Should lethal arrhythmias in hypertrophic cardiomyopathy be predicted using non-electrophysiological methods?

Abstract

While sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) is due to arrhythmias, the guidelines for prediction of SCD are based solely on non-electrophysiological methods. This study aims to stimulate thinking about whether the interests of patients with HCM are better served by using current, ‘risk factor’, methods of prediction or by further development of electrophysiological methods to determine arrhythmic risk. Five published predictive studies of SCD in HCM, which contain sufficient data to permit analysis, were analysed to compute receiver operating characteristics together with their confidence bounds to compare their formal prediction either by bootstrapping or Monte Carlo analysis. Four are based on clinical risk factors, one with additional MRI analysis, and were regarded as exemplars of the risk factor approach. The other used an electrophysiological method and directly compared this method to risk factors in the same patients. Prediction methods that use conventional clinical risk factors and MRI have low predictive capacities that will only detect 50–60% of patients at risk with a 15–30% false positive rate [area under the curve (AUC) = ∼0.7], while the electrophysiological method detects 90% of events with a 20% false positive rate (AUC = ∼0.89). Given improved understanding of complex arrhythmogenesis, arrhythmic SCD is likely to be more accurately predictable using electrophysiologically based approaches as opposed to current guidelines and should drive further development of electrophysiologically based methods.

Accurate diagnosis of apical hypertrophic cardiomyopathy using explainable advanced electrocardiogram analysis

“…Furthermore, invasive electrophysiological studies have been shown to be superior to standard risk prediction models at identifying those at risk of fatal arrhythmias in HCM. 21 Similarly, measuring the QRS peak on a 3 min standard ECG to assess the QRS fragmentation is a metric that has been shown to predict ventricular arrhythmias in those with HCM, and in combination with scar quantification, offers improved risk stratification. 22 Further work is needed to understand whether A-ECG may have the power to identify those most at risk of sudden cardiac death in this disease cohort.…”

Validation of the HCM Risk‐SCD model in patients with hypertrophic cardiomyopathy and future perspectives

“…Recent European guidelines recommend cardiopulmonary exercise testing to assess the severity of exercise intolerance, evaluate changes in systolic blood pressure, and to identify candidates for septum reduction procedures early 2 . Since SCD in HCM is often due to ventricular arrhythmias caused by abnormal ventricular electrophysiology, it may be reasonable to include electrophysiological substrates as risk factors alongside clinical features 17 …”

“…2 Since SCD in HCM is often due to ventricular arrhythmias caused by abnormal ventricular electrophysiology, it may be reasonable to include electrophysiological substrates as risk factors alongside clinical features. 17 Current paradigms include the use of clinical risk factors and imaging parameters to identify individuals at high risk of SCD and recommend ICD implantation. However, the majority of SCD occurs in low-risk groups, indicating the limitations of current risk stratification approaches.…”

Etiologia, Possíveis Fatores De Riscos E Aspectos Relacionados À Identificação E Prevenção Da Morte Súbita Cardíaca

“…Essas características adicionais são particularmente relevantes em pacientes classificados com risco intermediário de MSC. Um estudo investigou o papel da eletrofisiologia na previsão de MSC em pacientes com CMH, sugerindo que a previsão de MSC e implantação de CDI pode precisar ser reavaliada 56 .…”