Risk stratification for sudden cardiac death in North America - current perspectives
Alfred E Buxton1, Jonathan W Waks1, Changyu Shen2
1Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
Insights
Sudden cardiac death (SCD) is a major concern. Implantable cardioverter-defibrillators (ICDs) help some patients, but better risk stratification is needed to identify those most likely to benefit from ICDs.
Area of Science:
- Cardiology
- Electrophysiology
Background:
- Sudden cardiac death (SCD) causes 360,000 US deaths annually, representing half of all cardiovascular deaths.
- Implantable cardioverter-defibrillators (ICDs) reduce mortality in patients with low left ventricular ejection fraction (LVEF).
- However, LVEF alone is insufficient for risk stratification, as many SCDs occur in patients without severe LV dysfunction or derive no benefit from ICDs due to competing mortality.
Purpose of the Study:
- To review studies on ICD use in patients with mild LV systolic dysfunction (LVEF >35%).
- To evaluate current ICD risk stratification models.
- To propose a cohort study for prospective validation of an ICD risk stratification score.
Main Methods:
- Literature review of studies on ICDs in mild LV systolic dysfunction.
- Analysis of existing ICD risk stratification models.
- Design of a prospective cohort study protocol.
Main Results:
- Current risk stratification models have limitations in identifying appropriate ICD candidates.
- Evidence suggests potential benefit of ICDs in specific subgroups with LVEF >35%.
Conclusions:
- Improved risk stratification tools are crucial for selecting patients who will benefit most from ICD implantation.
- Prospective validation of a novel ICD risk stratification score is warranted.
Abstract:
Sudden cardiac death (SCD) accounts for approximately 360,000 deaths annually in the United States, and is the cause of half of all cardiovascular deaths. In patients with severely depressed left ventricular ejection fraction (LVEF), implantable cardioverter-defibrillators (ICDs) have been shown to significantly reduce total mortality, but many factors beyond LVEF influence the relative benefit afforded by ICD implantation. In fact, among patients with prior myocardial infarction, approximately half of all SCDs occur in patients without severe LV dysfunction, and in analyses of large ICD trials, certain patient subgroups derive no benefit to ICD implantation despite having low LVEF, often due to competing non-arrhythmic mortality. Improved risk stratification tools to help select patients who are likely to derive the most benefit from ICD implantation are therefore needed. This manuscript will review studies evaluating use of ICDs in patients with mild LV systolic dysfunction and LVEF >35%, currently available ICD risk stratification models, and the rationale for designing a cohort study to prospectively validate use of an ICD risk stratification score.
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