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ICD indication in hypertrophic cardiomyopathy: which algorithm to use?

Marcelo Antônio Oliveira Santos-Veloso1,2, Ândrea Virgínia Ferreira Chaves1,2,3, Eveline Barros Calado4

  • 1Universidade Federal de Pernambuco, Programa de Pós-Graduação em Inovação Terapêutica - Recife (PE), Brazil.

Revista Da Associacao Medica Brasileira (1992)
|September 22, 2022
PubMed

Insights

Discrepancies exist in implantable cardioverter-defibrillator (ICD) indications for hypertrophic cardiomyopathy patients between European and American guidelines. Fragmented QRS did not predict outcomes, and current risk stratification algorithms show low accuracy.

Area of Science:

  • Cardiology
  • Electrophysiology
  • Genetics

Background:

  • Hypertrophic cardiomyopathy (HCM) is a primary genetic heart disease.
  • Implantable cardioverter-defibrillators (ICDs) are used for sudden cardiac death (SCD) prevention in HCM.
  • Current guidelines from the European Society of Cardiology (ESC) and American Heart Association (AHA) provide differing recommendations for ICD implantation.

Purpose of the Study:

  • To evaluate the agreement in ICD indications for HCM patients based on 2014 ESC and 2020 AHA guidelines.
  • To assess fragmented QRS (fQRS) as a predictor of cardiovascular outcomes in HCM.
  • To analyze the accuracy of SCD risk stratification algorithms in guiding ICD therapy.

Main Methods:

  • Retrospective cohort study of 81 HCM patients (≥16 years) from 2019-2021.
  • Kappa coefficient used to assess agreement between ESC and AHA guidelines for ICD indication.
  • Kaplan-Meier method for survival and incidence curves; fQRS presence analyzed.
  • Exclusion criteria: secondary myocardiopathy, follow-up <1 year.

Main Results:

  • fQRS identified in 44.4% of patients; no association with clinical parameters, echocardiography, fibrosis, or SCD risk.
  • During 4.8±3.4 years follow-up, no SCD occurred, but 20.6% of ICD recipients received appropriate shocks.
  • Shocks occurred in ESC low- to moderate-risk (3), moderate-risk (3), and AHA high-risk (4) patients.
  • Overall guideline agreement was 64% (kappa=0.270, p=0.007); C-statistic showed no difference in appropriate shock incidence (p=0.644).

Conclusions:

  • Sudden cardiac death risk stratification algorithms exhibit discrepancies in ICD indications for HCM.
  • Current risk stratification algorithms demonstrate low accuracy in predicting appropriate ICD shocks.
  • Fragmented QRS is not a reliable predictor of adverse cardiovascular outcomes in this HCM cohort.
Abstract

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