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. 2017 May 30;135(22):2106-2115.
doi: 10.1161/CIRCULATIONAHA.116.026910. Epub 2017 Mar 28.

Association Between Midwall Late Gadolinium Enhancement and Sudden Cardiac Death in Patients With Dilated Cardiomyopathy and Mild and Moderate Left Ventricular Systolic Dysfunction

Brian P Halliday  1 , Ankur Gulati  1 , Aamir Ali  1 , Kaushik Guha  1 , Simon Newsome  1 , Monika Arzanauskaite  1 , Vassilios S Vassiliou  1 , Amrit Lota  1 , Cemil Izgi  1 , Upasana Tayal  1 , Zohya Khalique  1 , Colin Stirrat  1 , Dominique Auger  1 , Nilesh Pareek  1 , Tevfik F Ismail  1 , Stuart D Rosen  1 , Ali Vazir  1 , Francisco Alpendurada  1 , John Gregson  1 , Michael P Frenneaux  1 , Martin R Cowie  1 , John G F Cleland  1 , Stuart A Cook  1 , Dudley J Pennell  2 , Sanjay K Prasad  1
Affiliations

Association Between Midwall Late Gadolinium Enhancement and Sudden Cardiac Death in Patients With Dilated Cardiomyopathy and Mild and Moderate Left Ventricular Systolic Dysfunction

Brian P Halliday et al. Circulation. .

Abstract

Background: Current guidelines only recommend the use of an implantable cardioverter defibrillator in patients with dilated cardiomyopathy for the primary prevention of sudden cardiac death (SCD) in those with a left ventricular ejection fraction (LVEF) <35%. However, registries of out-of-hospital cardiac arrests demonstrate that 70% to 80% of such patients have an LVEF >35%. Patients with an LVEF >35% also have low competing risks of death from nonsudden causes. Therefore, those at high risk of SCD may gain longevity from successful implantable cardioverter defibrillator therapy. We investigated whether late gadolinium enhancement (LGE) cardiovascular magnetic resonance identified patients with dilated cardiomyopathy without severe LV systolic dysfunction at high risk of SCD.

Methods: We prospectively investigated the association between midwall LGE and the prespecified primary composite outcome of SCD or aborted SCD among consecutive referrals with dilated cardiomyopathy and an LVEF ≥40% to our center between January 2000 and December 2011 who did not have a preexisting indication for implantable cardioverter defibrillator implantation.

Results: Of 399 patients (145 women, median age 50 years, median LVEF 50%, 25.3% with LGE) followed for a median of 4.6 years, 18 of 101 (17.8%) patients with LGE reached the prespecified end point, compared with 7 of 298 (2.3%) without (hazard ratio [HR], 9.2; 95% confidence interval [CI], 3.9-21.8; P<0.0001). Nine patients (8.9%) with LGE compared with 6 (2.0%) without (HR, 4.9; 95% CI, 1.8-13.5; P=0.002) died suddenly, whereas 10 patients (9.9%) with LGE compared with 1 patient (0.3%) without (HR, 34.8; 95% CI, 4.6-266.6; P<0.001) had aborted SCD. After adjustment, LGE predicted the composite end point (HR, 9.3; 95% CI, 3.9-22.3; P<0.0001), SCD (HR, 4.8; 95% CI, 1.7-13.8; P=0.003), and aborted SCD (HR, 35.9; 95% CI, 4.8-271.4; P<0.001). Estimated HRs for the primary end point for patients with an LGE extent of 0% to 2.5%, 2.5% to 5%, and >5% compared with those without LGE were 10.6 (95% CI, 3.9-29.4), 4.9 (95% CI, 1.3-18.9), and 11.8 (95% CI, 4.3-32.3), respectively.

Conclusions: Midwall LGE identifies a group of patients with dilated cardiomyopathy and an LVEF ≥40% at increased risk of SCD and low risk of nonsudden death who may benefit from implantable cardioverter defibrillator implantation.

Clinical trial registration: URL: http://clinicaltrials.gov. Unique identifier: NCT00930735.

Keywords: cardiovascular MRI; dilated cardiomyopathy; implantable cardioverter-defibrillator; late gadolinium enhancement; sudden cardiac death.

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Figures

Figure 1.
Figure 1.
Identification of the study population. Flow chart detailing the identification, inclusion, and exclusion of patients. CAD indicates coronary artery disease; CMR, cardiovascular magnetic resonance; LGE, late gadolinium enhancement; LVEDV, left ventricular end-diastolic volume; and LVEF, left ventricular ejection fraction.
Figure 2.
Figure 2.
Primary end point survival analysis. Kaplan-Meier curve of the time to first event for the primary end point by presence (red line) or absence (blue line) of midwall late gadolinium enhancement (LGE).
Figure 3.
Figure 3.
Five-year risk estimates of the primary end point. Five-year risk estimates for primary end point based on LVEF alone (green line) and midwall LGE status in addition to LVEF (red line, presence of LGE; blue line, absence of LGE). LGE indicates late gadolinium enhancement; and LVEF, left ventricular ejection fraction.
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References

    1. Russo AM, Stainback RF, Bailey SR, Epstein AE, Heidenreich PA, Jessup M, Kapa S, Kremers MS, Lindsay BD, Stevenson LW. ACCF/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR 2013 appropriate use criteria for implantable cardioverter-defibrillators and cardiac resynchronization therapy. J Am Coll Cardiol. 2013;61:1318–1368. - PubMed
    1. Priori SG, Blomstrom-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, Elliott PM, Fitzsimons D, Hatala R, Hindricks G, Kirchhof P, Kjeldsen K, Kuck KH, Hernandez-Madrid A, Nikolaou N, Norekval TM, Spaulding C, Van Veldhuisen DJ. 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J. 2015;36:2793–2867. - PubMed
    1. Gorgels AP, Gijsbers C, de Vreede-Swagemakers J, Lousberg A, Wellens HJ. Out-of-hospital cardiac arrest–the relevance of heart failure: the Maastricht Circulatory Arrest Registry. Eur Heart J. 2003;24:1204–1209. - PubMed
    1. Stecker EC, Vickers C, Waltz J, Socoteanu C, John BT, Mariani R, McAnulty JH, Gunson K, Jui J, Chugh SS. Population-based analysis of sudden cardiac death with and without left ventricular systolic dysfunction: two-year findings from the Oregon Sudden Unexpected Death Study. J Am Coll Cardiol. 2006;47:1161–1166. doi: 10.1016/j.jacc.2005.11.045. - PubMed
    1. Goldberger JJ, Cain ME, Hohnloser SH, Kadish AH, Knight BP, Lauer MS, Maron BJ, Page RL, Passman RS, Siscovick D, Stevenson WG, Zipes DP. American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society scientific statement on noninvasive risk stratification techniques for identifying patients at risk for sudden cardiac death. Heart Rhythm. 2008;5:e1–e21. - PubMed

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