risk. Programmed ventricular stimulation (PVS) helps assess this risk, but its accuracy varies across different cardiomyopathies, necessitating improved risk stratification methods.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Context:
- Patients with ischemic heart disease (ICM), dilated (DCM), hypertrophic (HCM), or arrhythmogenic right ventricular cardiomyopathy (ARVCM) have a high risk of sudden cardiac death (SCD).
- Internal cardioverter defibrillators (ICDs) treat ventricular tachyarrhythmias causing SCD, but many high-risk patients do not require them.
- Accurate risk stratification markers are needed to avoid unnecessary ICD implantation due to risks, inconvenience, and costs.
Purpose:
- To evaluate the prognostic ability of programmed ventricular stimulation (PVS) in stratifying SCD risk across various cardiomyopathies.
- To highlight the limitations of PVS, particularly its modest prognostic value and poor negative predictive value in certain patient groups.
- To explore future directions for improving SCD risk stratification, including combining PVS with noninvasive parameters and its role in guiding ablation therapy.
Summary:
- Programmed ventricular stimulation (PVS) is used to assess sudden cardiac death (SCD) risk in patients with ICM, DCM, HCM, and ARVCM.
- PVS shows some utility in ICM patients with reduced ejection fraction (30-40%), identifying those at higher SCD risk.
- The prognostic value of PVS is less clear in DCM, HCM, and ARVCM, as arrhythmia inducibility does not consistently correlate with risk, and noninducibility does not guarantee a good prognosis.
Impact:
- Current German guidelines provide class IIb recommendations for PVS in specific ICM, HCM, or ARVCM patients, acknowledging its uncertainties.
- Future research should focus on integrating PVS with noninvasive markers to enhance prognostic accuracy.
- Expanding PVS to guide ventricular arrhythmia ablation could potentially reduce SCD risk in affected patients.
Abstract:
Patients with ischemic heart disease and left ventricular systolic dysfunction (ICM), dilated (DCM), hypertrophic (HCM), or arrhythmogenic right ventricular cardiomyopathy (ARVCM) carry a high risk of sudden cardiac death (SCD). Ventricular tachyarrhythmias are most often the cause of SCD, which can be treated with internal cardioverter defibrillators (ICDs). However, a great proportion of these high-risk patients will never experience potentially lethal ventricular arrhythmias, and as such will never be in need of these devices. Given the risks, inconvenience, and costs of ICDs, markers that adequately stratify patients according to their risk of SCD are needed. Programmed ventricular stimulation (PVS) has long been used to identify the patients' risk of SCD. However, the prognostic ability of PVS is only modest and the negative predictive value is poor. As far as patients with ICM are concerned, recent data from the MUSTT and MADIT II trials demonstrate that in patients with a left ventricular ejection fraction between 30% and 40%, inducibility by PVS can help to identify patients who are at particularly increased risk of SCD. The value of PVS in patients with DCM, HCM, and ARVCM for risk stratification of SCD is less clear and the available data even more limited. In these patients, the inducibility of ventricular tachyarrhythmias does not clearly correlate with VT/VF (ventricular tachycardia/ventricular fibrillation) risk, and more importantly, noninducibility does not portend good prognosis. The current German guidelines appreciate these uncertainties of PVS for risk stratification with class IIb recommendations in certain patients with ICM, HCM or ARVCM. In the future, combining the results of invasive PVS with other noninvasive parameters may improve its prognostic value. Furthermore, expanding the role of PVS to guiding therapeutic ablation of ventricular arrhythmias may influence patient's future risk of SCD.
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