Myocardial scar characteristics based on cardiac magnetic resonance imaging is associated with ventricular tachyarrhythmia in patients with ischemic cardiomyopathy
Introduction
Sudden cardiac death (SCD) is a leading cause of death in Western society [1]. Patients with reduced left ventricular ejection fraction (LVEF) (< 35%) after myocardial infarction are known to be at increased risk of SCD. In multiple randomized, controlled trials, with inclusion mainly based on LVEF, the use of an Implantable Cardioverter Defibrillator (ICD) reduced mortality [2], [3], [4], [5]. Current guidelines therefore use LVEF as the primary indicator for prophylactic ICD implantation after myocardial infarction. However, only 35% of the patients with prophylactic ICD implantation receive appropriate ICD therapy. Therefore, the use of LVEF as an indicator for ICD implantation is far from ideal [2], [6], [7]. Furthermore, an increased risk of heart failure has been reported due to unnecessary ventricular pacing [6]. There is an obvious need for more effective risk stratification for primary prevention in patients with ischemic cardiomyopathy. Cardiac magnetic resonance imaging (CMR) with late gadolinium enhanced contrast (LGE) can be used to detect myocardial scar size and heterogeneity [8], [9], [10]. As myocardial scar is an important substrate for developing ventricular tachyarrhythmia (VT) in ischemic cardiomyopathy, CMR might be useful in the prediction of future VT [11], [12], [13], [14], [15], [16], [17]. Although scar characteristics assessed by CMR are promising with regard to prediction of VT in patients with ischemic cardiomyopathy, evidence is conflicting and published papers are hampered by varying methods, limited patient and outcome numbers. Therefore, we examined in this study the potential role of multiple myocardial scar characteristics measured by CMR in predicting sustained VT and/or appropriate ICD therapy in a relatively large unselected group of patients with ischemic cardiomyopathy with long follow-up.
Section snippets
Study population
This is a single centre prospective observational study to assess the additional value of CMR characteristics in determining which patients with decreased LVEF, due to coronary artery disease, are at risk for developing life threatening VT and therefore will have benefit from ICD implantation. Patients were recruited in a single, tertiary teaching hospital in the Netherlands (Isala Klinieken, Zwolle, The Netherlands). Inclusion period was from March 2004 until November 2010. The study
Results
Ninety-nine patients were included. CMR quality was rated as ‘excellent’ in 11 (11.1%) and ‘good’ in 83 (83.8%) and ‘poor’ in 5 patients (5.1%). Patients with poor CMR quality were excluded from the study. Fig. 2 shows the inclusion and follow-up scheme. Median follow-up was 5.4 years (IQR, 4.5–6.6 years). The primary endpoint (sustained VT, and/or appropriate ICD therapy) occurred in 34 of the 94 (36.2%) patients. The secondary endpoint (all-cause mortality) occurred in 26 of the 94 (27.7%)
Discussion
The key finding of this study is the significant association of the ratio of peri-infarction to core infarction based on CMR with incident VT and appropriate ICD therapy. Reduced LVEF and age are associated with all-cause mortality. This is, to our knowledge, the first study describing the potential predictive value of the ratio of peri-infarction to core infarction mass, in terms of future VT and appropriate ICD therapy. Our study consisted of 94 patients with a median follow-up of more than 5
Conclusion
This study shows that CMR based indices and scar heterogeneity, provides additional information regarding future VT risk and all-cause mortality, in patients with ischemic cardiomyopathy undergoing prophylactic ICD implantation. Age and reduced LVEF are associated with all-cause mortality, whereas a relatively large peri-infarction mass is associated with sustained VT and appropriate ICD therapy.
Online graph I. Cumulative incidence plots
Cumulative incidence plots of VT and/or appropriate shock (A) with death (B) as competing event demonstrates a higher risk of ventricular tachycardia and appropriate shock among patients with a higher peri-infarction to core-infarction ratio P = 0.03 between the first tertile (0.60) and third tertile (0.80) for the ratio peri-infarct mass/ infarct core mass.
The following are the Supplementary data related to this article.
Conflict of interest disclosures
The authors have no conflicts of interest.
Acknowledgements
The authors thank Vera Derks for her skillful assistance and Petra Koopmans for her assistance during statistics analysis.
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