Sudden Cardiac Death Risk Stratification: Are We Making Progress? February 18, 2010
Posted by Andrea M. Russo, MD, FACC, FHRS in Scientific Sessions.Tags: ICD, Implantable Cardioverter Defibrillator, Risk stratification, SCD, Sudden Cardiac Death
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Are we making any headway in the evaluation and treatment of sudden cardiac death?
Up to now, indications for implantable cardioverter defibrillators (ICDs) and risk stratification criteria have been based primarily on left ventricular function. Enrollment criteria in the major clinical trials evaluating the benefit of prophylactic ICD therapy have used left ventricular ejection fraction (LVEF) criteria of ≤30 to 40% as requisites for enrollment. However, most individuals who die suddenly in the population have an LVEF of >40%. In addition, many patients who receive ICDs based on current eligibility criteria may not receive appropriate ICD therapy for several years of follow-up post-implantation.
How can we identify those patients who are at highest risk? How can we avoid implanting devices in individuals who will never use them? Or, do we just need to “wait longer” to identify a tangible benefit in most individuals with reduced LV function? What are some of the newer methodologies in risk stratification, and are they making a difference? What is the future with respect to genetic testing, and how will this help with respect to better risk stratification? In addition, is there any role for MRI or other non-invasive tests for enhancing risk stratification?
Tell me what you think in the comments section or hear more about the debate on this topic at the Heart Rhythm Society annual meeting to be held in May 2010 in Denver!
Editor’s Note: If you will be attending Heart Rhythm 2010, you can find sessions that deal with the questions raised by Dr. Russo. Visit the Society’s Online Itinerary Planner and type “stratification” in the Simple Search field under ‘Browse’.
Heart Rhythm Society
Laurie Racenet, RN, MSN, ANP
Michael Giudici, MD, FACC, FACP, FHRS
Heather M. Ross, DNP, ANP-BC, CCDS, CEPS, FHRS
Anne Dubin, MD, FHRS
John D. Day, MD, FHRS
Andrea M. Russo, MD, FACC, FHRS
Joshua M. Cooper, MD, FACC
Amit J. Shanker, MD, FHRS, FACC
Bruce Stambler, MD
David Wiggins, RN, BS BME, CEPS
Fred M. Kusumoto, MD, FHRS
Leonard Ganz, MD, FHRS
christinechiuman
Craig Delaughter, MD, PhD
Ariana Del Negro, Heart Rhythm 2010 Quality
Peng-Sheng Chen, MD, FHRS
MSKremers MD,FHRS
Ann C. Garlitski, MD, FACC, FHRS
Alan Cheng, MD, FHRS
Ulrika Birgersdotter-Green, MD
Christopher Clyne, MD, FHRS
Kathleen Blake, MD, MPH, FHRS
David Scher, MD, FHRS
Sanjay Deshpande, MD, FHRS
The VEST/PREDICTS trial (sponsored by NHLBI) is looking at this subject including potential SCD risk stratification based on Baroreflex Sensitivity, T-Wave Alternans, and Signal-average ECG markers among others.
Microvolt T-Wave Alternans was developed at MIT for NASA for use on astronauts to determine their susceptibility to sudden cardiac arrest. It received FDA approval in 1999, has NCD and CPT reimbursement codes, is non-invasive, takes a half-hour to perform and costs around $400. By comparison, electrophysiology is invasvie, takes about two hours to perform and costs anywhere between $3,000 and $8,000. MTWA is also the first economical test to determine who really needs an ICD. Columbia University studied 170,000 ICDs and determined that nearly one-third were unnecessary. At $70,000 each, that’s an expensive waste. Google “MTWA’ for more information.