title: Improving the appropriateness of sudden arrhythmic death primary prevention by implantable cardioverter-defibrillator therapy in patients with low left ventricular ejection fraction. Point of view.
abstract: It is generally accepted that the current guidelines for the primary prevention of sudden arrhythmic death, which are based on ejection fraction, do not allow the optimal selection of patients with low left ventricular ejection fraction of ischemic and nonischemic etiology for implantation of a cardioverter-defibrillator. Ejection fraction alone is limited in both sensitivity and specificity. An analysis of the risk of sudden arrhythmic death with a combination of multiple tests (ejection fraction associated with one or more arrhythmic risk markers) could partially compensate for these limitations. We propose a polyparametric approach for defining the risk of sudden arrhythmic death using ejection fraction in combination with other clinical and arrhythmic risk markers (i.e. late gadolinium enhancement cardiac magnetic resonance, T-wave alternans, programmed ventricular stimulation, autonomic tone, and genetic testing) that have been validated in nonrandomized trials. In this article, we examine these approaches to identify three subsets of patients who cannot be comprehensively assessed by the current guidelines: patients with ejection fraction of 35% or less and a relatively low risk of sudden arrhythmic death despite the ejection fraction value; patients with ejection fraction of 35% or less and high competitive risk of death due to evolution of heart failure or noncardiac causes; and patients with ejection fraction between 35 and 45% with relatively high risk of sudden arrhythmic death despite the ejection fraction value.
authors.affiliation: aCardiology Department, S. Chiara Hospital - Healthcare Research and Innovation Program, PAT-FBK, Trento bCardiology Department, Garibaldi-Nesima Hospital, Catania cU.O. of Cardiology, Versilia Hospital, Lido di Camaiore (LU) dDivision of Cardiology, Pederzoli Hospital, Peschiera del Garda (VR) eCardiovascular Center, Azienda Servizi Sanitari N.1 - University of Trieste, Trieste fU.O of Cardiology, Azienda Istituti Ospitalieri, Cremona gCardiology Department, Niguarda Ca' Granda Hospital, Milano, Italy hCardiovascular Institute, University of Colorado Denver AMC, Aurora, Colorado, USA iDepartment of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese jGVM, Maria Cecilia Hospital, Care and Research - ES Health Science Foundation, Cotignola (RA), Italy.
authors.forename: Marcello
authors.initials: M
authors.lastname: Disertori
authors.forename: Michele M
authors.initials: MM
authors.lastname: Gulizia
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Casolo
authors.forename: Pietro
authors.initials: P
authors.lastname: Delise
authors.forename: Andrea
authors.initials: A
authors.lastname: Di Lenarda
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Di Tano
authors.forename: Maurizio
authors.initials: M
authors.lastname: Lunati
authors.forename: Luisa
authors.initials: L
authors.lastname: Mestroni
authors.forename: Jorge
authors.initials: J
authors.lastname: Salerno-Uriarte
authors.forename: Luigi
authors.initials: L
authors.lastname: Tavazzi
mesh_terms: D001145:Arrhythmias, Cardiac / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000517:prevention & control*; D016757:Death, Sudden, Cardiac / Q000209:etiology / Q000517:prevention & control; D017147:Defibrillators, Implantable; D006801:Humans; D011322:Primary Prevention / Q000379:methods; D013318:Stroke Volume / Q000502:physiology; D018487:Ventricular Dysfunction, Left / Q000150:complications / Q000503:physiopathology / Q000628:therapy*