Sudden Cardiac Death Risk Stratification in Patients With Nonischemic Dilated Cardiomyopathy

• Published in: Journal of the American College of Cardiology Vol. 63; no. 18; pp. 1879 - 1889
• Main Authors: Goldberger, Jeffrey J., MD, MBA, Subačius, Haris, MA, Patel, Taral, MD, Cunnane, Ryan, MD, Kadish, Alan H., MD
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 13-05-2014; Elsevier; Elsevier Limited
• Subjects: Adult; Aged; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; arrhythmia; Biological and medical sciences; Cardiac arrhythmia; Cardiology; Cardiology. Vascular system; cardiomyopathy; Cardiomyopathy, Dilated - diagnosis; Cardiomyopathy, Dilated - mortality; Cardiovascular; Cohort Studies; Death, Sudden, Cardiac - epidemiology; Death, Sudden, Cardiac - prevention & control; Electrocardiography; Emergency and intensive care: neonates and children. Prematurity. Sudden death; Female; Follow-Up Studies; Heart; Heart attacks; Humans; Intensive care medicine; Internal Medicine; Male; Medical sciences; Middle Aged; Mortality; Myocarditis. Cardiomyopathies; Risk Factors; sudden death; BRS; electrophysiology study; LVEF; EPS; T-wave alternans; HRT; sudden cardiac death; HRV; left ventricular end-diastolic dimension; left ventricular ejection fraction; sudden death; heart rate variability; cardiomyopathy; signal-averaged electrocardiogram; implantable cardioverter-defibrillator; TWA; baroreflex sensitivity; ventricular fibrillation; CI; NSVT; nonischemic dilated cardiomyopathy; ICD; SAECG; LVEDD; VF; nonsustained ventricular tachycardia; ventricular tachycardia; SCD; arrhythmia; heart rate turbulence; confidence interval; NIDCM; VT; Human; Sudden death; Patient; Cardiovascular disease; Risk; Myocardial disease; Congestive hypertrophic cardiomyopathy; Dilated cardiomyopathy; Heart disease; Risk factor; Circulatory system; Cardiology; Stratification
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2013.12.021

Objectives The purpose of this study was to provide a meta-analysis to estimate the performance of 12 commonly reported risk stratification tests as predictors of arrhythmic events in patients with nonischemic dilated cardiomyopathy. Background Multiple techniques have been assessed as predictors of death due to ventricular tachyarrhythmias/sudden death in patients with nonischemic dilated cardiomyopathy. Methods Forty-five studies enrolling 6,088 patients evaluating the association between arrhythmic events and predictive tests (baroreflex sensitivity, heart rate turbulence, heart rate variability, left ventricular end-diastolic dimension, left ventricular ejection fraction, electrophysiology study, nonsustained ventricular tachycardia, left bundle branch block, signal-averaged electrocardiogram, fragmented QRS, QRS-T angle, and T-wave alternans) were included. Raw event rates were extracted, and meta-analysis was performed using mixed effects methodology. We also used the trim-and-fill method to estimate the influence of missing studies on the results. Results Patients were 52.8 ± 14.5 years of age, and 77% were male. Left ventricular ejection fraction was 30.6 ± 11.4%. Test sensitivities ranged from 28.8% to 91.0%, specificities from 36.2% to 87.1%, and odds ratios from 1.5 to 6.7. Odds ratio was highest for fragmented QRS and TWA (odds ratios: 6.73 and 4.66, 95% confidence intervals: 3.85 to 11.76 and 2.55 to 8.53, respectively) and lowest for QRS duration (odds ratio: 1.51, 95% confidence interval: 1.13 to 2.01). None of the autonomic tests (heart rate variability, heart rate turbulence, baroreflex sensitivity) were significant predictors of arrhythmic outcomes. Accounting for publication bias reduced the odds ratios for the various predictors but did not eliminate the predictive association. Conclusions Techniques incorporating functional parameters, depolarization abnormalities, repolarization abnormalities, and arrhythmic markers provide only modest risk stratification for sudden cardiac death in patients with nonischemic dilated cardiomyopathy. It is likely that combinations of tests will be required to optimize risk stratification in this population.