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Improved Risk Stratification for Ventricular Arrhythmias and Sudden Death in Patients With Nonischemic Dilated
Andrea Di Marco1, Pamela Frances Brown2, Joshua Bradley2
1Department of Cardiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain; Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom.
Insights
Late gadolinium enhancement (LGE) on cardiac MRI strongly predicts ventricular arrhythmias (VA) and sudden death in dilated cardiomyopathy (DCM). A new algorithm combining LGE and left ventricular ejection fraction (LVEF) improves risk stratification for these events.
Area of Science:
- Cardiology
- Medical Imaging
- Electrophysiology
Background:
- Risk stratification for ventricular arrhythmias (VA) and sudden death in nonischemic dilated cardiomyopathy (DCM) is currently suboptimal.
- Improved methods are needed to identify patients at high risk for life-threatening arrhythmias.
Purpose of the Study:
- To develop an improved risk stratification algorithm for VA and sudden death in patients with DCM.
- To evaluate the predictive value of late gadolinium enhancement (LGE) and left ventricular ejection fraction (LVEF) for arrhythmic events.
Main Methods:
- Retrospective cohort study of 1,165 patients with DCM who underwent cardiac magnetic resonance with LGE.
- Combined arrhythmic endpoint included appropriate implantable cardioverter-defibrillator therapies, sustained ventricular tachycardia, resuscitated cardiac arrest, and sudden death.
- Development of a risk stratification algorithm integrating LGE and LVEF strata.
Main Results:
- LGE was a strong independent predictor of the arrhythmic endpoint (HR: 9.7, p < 0.001), consistent across LVEF strata.
- Specific LGE patterns (epicardial, transmural, septal/free-wall) were associated with heightened risk.
- The LGE-LVEF algorithm significantly outperformed LVEF alone in risk reclassification (34% of patients) and prediction (AUC 0.82 vs. 0.7).
Conclusions:
- LGE is a significant and consistent predictor of VA or sudden death in DCM.
- A novel algorithm combining LGE and LVEF improves risk stratification for VA and sudden death.
- This algorithm has important implications for guiding implantable cardioverter-defibrillator allocation in DCM patients.
Background:
Risk stratification for ventricular arrhythmias (VA) and sudden death in nonischemic dilated cardiomyopathy (DCM) remains suboptimal.
Objectives:
The goal of this study was to provide an improved risk stratification algorithm for VA and sudden death in DCM.
Methods:
This was a retrospective cohort study of consecutive patients with DCM who underwent cardiac magnetic resonance with late gadolinium enhancement (LGE) at 2 tertiary referral centers. The combined arrhythmic endpoint included appropriate implantable cardioverter-defibrillator therapies, sustained ventricular tachycardia, resuscitated cardiac arrest, and sudden death.
Results:
In 1,165 patients with a median follow-up of 36 months, LGE was an independent and strong predictor of the arrhythmic endpoint (hazard ratio: 9.7; p < 0.001). This association was consistent across all strata of left ventricular ejection fraction (LVEF). Epicardial LGE, transmural LGE, and combined septal and free-wall LGE were all associated with heightened risk. A simple algorithm combining LGE and 3 LVEF strata (i.e., ≤20%, 21% to 35%, >35%) was significantly superior to LVEF with the 35% cutoff (Harrell's C statistic: 0.8 vs. 0.69; area under the curve: 0.82 vs. 0.7; p < 0.001) and reclassified the arrhythmic risk of 34% of patients with DCM. LGE-negative patients with LVEF 21% to 35% had low risk (annual event rate 0.7%), whereas those with high-risk LGE distributions and LVEF >35% had significantly higher risk (annual event rate 3%; p = 0.007).
Conclusions:
In a large cohort of patients with DCM, LGE was found to be a significant, consistent, and strong predictor of VA or sudden death. Specific high-risk LGE distributions were identified. A new clinical algorithm integrating LGE and LVEF significantly improved the risk stratification for VA and sudden death, with relevant implications for implantable cardioverter-defibrillator allocation.
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