Improved risk-stratification for ventricular arrhythmias and sudden death in non-ischemic dilated cardiomyopathy

Andrea Di Marco, Pamela Frances Brown, J Bradley, Gaetano Nucifora, Edward Claver, Fernando de Frutos, Paolo Domenico Dallaglio, Josep Comin-Colet, Ignasi Anguera, Christopher Miller, Matthias Schmitt

Research output: Contribution to journalArticlepeer-review

Abstract

Background Risk-stratification for ventricular arrhythmias (VA) and sudden death (SD) in non-ischemic dilated cardiomyopathy (DCM) remains sub-optimal. Objectives To provide an improved risk-stratification algorithm for VA and SD in DCM. Methods Retrospective cohort study of consecutive patients with DCM who underwent cardiac magnetic resonance with late gadolinium enhancement (LGE) at two tertiary referral centers. The combined arrhythmic endpoint included appropriate implantable defibrillator (ICD) therapies, sustained ventricular tachycardia, resuscitated cardiac arrest and SD. Results In 1165 patients with median follow-up of 36 months, LGE was an independent and strong predictor of the arrhythmic endpoint (HR 9.9, p<0.001). This association was consistent across all strata of left ventricular ejection fraction (LVEF). Epicardial LGE, transmural LGE and combined septal and free-wall LGE were all associated with heightened risk. A simple algorithm combining LGE and three LVEF strata (≤20%, 21%-35%, >35%) was significantly superior to LVEF with the 35% cut-off (Harrell’s C 0.8 vs 0.69, AUC 0.82 vs 0.7, p<0.001) and reclassified the arrhythmic risk of 34% of DCM patients: LGE- patients with LVEF 21%-35% had low risk (annual event rate 0.7%) while those with high-risk LGE distributions and LVEF>35% had significantly higher risk (annual event rate 3%, p=0.007). Conclusions In a large cohort of patients with DCM, LGE was found to be a significant, consistent and strong predictor of VA or SD. Specific high-risk LGE distributions were identified. A new clinical algorithm integrating LGE and LVEF significantly improved the risk-stratification for VA and SD, with relevant implications for ICD allocation.
Original languageEnglish
JournalJournal of the American College of Cardiology
Publication statusAccepted/In press - 6 Apr 2021

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