Assessment of Myocardial Scarring Improves Risk Stratification in Patients Evaluated for Cardiac Defibrillator Implantation

Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, NC 27710, USA.
Journal of the American College of Cardiology (Impact Factor: 15.34). 07/2012; 60(5):408-20. DOI: 10.1016/j.jacc.2012.02.070
Source: PubMed

ABSTRACT We tested whether an assessment of myocardial scarring by cardiac magnetic resonance imaging (MRI) would improve risk stratification in patients evaluated for implantable cardioverter-defibrillator (ICD) implantation.
Current sudden cardiac death risk stratification emphasizes left ventricular ejection fraction (LVEF); however, most patients suffering sudden cardiac death have a preserved LVEF, and many with poor LVEF do not benefit from ICD prophylaxis.
One hundred thirty-seven patients undergoing evaluation for possible ICD placement were prospectively enrolled and underwent cardiac MRI assessment of LVEF and scar. The pre-specified primary endpoint was death or appropriate ICD discharge for sustained ventricular tachyarrhythmia.
During a median follow-up of 24 months the primary endpoint occurred in 39 patients. Whereas the rate of adverse events steadily increased with decreasing LVEF, a sharp step-up was observed for scar size >5% of left ventricular mass (hazard ratio [HR]: 5.2; 95% confidence interval [CI]: 2.0 to 13.3). On multivariable Cox proportional hazards analysis, including LVEF and electrophysiological-study results, scar size (as a continuous variable or dichotomized at 5%) was an independent predictor of adverse outcome. Among patients with LVEF >30%, those with significant scarring (>5%) had higher risk than those with minimal or no (≤5%) scarring (HR: 6.3; 95% CI: 1.4 to 28.0). Those with LVEF >30% and significant scarring had risk similar to patients with LVEF ≤30% (p = 0.56). Among patients with LVEF ≤30%, those with significant scarring again had higher risk than those with minimal or no scarring (HR: 3.9; 95% CI: 1.2 to 13.1). Those with LVEF ≤30% and minimal scarring had risk similar to patients with LVEF >30% (p = 0.71).
Myocardial scarring detected by cardiac MRI is an independent predictor of adverse outcome in patients being considered for ICD placement. In patients with LVEF >30%, significant scarring (>5% LV) identifies a high-risk cohort similar in risk to those with LVEF ≤30%. Conversely, in patients with LVEF ≤30%, minimal or no scarring identifies a low-risk cohort similar to those with LVEF >30%.

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Available from: Michele Parker, Dec 29, 2014
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Questions & Answers about this publication

  • Nathan Mewton asked a question in Cardiac MRI:
    When are we going to use cardiac delayed enhancement in the risk stratification of ICD implantation candidates?
    LVEF is almost the only parameter used to decide upon ICD implantation in patients for primary prevention, all this based upon MADIT and MADIT-affiliated trials. This strategy has led us to over-implant ICD devices in patients with significant consequences on health economics and patient morbidity.
    Delayed enhancement, one of the most robust parameters brought to the table by MRI, has now heavy evidence backing up its predictive value on cardiac mortality and ventricular arrhythmias in various types of cardiomyopathies.
    We need to re-do the MADIT trials implementing delayed enhancement in the therapeutic management decision.