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Curso de Atualização em Medicina Cardiovascular 2019
Reunião Anual Conjunta dos Grupos de Estudo de Cirurgia Cardíaca, Doenças Valvulares e Ecocardiografia da SPC
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07. Syncope and Bradycardia
08. Ventricular Arrhythmias and Sudden Cardiac Death (SCD)
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31. Pharmacology and Pharmacotherapy
32. Cardiovascular Nursing
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Delayed enhancement outperforms current criteria for ICD implantation in Hypertrophic Cardiomyopathy
Session:
CO - Prémio Jovem Investigador (Investigação Clínica)
Speaker:
Pedro Freitas
Congress:
CPC 2019
Topic:
C. Arrhythmias and Device Therapy
Theme:
08. Ventricular Arrhythmias and Sudden Cardiac Death (SCD)
Subtheme:
08.2 Ventricular Arrhythmias and SCD - Epidemiology, Prognosis, Outcome
Session Type:
Comunicações Orais
FP Number:
---
Authors:
Pedro Freitas; António Miguel Ferreira; Edmundo Arteaga-Fernández; Daniel Nascimento Matos; João Abecasis; Carla Rodrigues Carvalho; Hugo Marques; Nuno Cardim; Murillo de Oliveira Antunes; Carlos Eduardo Rochitte
Abstract
<p><strong>Background: </strong>Identifying the patients with Hypertrophic Cardiomyopathy (HCM) in whom the risk of sudden cardiac death (SCD) justifies the implantation of a cardioverter-defibrillator (ICD) in primary prevention remains challenging. Different risk stratification tools and criteria are applied by the European and American guidelines in this setting. We sought to assess the role of late-gadolinium enhancement (LGE) in improving these risk stratification strategies.</p> <p><strong>Methods: </strong>We conducted an international multicentric retrospective analysis of HCM patients undergoing cardiac magnetic resonance for diagnostic confirmation and/or risk stratification. Eligibility for ICD was assessed according to the HCM Risk-SCD score and the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) algorithm. The amount of LGE was quantified (LGE%) and categorized into: ≤ 10%; 10.1-19.9%; ≥ 20% of total myocardial mass. The primary endpoint was a composite of SCD, aborted SCD, sustained ventricular tachycardia (VT), or appropriate ICD discharge.</p> <p><strong>Results: </strong>A total of 493 patients were available for analysis (58% male, median age 46 years). LGE was present in 82% of patients, with a median LGE% of 2.9% (IQR 0.4-8.4%). The concordance between risk assessment by the HCM Risk-SCD, ACCF/AHA and LGE was relatively poor (weighted Κ values 0.17 to 0.51).</p> <p>During a median follow-up of 3.4 years (IQR 1.5-6.8 years), 25 patients experienced an event (14 SCDs, 2 aborted SCDs, 6 sustained VTs, and 3 appropriate ICD discharges). The amount of LGE was the only independent predictor of outcome (adjusted HR: 1.09 for each 1% of LGE; 95% CI: 1.06-1.13; <em>p</em> < 0.001) even after adjustment for the HCM Risk-SCD and ACCF/AHA criteria. The amount of LGE showed greater discriminative power (C-statistic 0.85; 95% CI: 0.78-0.92) than the ACCF/AHA (C-statistic 0.60; 95% CI: 0.49-0.71; <em>p</em> for comparison < 0.001) and the HCM Risk-SCD (C-statistic 0.69; 95% CI: 0.60-0.78; <em>p </em>for comparison = 0.006). LGE was able to significantly improve the discriminative power of the ACCF/AHA and HCM Risk-SCD criteria, with net reclassification improvements of 0.39 and 0.44, respectively. Kaplan-Meier survival curves support these findings (Figure).</p> <p><strong>Conclusions: </strong>The amount of myocardial late gadolinium enhancement seems to outperform the guideline-recommended HCM Risk-SCD score and ACCF/AHA algorithm in the identification of HCM patients at increased risk of sudden cardiac death.</p>
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