Performance of 2020 AHA/ACC HCM Guidelines and Incremental Value of Myocardial Strain for Predicting SCD
Hyun-Jung Lee1, Hyung-Kwan Kim1, Sang Chol Lee2
1Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
Insights
The 2020 AHA/ACC guidelines for sudden cardiac death (SCD) risk in hypertrophic cardiomyopathy (HCM) showed modest predictive power in an Asian cohort. Incorporating myocardial strain measures like LV GLS and LARS can enhance SCD risk prediction in HCM patients.
Area of Science:
- Cardiology
- Cardiovascular Research
- Medical Guidelines
Background:
- The 2020 American Heart Association (AHA)/American College of Cardiology (ACC) guidelines require international validation for sudden cardiac death (SCD) risk stratification in hypertrophic cardiomyopathy (HCM).
- Assessing the performance of existing guidelines and the added value of myocardial strain imaging is crucial for improving SCD prediction in HCM.
Purpose of the Study:
- To investigate the performance of the 2020 AHA/ACC and 2014 European Society of Cardiology (ESC) guidelines for SCD risk stratification in a large HCM cohort.
- To evaluate the incremental predictive value of left ventricular global longitudinal strain (LV GLS) and left atrial reservoir strain (LARS) for SCD events.
Main Methods:
- Stratified SCD risk in 1,416 HCM patients using the 2020 AHA/ACC and 2014 ESC guidelines.
- Measured LV GLS and LARS in all patients and tracked SCD events over time.
- Analyzed the association of risk factors, myocardial strain parameters, and guideline performance with SCD outcomes.
Main Results:
- The 2020 AHA/ACC guidelines demonstrated modest predictive power for SCD events in this cohort.
- Decreased LV GLS (<13%) and LARS (<21%) were independently associated with increased SCD risk.
- Adding LV GLS and LARS to existing guidelines significantly improved the prediction of SCD events.
Conclusions:
- The 2020 AHA/ACC guidelines are moderately predictive of SCD in Asian HCM patients.
- Implantable cardioverter-defibrillators may be considered for patients with multiple risk factors.
- Myocardial strain parameters (LV GLS and LARS) offer incremental value for refining SCD risk prediction in HCM.
Background:
The 2020 American Heart Association (AHA)/American College of Cardiology (ACC) guidelines for sudden cardiac death (SCD) risk stratification in hypertrophic cardiomyopathy (HCM) need further international validation.
Objectives:
Performance of the guidelines and the incremental value of myocardial strain for predicting SCD in HCM were investigated.
Methods:
In 1,416 HCM patients, SCD risk was stratified according to the 2020 AHA/ACC and 2014 European Society of Cardiology (ESC) guidelines. Left ventricular (LV) global longitudinal strain (GLS) and left atrial reservoir strain (LARS) were measured. The main outcome consisted of SCD events.
Results:
Overall, 29.1% had major risk factors (RFs), and 14.7% had nonmajor RFs in the absence of major RFs; estimated 5-year SCD event rates were 6.8% and 2.3%, respectively. SCD risk was significantly increased in the former group but not in the latter. When stratified by the number of RFs, 5-year SCD event rates were 1.9%, 3.0%, 4.9%, and 18.4% for patients with 0, 1, 2, and 3 or more RFs, respectively. SCD risk was elevated in patients with multiple RFs but not in those with a single RF. Performance of the AHA/ACC and ESC guidelines did not differ significantly over 10 years (5-year time-dependent area under the curve: 0.677 vs 0.724; P = 0.235). Decreased LV GLS and LARS were independently associated with SCD events with optimal cutoffs of LV GLS <13% and LARS <21%. Adding LV GLS and LARS to the guidelines had incremental predictive value.
Conclusions:
The 2020 AHA/ACC guidelines were predictive of SCD events with modest power in a large Asian HCM cohort. Implantable cardioverter-defibrillators are reasonable in patients with multiple RFs, and consideration of myocardial strain can improve SCD prediction.
