Prognostic Role of Ventricular Ectopic Beats in Systemic Sclerosis: A Prospective Cohort Study Shows ECG Indexes Predicting the Worse Outcome
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Giacomo De Luca1, Silvia Laura Bosello1, Francesca Augusta Gabrielli2
1Institute of Rheumatology and Affine Sciences - Department of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy.
Insights
Frequent ventricular ectopic beats (VEBs) detected by 24-hour ECG-Holter monitoring can identify Systemic Sclerosis patients at high risk for sudden cardiac death. This aids in selecting patients who may benefit from implantable cardioverter-defibrillator (ICD) implantation.
Area of Science:
- Cardiology
- Rheumatology
- Medical Diagnostics
Background:
- Arrhythmias are a significant cause of mortality in Systemic Sclerosis (SSc), contributing to 6% of deaths.
- Sudden cardiac death (SCD) is a major concern in SSc patients, highlighting the need for improved risk stratification.
- Identifying prognostic electrocardiogram (ECG) indexes is crucial for preventing adverse cardiac events in SSc.
Purpose of the Study:
- To evaluate the role of 24-hour ECG-Holter in risk-stratifying SSc patients for life-threatening arrhythmias and SCD.
- To define specific ECG criteria indicative of poor prognosis in SSc.
- To determine the utility of Holter monitoring as an adjunct to existing risk assessment tools.
Main Methods:
- A prospective cohort study involving 100 SSc patients with cardiac symptoms or signs.
- 24-hour ECG-Holter monitoring was performed on all participants.
- The primary endpoint was a composite of SCD or the need for implantable cardioverter-defibrillator (ICD) implantation.
Main Results:
- 56% of patients showed 24-hour ECG-Holter abnormalities, with 24% exhibiting frequent ventricular ectopic beats (VEBs).
- VEBs correlated with elevated high-sensitive cardiac troponin T (hs-cTnT) and reduced left-ventricular ejection fraction (LV-EF).
- VEBs exceeding 1190/24h demonstrated 100% sensitivity and 83% specificity for predicting the primary endpoint (AUROC = 0.92).
Conclusions:
- Frequent VEBs (>1190/24h) on Holter monitoring identify SSc patients at high risk for life-threatening arrhythmias.
- 24-hour ECG-Holter is a valuable tool for risk-stratifying SSc patients for SCD.
- ICD implantation may be a life-saving intervention for high-risk SSc patients identified by Holter monitoring.
Background:
Arrhythmias are frequent in Systemic Sclerosis (SSc) and portend a bad prognosis, accounting alone for 6% of total deaths. Many of these patients die suddenly, thus prevention and intensified risk-stratification represent unmet medical needs. The major goal of this study was the definition of ECG indexes of poor prognosis.
Methods:
We performed a prospective cohort study to define the role of 24h-ECG-Holter as an additional risk-stratification technique in the identification of SSc-patients at high risk of life-threatening arrhythmias and sudden cardiac death (SCD). One-hundred SSc-patients with symptoms and/or signs suggestive of cardiac involvement underwent 24h-ECG-Holter. The primary end-point was a composite of SCD or need for implantable cardioverter defibrillator (ICD).
Results:
Fifty-six patients (56%) had 24h-ECG-Holter abnormalities and 24(24%) presented frequent ventricular ectopic beats (VEBs). The number of VEBs correlated with high-sensitive cardiac troponin T (hs-cTnT) levels and inversely correlated with left-ventricular ejection fraction (LV-EF) on echocardiography. During a mean follow-up of 23.1±16.0 months, 5 patients died suddenly and two required ICD-implantation. The 7 patients who met the composite end-point had a higher number of VEBs, higher levels of hs-cTnT and NT-proBNP and lower LV-EF (p = 0.001 for all correlations). All these 7 patients had frequent VEBs, while LV-EF was not reduced in all and its range was wide. At ROC curve, VEBs>1190/24h showed 100% of sensitivity and 83% of specificity to predict the primary end-point (AUROC = 0.92,p<0.0001). Patients with VEBS>1190/24h had lower LV-EF and higher hs-cTnT levels and, at multivariate analysis, the presence of increased hs-cTnT and of right bundle branch block on ECG emerged as independent predictors of VEBs>1190/24h. None of demographic or disease-related characteristics emerged as predictors of poor outcome.
Conclusions:
VEBS>1190/24h identify patients at high risk of life-threatening arrhythmic complications. Thus, 24h-ECG-Holter should be considered a useful additional risk-stratification test to select SSc-patients at high-risk of SCD, in whom an ICD-implantation could represent a potential life-saving intervention.
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