Risk stratification for sudden cardiac death in nonischemic dilated cardiomyopathy: a moving target?
Laura Bradel1,2, Katherine Kovrizhkin3, Harout Yacoub1,2
1Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, United States.
Frontiers in Cardiovascular Medicine
|June 5, 2026
Summary
Risk stratification for sudden cardiac death (SCD) in non-ischemic dilated cardiomyopathy (NICM) is challenging. Current markers, including left ventricular ejection fraction (LVEF), are insufficient; novel imaging and integrated approaches are needed for better prediction.
Area of Science:
- Cardiology
- Medical Imaging
- Electrophysiology
Background:
- Risk stratification for sudden cardiac death (SCD) in non-ischemic dilated cardiomyopathy (NICM) with left ventricular ejection fraction (LVEF) ≤35% remains controversial.
- Low LVEF alone is insufficient for distinguishing arrhythmic from nonarrhythmic mortality, necessitating investigation into electrical instability markers.
Purpose of the Study:
- To review current and emerging strategies for SCD risk stratification in NICM.
- To evaluate the role of Cardiac Magnetic Resonance (CMR) imaging with late gadolinium enhancement (LGE) and integrated multimodal approaches.
Main Methods:
- Review of prior studies evaluating noninvasive and invasive markers for SCD prediction.
- Assessment of Cardiac Magnetic Resonance (CMR) imaging, specifically late gadolinium enhancement (LGE), for myocardial fibrosis characterization.
- Evaluation of emerging tiered approaches combining clinical, imaging, and electrophysiologic data.
Main Results:
- No single noninvasive or invasive marker has consistently improved SCD prediction beyond LVEF.
- CMR-LGE shows association with SCD and arrhythmic events, but methodological heterogeneity limits current guideline inclusion.
- Emerging multimodal frameworks show promise but lack guideline-level validation.
Conclusions:
- Current markers, including LVEF and traditional electrophysiologic tests, are inadequate for precise SCD risk stratification in NICM.
- Standardization of CMR quantification and prospective validation of multimodal risk models are crucial for future advancements.
- Accurate SCD risk stratification in NICM requires further research into standardized imaging, serial biomarkers, and integrated predictive models.
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