A combined anatomic and electrophysiologic substrate based approach for sudden cardiac death risk stratification

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• 作者：Faisal M. Merchant ; Hui Zheng ; Thomas Bigger ; Richard Steinman ; Takanori Ikeda ; Roberto F.E. Pedretti ; Jorge A. Salerno-Uriarte ; Catherine Klersy ; Paul S. Chan ; Cheryl Bartone ; Stefan H. Hohnloser ; Jeremy N. Ruskin ; Antonis A. Armoundas
• 刊名：American Heart Journal
• 出版年：2013
• 出版时间：October, 2013
• 年：2013
• 卷：166
• 期：4
• 页码：744-752
• 全文大小：350 K

文摘

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Background

Although left ventricular ejection fraction (LVEF) is the primary determinant for sudden cardiac death (SCD) risk stratification, in isolation, LVEF is a sub-optimal risk stratifier. We assessed whether a multi-marker strategy would provide more robust SCD risk stratification than LVEF alone.

Methods

We collected patient-level data (n = 3355) from 6 studies assessing the prognostic utility of microvolt T-wave alternans (MTWA) testing. Two thirds of the group was used for derivation (n = 2242) and one-third for validation (n = 1113). The discriminative capacity of the multivariable model was assessed using the area under the receiver-operating characteristic curve (c-index). The primary endpoint was SCD at 24 months.

Results

In the derivation cohort, 59 patients experienced SCD by 24 months. Stepwise selection suggested that a model based on 3 parameters (LVEF, coronary artery disease and MTWA status) provided optimal SCD risk prediction. In the derivation cohort, the c-index of the model was 0.817, which was significantly better than LVEF used as a single variable (0.637, P < .001). In the validation cohort, 36 patients experienced SCD by 24 months. The c-index of the model for predicting the primary endpoint was again significantly better than LVEF alone (0.774 vs 0.671, P = .020).

Conclusions

A multivariable model based on presence of coronary artery disease, LVEF and MTWA status provides significantly more robust SCD risk prediction than LVEF as a single risk marker. These findings suggest that multi-marker strategies based on different aspects of the electro-anatomic substrate may be capable of improving primary prevention implantable cardioverter-defibrillator treatment algorithms.