Arrhythmic risk stratification in heart failure mid-range ejection fraction patients with a non-invasive guiding to programmed ventricular stimulation two-step approach

Petros Arsenos; Konstantinos A Gatzoulis; Ioannis Doundoulakis; Polychronis Dilaveris; Christos-Konstantinos Antoniou; Soulaidopoulos Stergios; Skevos Sideris; Sotiropoulos Ilias; Dimitrios Tousoulis

doi:10.1002/joa3.12416

Arrhythmic risk stratification in heart failure mid-range ejection fraction patients with a non-invasive guiding to programmed ventricular stimulation two-step approach

J Arrhythm. 2020 Aug 2;36(5):890-898. doi: 10.1002/joa3.12416. eCollection 2020 Oct.

Authors

Petros Arsenos^{1

2}, Konstantinos A Gatzoulis¹, Ioannis Doundoulakis¹, Polychronis Dilaveris¹, Christos-Konstantinos Antoniou¹, Soulaidopoulos Stergios¹, Skevos Sideris³, Sotiropoulos Ilias³, Dimitrios Tousoulis¹

Affiliations

¹ First Department of Cardiology and Electrophysiology Laboratory Hippokration General Hospital National and Kapodistrian University of Athens School of Medicine Athens Greece.
² Arsenos Heart and Biosignals Lab Avlonas Greece.
³ State Department of Cardiology Hippokration General Hospital Athens Greece.

Abstract

Background: Although some post myocardial infarction (post-MI) and dilated cardiomyopathy (DCM) patients with mid-range ejection fraction heart failure (HFmrEF/40%-49%) face an increased risk for arrhythmic sudden cardiac death (SCD), current guidelines do not recommend an implantable cardiac defibrilator (ICD). We risk stratified hospitalized HFmrEF patients for SCD with a combined non-invasive risk factors (NIRFs) guiding to programmed ventricular stimulation (PVS) two-step approach.

Methods: Forty-eight patients (male = 83%, age = 64 ± 14 years, LVEF = 45 ± 5%, CAD = 69%, DCM = 31%) underwent a NIRFs screening first-step with electrocardiogram (ECG), SAECG, Echocardiography and 24-hour ambulatory ECG (AECG). Thirty-two patients with presence of one of three NIRFs (SAECG ≥ 2 positive criteria for late potentials, ventricular premature beats ≥ 240/24 hours, and non-sustained ventricular tachycardia [VT] episode ≥ 1/24 hours) were further investigated with PVS. Patients were classified as either low risk (Group 1, n = 16, NIRFs-), moderate risk (Group 2, n = 18, NIRFs+/PVS-), and high risk (Group 3, n = 14, NIRFs+/PVS+). All in Group 3 received an ICD.

Results: After 41 ± 18 months, 9 of 48 patients, experienced the major arrhythmic event (MAE) endpoint (clinical VT/fibrillation = 3, appropriate ICD activation = 6). The endpoint occurred more frequently in Group 3 (7/14, 50%) than in Groups 1 and 2 (2/34, 5.8%). Logistic regression model adjusted for PVS, age, and LVEF revealed that PVS was an independent MAE predictor (OR: 21.152, 95% CI: 2.618-170.887, P = .004). Kaplan-Meier curves diverged significantly (log rank, P < .001) while PVS negative predictive value was 94%.

Conclusions: In hospitalized HFmrEF post-MI and DCM patients, a NIRFs guiding to PVS two-step approach efficiently detected the subgroup at increased risk for MAE.

Keywords: arrhythmic sudden cardiac death; mid‐range ejection fraction heart failure; non‐invasive risk factors; programmed ventricular stimulation; two‐step risk stratification approach.