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Canadian Journal of Cardiology

A Novel Risk Stratification Score for Sudden Cardiac Death Prediction in Middle-Aged, Nonischemic Dilated Cardiomyopathy Patients: The ESTIMATED Score

  • Xiaofei Li
    Affiliations
    Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Xiaohan Fan
    Affiliations
    Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Shuang Li
    Affiliations
    Department of Cardiac MR, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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  • Wei Sun
    Affiliations
    Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Kalyanam Shivkumar
    Affiliations
    UCLA Cardiac Arrhythmia Center, University of California-Los Angeles, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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  • Shihua Zhao
    Affiliations
    Department of Cardiac MR, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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  • Minjie Lu
    Affiliations
    Department of Cardiac MR, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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  • Yan Yao
    Correspondence
    Corresponding authors: Dr Yan Yao, or Dr Xiaohan Fan, or Dr Minjie Lu, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Rd, Xicheng District, Beijing 100037, China. Tel.: +86-10-68334688; fax: +86-10-88322426.
    Affiliations
    Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Published:November 15, 2019DOI:https://doi.org/10.1016/j.cjca.2019.11.009

      Abstract

      Background

      We aimed to develop a risk score (LGE Based Prediction of SCD Risk in Nonischemic Dilated Cardiomyopathy [ESTIMATED]) based on late gadolinium enhancement (LGE) cardiac magnetic resonance to predict sudden cardiac death (SCD) in patients with nonischemic dilated cardiomyopathy (NIDCM) and left ventricular ejection fraction ≤ 35%.

      Methods

      We recruited 395 consecutive middle-aged patients with NIDCM and performed 3-year follow-up for SCD events. The score was developed and verified in 295 primary prevention patients, and the predictive value was confirmed by comparing the SCD events between the high-risk patients stratified by the score and 100 secondary prevention patients.

      Results

      The ESTIMATED score (constructed by the LGE extent > 14%, syncope, atrial flutter/fibrillation, nonsustained ventricular tachycardia, advanced atrioventricular block, and age ≤ 20 or > 50 years) showed good calibrations for SCD prediction in the derivation (C-statistic: 0.80, 95% confidence interval: 0.74-0.86) and validation set (C-statistic: 0.80, 95% confidence interval: 0.71-0.87). By the score, 20.3% of primary prevention patients were categorized as high risk (≥ 3 points), 28.1% as intermediate risk (2 points), and 51.6% as low risk (0-1 points) for 3-year SCD events (45.9% vs 20.1% vs 5.1%, P < 0.0001). The 3-year SCD events were also well in agreement with the score stratification in patients without implantable cardioverter-defibrillator. High-risk primary prevention patients selected by the score in the derivation and validation sets had 3-year SCD events comparable with that in secondary prevention patients (47.6% vs 40.6% vs 38.7%, P = 0.81).

      Conclusions

      Our study derived and validated an LGE-based (ESTIMATED) risk score providing refined SCD prediction. The score may help to identify candidates for primary prevention implantable cardioverter-defibrillator in patients with NIDCM.

      Résumé

      Introduction

      Nous avions pour objectif d’élaborer un score de risque (ESTIMÉ) fondé sur le rehaussement tardif après injection de gadolinium (RTG) en imagerie cardiaque par résonance magnétique pour prédire la mort subite d’origine cardiaque (MSOC) des patients ayant une cardiomyopathie dilatée non ischémique (CMDNI) et une fraction d’éjection ventriculaire ≤ 35 %.

      Méthodes

      Nous avons recruté 395 patients consécutifs d’âge moyen qui avaient une CMDNI et réalisé un suivi de 3 ans sur les événements de MSOC. Nous avons élaboré le score et l’avons vérifié auprès de 295 patients en prévention primaire, et nous avons confirmé la valeur prédictive en comparant les événements de MSOC entre les patients exposés à un risque élevé stratifiés selon le score et 100 patients en prévention secondaire.

      Résultats

      Le score ESTIMÉ (élaboré par l’étendue de RTG > 14 %, la syncope, le flutter ou la fibrillation auriculaire, la tachycardie ventriculaire non soutenue, le bloc auriculo-ventriculaire avancé et l’âge ≤ 20 ou > 50 ans) a montré de bons étalonnages pour prédire la MSOC dans la dérivation (statistique C : 0,80, intervalle de confiance [IC] à 95 % : 0,74-0,86) et l’ensemble de validation (statistique C : 0,80, IC à 95 % : 0,71-0,87). Selon le score, 20,3 % des patients en prévention primaire ont été classés dans la catégorie des patients exposés à un risque élevé (≥ 3 points), 28,1 %, dans la catégorie des patients exposés à un risque intermédiaire (2 points), et 51,6 %, dans la catégorie des patients exposés à un risque faible (0-1 point) de subir des événements de MSOC durant 3 ans (45,9 % vs 20,1 % vs 5,1 %, P < 0,0001). Les événements de MSOC durant 3 ans se sont révélés conformes à la stratification par score des patients sans défibrillateur cardioverteur implantable. Les patients en prévention primaire exposés à un risque élevé sélectionnés par le score dans la dérivation et les ensembles de validation ont eu des événements de MSOC durant les 3 ans comparables à ceux des patients en prévention secondaire (47,6 % vs 40,6 % vs 38,7 %, P = 0,81).

      Conclusions

      Notre étude a permis d’établir et de valider un score de risque (ESTIMÉ) fondé sur le RTG qui fournit une prédiction affinée de la MSOC. Le score peut aider à déterminer les candidats à l’implantation d’un défibrillateur cardioverteur en prévention primaire parmi les patients ayant une CMDNI.
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      Linked Article

      • Predicting Sudden Death in Dilated Cardiomyopathy: The Potential Power of Magnetic Resonance Imaging as a Critical Tool
        Canadian Journal of CardiologyVol. 36Issue 7
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          Heart failure caused by left-ventricular dysfunction is a growing problem in contemporary cardiology practice, and the incidence of nonischemic dilated cardiomyopathy (NIDCM) is increasing. Medical therapy for NIDCM has evolved and improved substantially in recent years, with improved prognosis;1 however, sudden unexpected death, presumably often caused by ventricular tachycardia or fibrillation, remains an important and incompletely understood problem in patients with NIDCM. Implantable cardioverter defibrillators (ICDs) are effective in terminating sustained ventricular tachycardia or ventricular fibrillation if they occur, and thus it seems self-evident that defibrillators would reduce mortality in patients at more than minimal risk of sustained ventricular arrhythmias with NIDCM.
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