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Abstract
BackgroundNoninvasive risk stratification aims to detect abnormalities in the pathophysiological mechanisms underlying ventricular arrhythmias. We studied the predictive value of repeating risk stratification in patients with an implantable cardioverter‐defibrillator (ICD).MethodsThe EUTrigTreat clinical study was a prospective multicenter trial including ischemic and nonischemic cardiomyopathies and arrhythmogenic heart disease. Left ventricular ejection fraction ≤40% (LVEF), premature ventricular complexes >400/24 hr (PVC), non‐negative microvolt T‐wave alternans (MTWA), and abnormal heart rate turbulence (HRT) were considered high risk. Tests were repeated within 12 months after inclusion. Adjusted Cox regression analysis was performed for mortality and appropriate ICD shocks.ResultsIn total, 635 patients had analyzable baseline data with a median follow‐up of 4.4 years. Worsening of LVEF was associated with increased mortality (HR 3.59, 95% CI 1.17–11.04), as was consistent abnormal HRT (HR 8.34, 95%CI 1.06–65.54). HRT improvement was associated with improved survival when compared to consistent abnormal HRT (HR 0.10, 95%CI 0.01–0.82). For appropriate ICD shocks, a non‐negative MTWA test or high PVC count at any moment was associated with increased arrhythmic risk independent of the evolution of test results (worsening: HR 3.76 (95%CI 1.43–9.88) and HR 2.50 (95%CI 1.15–5.46); improvement: HR 2.80 (95%CI 1.03–7.61) and HR 2.45 (95%CI 1.07–5.62); consistent: HR 2.47 (95%CI 0.95–6.45) and HR 2.40 (95%CI 1.33–4.33), respectively). LVEF improvement was associated with a lower arrhythmic risk (HR 0.34, 95%CI 0.12–0.94).ConclusionsRepeating LVEF and HRT improved the prediction of mortality, whereas stratification of ventricular arrhythmias may be improved by repeating LVEF measurements, MTWA and ECG Holter monitoring.
Highlights
Implantable cardioverter-defibrillators (ICDs) have been shown to improve survival in patients at risk of sudden cardiac death (Bardy et al, 2005; Moss et al, 2002)
There is an ongoing search for noninvasive risk stratification to guide the decision for ICD implantation, such as heart rate turbulence (HRT), microvolt T-wave alternans (MTWA), and quantification of fibrosis on cardiac MRI (Bauer et al, 2008; Costantini et al, 2009; Huikuri et al, 2001)
Worsening of Left ventricular ejection fraction ≤40% (LVEF) was associated with increased mortality and higher rate of appropriate ICD shocks, whereas LVEF improvement was associated with decreased mortality but the risk of appropriate ICD shocks remained present
Summary
Implantable cardioverter-defibrillators (ICDs) have been shown to improve survival in patients at risk of sudden cardiac death (Bardy et al, 2005; Moss et al, 2002). Baseline assessment included clinical characteristics, medical history, co-morbidities, and drug treatment; laboratory samples, including renal function, high-sensitive C-reactive protein (hsCRP), and N-terminal pro-B-type natriuretic protein (NT-proBNP); echocardiography for LVEF; EP study and noninvasive ECG-based risk stratification with microvolt T-wave alternans testing and 24-hr ECG Holter monitoring. It was recommended, but not mandatory, to repeat the noninvasive risk stratification between 6 months and 1 year after inclusion. If the patient was unable to exercise, heart rate could be increased gradually by a stepwise atrial pacing protocol in case of a dual-chamber ICD or cardiac resynchronization therapy (Seegers et al, 2012). For further analysis of MTWA results, positive and indeterminate results were grouped as non-negative
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