ICDs in nonischemic cardiomyopathy
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This document discusses considerations for implanting an ICD in patients with non-ischemic cardiomyopathy without arrhythmia. It notes that while guidelines are based on LVEF, this is not specific or sensitive in identifying patients who benefit. The presence of late gadolinium enhancement on cardiac MRI can help identify higher-risk patients, as those without enhancement have a much lower risk of sudden death. The document also notes that older patient age decreases the benefits of an ICD. More research is still needed to refine risk stratification and guideline indications.
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ICDs in nonischemic cardiomyopathy
- 1. When to consider an ICD in the non-ischemic cardiomyopathy patient without arrhythmia? Sergio L. Pinski, MD, FHRS Cleveland Clinic Florida Weston, FL, USA
- 2. SCD-HeFT and subsequent meta-analysis Bardy et al. N Engl J Med 2005;352:2251 Desai et al. JAMA 2004;292:2874
- 3. Declining risk of sudden death in NICM Kober et al. N Engl J Med 2017;377:41
- 4. The DANISH study Kober et al. N Engl J Med 2016;375:1221
- 5. Khamis et al. J Clin Epidemiol 2019;113:147
- 6. Cochrane Meta-Analysis El Moheb et al. Cochrane Database Systematic Reviews 2018
- 7. EHRA Survey shortly after DANISH Haugaa et al. Europace 2017;19:660
- 8. Refining the indication-Risk stratification • Select patients with higher risk of sudden cardiac death but lower risk of death due to heart failure and competing comorbidities
- 9. Elming et al. Circulation 2017;136:1772 Older age limits the benefits of ICD
- 10. Saba et al. Heart Rhythm 2019;16:1065 CRT-P vs CRT-D in elderly pts with NICM
- 11. Kristensen et al. JACC Heart Fail 2019:(in press) Risk models in DANISH
- 12. Goldberger et al. JACC 2014;63:1879 Electrical parameters are mediocre in identifying NICM pts ar risk for sudden death
- 13. Gulati et al. JAMA 2013;309:896
- 14. Gulati et al. JAMA 2013;309:896
- 15. Halliday et al. J Am Coll Cardiol Img 2019;12:1645
- 16. Becker et al. JACC Cardiovasc Imag 2018;11:1274 Meta-analysis of LGE as predictor of ventricular arrhythmias or LV remodeling in DCM
- 17. Ongoing randomized trial • Cardiac Magnetic Resonance GUIDEd Management of Mild- moderate Left Ventricular Systolic Dysfunction (CMR- GUIDE) • ~ 400 pts with ischemic or nonischemic cardiomyopathy, LVEF 36 to 50%, + LGE • Randomized to ICD vs ILR • End-point is composite of SCD or hemodynamically significant ventricular arrhythmia • 2023
- 18. Di Marco et al. J Am Coll Cardiol HF 2017;5:28 Meta-analysis of LGE as predictor of SD or ventricular arrhythmias in DCM
- 20. ”Non-ischemic” cardiomyopathy • Acromegaly • AL amyloidosis • Alcoholic • Anthracycline • Arrhythmogenic LV • Chagas’ disease • “Burn out” HCM • Cocaine/metamphetamine • Genetic/familial dilated • Hemochromatosis • Inflammatory/autoimmune • PVC-induced • LBBB-induced • LV non-compaction • Muscular dystrophies • Pacing-induced • Peripartum • Post myocarditis • Sarcoidosis • Tachycardia-induced
- 21. Kayvanpour et al. Clin Res Cardiol 2017:106:135 Genetic causes of dilated cardiomyopathy
- 22. Peters et al. Heart Lung Circ 2019;28:31 Correlation between mutated genes and cardiomyopathy phenotype
- 23. Wahbi et al. Circulation 2019;140:293 Prognostic score for pts with lamin mutations
- 24. Ortiz-Genga et al. JACC 2016:68:2440 Truncating filamin C (FLCN) mutations carry high risk of sudden cardiac death
- 25. Gacita & McNally. Circ Heart Fail 2019;12:e005850 Proposed algorithm for high-risk mutations
- 26. Cleland et al. JACC 2017:70:1028 Reclassification of Risk of Sudden Death
- 27. My approach to ICD in nonischemic cardiomyopathy Familial DCM with SCD or mutation with high risk of sudden death (LMNA, SCN5A, RBM20, FLCN) Significant LGE in CRM? Treatable condition? Low risk of competing mortality? (younger age, no severe HF (or transplant listed), no comorbidities) Detailed clinical and family history, deep phenotyping (CMR +), genotyping (ie, MOGE(S) classification, JACC 2014;64:304) ICD ICD No ICD, treat and reevalaute ICD
- 28. Prabhu et al. J Am Coll Cardiol 2017;70:1949 Prabhu et al. J Am Coll Cardiol EP 2018;4:999 AF ablation and LV fibrosis: The CAMERA- MRI Study
- 29. Leyva et al. J Am Coll Cardiol 2012;60:1659 Patients with NICM and no fibrosis have excellent long-term prognosis with CRT-P alone
- 30. Saini et al. JACC Clin Electrophysiol 2016;2:307 CRT responders have lower risk of ventricular arrhythmia
- 31. Interesting Clinical Dilemma • Younger patient with heart block and mild LV dysfunction requiring more or less urgent pacemaker (LMNA, SCN5A, sarcoidosis) • Family history? • Extracardiac features? Chest CT for sarcoidosis • Same day in hospital CMR generally not available • Turn around time for genetic test, biopsy too long • ? EP study. • DF-1 ICD lead for RV pacing with pacemaker- Not MRI compatible
- 32. Conclusions • Current guidelines, based on LVEF, are not specific or sensitive to identify pts who benefit from ICD • “Nonischemic” cardiomyopathy should not be longer used. Appropriate disease characterization identifies pts with diffent risks, natural history and response to treatment • Absence of LGE in CMR identifies pts with much lower risk of sudden death, at any given LVEF • Older age decreases the benefit of ICDs • RCTs to expand indications are likely. However, large RCTs to restrict indications are not forthcoming. We will have to use clinical judgement.