Arrhythmic risk stratification in post-myocardial infarction patients with preserved ejection fraction: the PRESERVE EF study.

AIMS: Sudden cardiac death (SCD) annual incidence is 0.6-1% in post-myocardial infarction (MI) patients with left ventricular ejection fraction (LVEF)≥40%. No recommendations for implantable cardioverter-defibrillator (ICD) use exist in this population. METHODS AND RESULTS: We introduced a combined non-invasive/invasive risk stratification approach in post-MI ischaemia-free patients, with LVEF ≥ 40%, in a multicentre, prospective, observational cohort study. Patients with at least one positive electrocardiographic non-invasive risk factor (NIRF): premature ventricular complexes, non-sustained ventricular tachycardia, late potentials, prolonged QTc, increased T-wave alternans, reduced heart rate variability, abnormal deceleration capacity with abnormal turbulence, were referred for programmed ventricular stimulation (PVS), with ICDs offered to those inducible. The primary endpoint was the occurrence of a major arrhythmic event (MAE), namely sustained ventricular tachycardia/fibrillation, appropriate ICD activation or SCD. We screened and included 575 consecutive patients (mean age 57 years, LVEF 50.8%). Of them, 204 (35.5%) had at least one positive NIRF. Forty-one of 152 patients undergoing PVS (27-7.1% of total sample) were inducible. Thirty-seven (90.2%) of them received an ICD. Mean follow-up was 32 months and no SCDs were observed, while 9 ICDs (1.57% of total screened population) were appropriately activated. None patient without NIRFs or with NIRFs but negative PVS met the primary endpoint. The algorithm yielded the following: sensitivity 100%, specificity 93.8%, positive predictive value 22%, and negative predictive value 100%. CONCLUSION: The two-step approach of the PRESERVE EF study detects a subpopulation of post-MI patients with preserved LVEF at risk for MAEs that can be effectively addressed with an ICD. CLINICALTRIALS.GOV IDENTIFIER: NCT02124018.

Percutaneous lead extraction and repositioning: An effective and safe therapeutic strategy for early ventricular lead perforation with dislocation both inside and outside the pericardial sac following a cardiac device implantation.

INTRODUCTION: Cardiac perforation of the right ventricle associated with pacemaker or implantable cardioverter defibrillator (ICD) leads' implantation is uncommon, albeit potentially life-threatening, complication. The aim of this study is to further identify the optimal therapeutic strategy, especially when lead dislocation has occurred outside the pericardial sac. METHODS AND RESULTS: The study population included 10 consecutive patients (six female, mean age: 66.5 years old) diagnosed with early ventricular lead perforation following a pacemaker or ICD implantation, with significant protrusion inside the pericardial sac (n = 2) or migration of the lead at the pleural space ( n = 3), the diaphragm ( n = 1), or the abdominal cavity ( n = 4), during the period 2013-2017. All patients were symptomatic; however, individuals presenting with hemodynamic instability were excluded. The outcome of the percutaneous therapeutic approach was retrospectively assessed. All patients underwent a successful removal of the perforating lead percutaneously at the electrophysiology lab, by direct traction, and repositioning in another location of the right ventricle. The operation was performed by a multidisciplinary team, under continuous hemodynamic and transesophageal echocardiographic monitoring and cardiac surgical backup. The periprocedural period was uneventful. Subjects were followed up for at least 1 year. Interestingly, all patients developed a type of postcardiac injury syndrome, successfully treated with a 3-month regimen of ibuprofen and colchicine. CONCLUSION: Percutaneous traction and repositioning of the perforating ventricular lead are effective, safe, and less invasive compared with the thoracotomy method in hemodynamically stable patients when dislocation has occurred outside the pericardial sac provided that there is no visceral organs injury.

Heart failure study of multipoint pacing effects on ventriculoarterial coupling: Rationale and design of the HUMVEE trial.

Cardiac resynchronization therapy (CRT) is an established therapy for symptomatic heart failure (HF). Unfortunately, many recipients remain nonresponders. Studies have revealed the potential role of multipoint pacing (MPP) in improving response and outcomes. The aim of this study is to compare the effects of MPP against those of standard biventricular pacing (BVP) on (i) ventriculoarterial coupling (VAC) and energy efficiency of the failing heart, (ii) diastolic function, (iii) quality of life, and (iv) NT-proBNP levels and glomerular filtration rate (GFR) during a follow-up of 13 months. HUMVEE is a single-center, prospective, observational, crossover cohort study. Seventy-six patients with BVP indication will be implanted with a system able to deliver both pacing modes. BVP will be activated at implantation and optimized 1 month after. At 6 months postoptimization MPP will be activated and optimized. Optimization will be performed based on stroke volume maximization, as assessed by ultrasound. Laboratory measurements (GFR and NT-proBNP) and echocardiographic studies (VAC calculation, strain rate, diastolic function) will be performed at implantation, 6 months post-BVP optimization and at the end of 13 months of follow-up (6 months post-MPP optimization). Potential reduction in arrhythmogenesis by MPP will also be assessed. MPP is a pacing modality with the potential to improve HF patients' outcomes. The HUMVEE trial will attempt to associate any potential added beneficial effects of MPP over standard BVP with alterations in VAC and energy efficiency of the heart, thus uncovering a novel mechanistic link between MPP and improved outcomes in HF.

Sustained ventricular tachycardia as a first manifestation of hypertrophic cardiomyopathy with mid-ventricular obstruction and apical aneurysm in an elderly female patient.

Sustained ventricular tachycardia complicating left ventricular apical aneurysms has been reported previously solely in middle-aged patients with hypertrophic cardiomyopathy and mid-cavity obstruction. We report a case of an elderly female patient who presented with incessant ventricular tachycardia as the first clinical manifestation of hypertrophic cardiomyopathy with mid-ventricular obstruction and apical aneurysm.

Left Ventricular Pacing through Coronary Sinus Is Feasible and Safe for Patients with Prior Tricuspid Valve Intervention.

BACKGROUND: In the presence of tricuspid valve intervention, right ventricular lead implantation is associated with the potential risk of tricuspid valve malfunction leading to a tricuspid regurgitation. Few cases have been reported with successful left ventricular pacing via the coronary sinus (CS) after tricuspid valve replacement or repair. In this retrospective study, we present the long-term clinical outcomes of 17 patients who underwent CS lead implantation and left ventricular pacing. METHODS: Seventeen consecutive patients referred to our institution with an indication of postprocedural pacemaker (PM) implantation after tricuspid valve intervention were retrospectively included in the study. The indication for device implantation in all patients was atrial fibrillation with a symptomatic pause ≥ 3.0 seconds. Thus, all devices implanted were ventricular rate responsive (VVIR). RESULTS: All device implantations were successful and uncomplicated. Mean operation time was 60 ± 8 minutes. Mean fluoroscopy time was 8.3 ± 2.1 minutes. Mean R-wave sensing was 7.5 ± 2.0 mV with a mean slew rate of 2.2 V/s. A mean pacing threshold of 1.9 ± 0.3 V/0.4 ms was accepted as patients were not PM-dependent. The pacing impedance was 743.5 ± 109.71 Ohm. At 2-year follow-up, pacing sensing, threshold, and impedance values were unchanged and no lead dislodgement has been noted. CONCLUSIONS: In patients with tricuspid valve intervention, left ventricular pacing might be the treatment of choice for permanent ventricular pacing, with all the advantages of the endovenous route as a minimally invasive approach.

Outcomes of Same Day Pacemaker Implantation after TAVI.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is often associated with conduction disturbances, followed by permanent pacemaker (PPM) implantation. Because of the potential reversibility of these conduction disorders, controversy exists regarding the right timing of PPM implantation. TAVI is routinely performed under dual-antiplatelet and antithrombotic therapy, which poses an additional hemorrhagic risk on a same-day procedure. The aim of the present study was to evaluate the safety and effectiveness of same-day PPM implantation in patients undergoing TAVI. METHODS: Consecutive patients undergoing TAVI with Medtronic Corevalve bioprosthesis (Medtronic Inc., Minneapolis, MN, USA) in a tertiary center were divided into two study groups. Group A included patients undergoing PPM implantation the same day with TAVI, and Group B patients were implanted with a PPM later after TAVI and before hospital discharge. The two study groups were compared for all complications associated with PPM implantation. RESULTS: In total, 168 patients were included in the study. PPM was implanted in 65 patients (38.7%). In 23 patients, a PPM was implanted the same day with TAVI (Group A) and in 42 patients PPM implantation was postponed at least 1 day (Group B). Cephalic vein was the access used for the leads in the majority of cases. There was only one case of pneumothorax in Group B. There were no differences in the incidence of pocket hematomas between the study groups. CONCLUSIONS: Same-day PPM implantation after TAVI is safe and feasible. Strategies reducing pocket hematomas are essential in such patients of high hemorrhagic risk.

The Mystery of High-density Lipoprotein: Quantity or Quality? Update on Therapeutic Strategies.

This review summarizes the data challenging the concept that cardiovascular protection through high-density lipoprotein (HDL) is only associated with its serum concentration. This conventional impression about its protective role now appears obsolete. New aspects of its mechanisms are revealed and novel therapeutic strategies are based on them. However, data from long-term cost-effectiveness studies of treating HDL are still needed. There is a need for biomarkers that represent the functional characteristics of HDL in order to better quantify the total cardiovascular risk.

The association of Restless Legs Syndrome with hypertension and cardiovascular disease.

Restless Legs Syndrome (RLS), is a sensory-motor neurological disorder that appears to be surprisingly common in the community. Periodic limb movements in sleep are typically encountered in more than 80% of RLS patients and comprise involuntary muscular jerks in the lower limbs, such as flexion of the knees or ankles.  Iron deficiency and dopaminergic neuronal dysfunction in the central nervous system are currently thought to be the likely pathophysiological culprits. There is evidence linking RLS to hypertension and cardiovascular disease. This short review will first present a synopsis of epidemiological, clinical and pathophysiological data concerning the syndrome, and then information on the possible links between RLS and cardiovascular disorders.

Omentin, fat and heart: classical music with new instruments.

Obesity is a new pandemic and its cardiovascular and metabolic complications will be more evident in the near future. The need to elucidate the structure and function of adipose tissue is becoming more prominent. Body fat mass has long become not just a matter of quantification, but an area of great interest due to the paracrine, endocrine and autocrine properties of its elements. The novel adipokines are under intense investigation and omentin has come into the centre of interest due to its favourable effects on inflammation and glucose homeostasis. Not all aspects of omentin have been clarified. This review tries to focus on the current knowledge of these aspects and the future perspectives of this novel adipokine.

Aortic valve stenosis and arterial hypertension: a synopsis in 2013.

Systemic hypertension and aortic valve stenosis (AVS) are both age-related diseases. The pathophysiology of AVS shares some similarities with essential hypertension, which might be the link between the two diseases. Although AS is usually related with low blood pressure levels, approximately one third of patients with severe AS suffer from arterial hypertension, a percentage that can increase up to 50 % according some studies. This review will summarize various aspects regarding the prevalence the pathophysiology and the natural history of those two diseases that seems to be linked, as well as the effect of blood pressure and antihypertensive treatment on various echocardiographic parameters in patients with AVS.

Quantitative analysis of carotid plaque vasa vasorum by CEUS and correlation with histology after endarterectomy.

BACKGROUND: Intraplaque neovascularization and vasa vasorum (VV) proliferation contribute in the progression and rupture of atherosclerotic lesions. Contrast enhanced ultrasonography (CEUS) has been reported to attain data regarding intraplaque neovessels and VV. However, whether the detection of microbubbles by CEUS within atherosclerotic plaques truly represents microvessels is a point of concern. We aimed to evaluate stable and unstable carotid artery plaque (CAP) VV pattern by CEUS and its correlation with histology and immunochemistry. PATIENTS AND METHODS: Patients with CAP scheduled for plaque endarterectomy were enrolled. CAP was initially identified by conventional ultrasonography and subsequently CEUS (harmonic ultrasound imaging with simultaneous intravenous contrast agent injection) was performed. The recorded image loops were evaluated by a semi-automated method. Plaque specimens were excised and underwent histological and immunochemical (for CD34, Vascular Endothelial Growth Factor, CD68 and CD3 antibodies) analysis. RESULTS: Fourteen patients (67.6 ± 10.2 years, 10 males) with a 86.9 ± 11.5 % degree of carotid artery stenosis were evaluated. Histology showed that half of the plaques were unstable. Enhancement of plaque brightness on CEUS was significant for both stable and unstable plaque subgroups (p = 0.018 for both). Immunochemistry showed that microvessels, as assessed by CD34 antibody, were more dense in unstable vs. stable plaques (36.6 ± 17.4 vs. 13.0 ± 7.2 respectively, p = 0.002). However, correlation between plaque brigthness enhancement on CEUS and microvessel density was significant only for stable (r = 0.800, p = 0.031) plaques. CONCLUSIONS: The identification of brightness enhacement during CEUS in carotid atherosclerotic plaques may not always reflect the presence of VV.

Impact of arterial hypertension on the eye.

Systemic hypertension has been linked to a wide range of major eye diseases. High arterial blood pressure (BP) decreases choroidal circulatory flow, increases intraocular pressure, and is associated with retinal microvascular abnormalities and prevalence of retinal vein occlusion (RVO) and retinopathy. This review offers a comprehensive overview of ocular diseases associated with hypertension and emphasizes their importance as predictors to future cardiovascular events. It also gives evidence-based clinical data for the therapeutic approach of eye disease in hypertensive patients.

Echocardiography for prediction of 6-month and late response to cardiac resynchronization therapy: implementation of stress echocardiography and comparative assessment along with widely used dyssynchrony indices.

Non-response cardiac resynchronization therapy (CRT) remains an issue, despite the refinement of selection criteria. The purpose of this study was to investigate the role of stress echocardiography along with dyssynchrony parameters for identification of CRT responders or late responders. 106 symptomatic heart failure patients were examined before, 6 months and 2-4 years after CRT implementation. Inotropic contractile reserve (ICR) and inferolateral (IL) wall viability were studied by stress echocardiography. Dyssynchrony was assessed by: (1) Septal to posterior wall motion delay (SPWMD) by m-mode. (2) Septal to lateral wall delay (SLD) by TDI. (3) Interventricular mechanical delay (IVMD) by pulsed wave Doppler for (4) difference in time to peak circumferential strain (TmaxCS) by speckle tracking. (5) Apical rocking (ApR) and septal flash (SF) by visual assessment. At 6 months there were 54 responders, with 12 additional late responders. TmaxCS had the greatest predictive value with an area under curve (AUC) of 0.835, followed by the presence of both ICR and viability of IL wall (AUC 0.799), m-mode (AUC = 0.775) and presence of either ApR or SF (AUC = 0.772). Predictive ability of ApR and of ICR is augmented if late responders are also included. Performance of dyssynchrony parameters is enhanced, in patients with both ICR and IL wall viability. Stress echocardiography and dyssynchrony parameters are simple and reliable predictors of 6-month and late CRT response. A stepwise approach with an initial assessment of ICR and viability and, if positive, further dyssynchrony analysis, could assist decision making.

Evidence for no global effect of metabolic syndrome per se on early hypertensive sequelae.

OBJECTIVE: In the present study we assessed the impact of metabolic syndrome (MS) and its components on markers of cardiovascular and renal damage in a population of essential hypertensives. METHODS: A total of 651 consecutive, untreated and non-diabetic hypertensives (age 54 +/- 12 years, 340 males) who were included in the 3H Study, an ongoing registry of hypertension-related target organ damage, were considered for analysis. Left ventricular mass was indexed both for body surface area (LVMBSA) and for height2.7 (LVMheight2.7). Diastolic function was estimated by means of both conventional and tissue Doppler imaging (TDI) methods. Arterial stiffness was evaluated on the basis of carotid to femoral pulse wave velocity (c-f PWV) and microalbuminuria (MA) as albumin to creatinine ratio (ACR) 22-300 mg/g in men and 31-300 mg/g in women in two non-consecutive morning spot urine samples. RESULTS: MS (Adult Treatment Panel III criteria) was present in 201 hypertensives (30.9%). Hypertensives with MS had increased logACR (by 10%, P = 0.01) and higher prevalence of MA (17 versus 8%, P < 0.001). Both groups exhibited similar values of LVMBSA, transmitral and TDI-derived indexes and c-f PWV (NS for all) while LVMheight2.7 was significantly higher in hypertensives with MS (by 2.6 g/m2.7, P = 0.023). Multiple regression analysis revealed that MS was an independent predictor only of logACR (beta = 0.110, P = 0.007) and MA (odds ratio = 2.577, P < 0.001), while components of blood pressure affected all studied indices of organ damage. CONCLUSIONS: MS per se does not deteriorate cardiac adaptations and aortic stiffness beyond haemodynamic load in hypertension. The MS-related unfavourable effect is limited to the level of the glomerulus.

Association of obstructive sleep apnea with urinary albumin excretion in essential hypertension: a cross-sectional study.

BACKGROUND: Microalbuminuria reflects a state of widespread vascular dysfunction, whereas obstructive sleep apnea (OSA) further promotes atherosclerotic damage in hypertension. STUDY DESIGN: Cross-sectional. SETTING & PARTICIPANTS: In an outpatient hypertensive unit, 62 untreated hypertensive patients (aged 48 +/- 7 years; office blood pressure [BP], 151 +/- 8/97 +/- 7 mm Hg) with OSA and 70 hypertensive patients without OSA (apnea hypopnea index [AHI] < or = 5) matched for age, sex, smoking status, body mass index, and 24-hour pulse pressure were studied. PREDICTOR VARIABLE: Hypertension and OSA compared with hypertension without OSA. OSA defined as AHI greater than 5, documented by polysomnography. OUTCOME VARIABLE: Albuminuria assessed by urinary albumin-creatinine ratio (ACR). MEASUREMENTS: Participants underwent polysomnography, ambulatory BP monitoring, echocardiography, routine metabolic profile assessment, and glomerular filtration rate estimation, whereas ACR was measured from 2 nonconsecutive morning spot urine samples. RESULTS: Hypertensive patients with OSA compared with those without OSA showed increased 24-hour diastolic BP (87 +/- 7 versus 85 +/- 7 mm Hg; P = 0.03) and nighttime pulse pressure (50 +/- 10 versus 45 +/- 10 mm Hg; P = 0.008), but did not differ regarding metabolic profile and estimated glomerular filtration rate. Albuminuria was greater by 57% in patients with OSA compared with those without OSA: log(10)ACR, 1.1 +/- 0.2 versus 0.7 +/- 0.4 mg/g; P < 0.001). In the entire study population, log10(ACR) correlated with log10(AHI) (r = 0.35; P < 0.001), minimum oxygen saturation during sleep (r = -0.33; P < 0.001), 24-hour pulse pressure (r = 0.38; P < 0.001), and nighttime pulse pressure (r = 0.21; P =0 .01). In a multivariable linear regression model, independent predictors of ACR were AHI (beta = 0.36; P < 0.001) and 24-hour pulse pressure (beta = 0.25; P = 0.01). LIMITATIONS: Cross-sectional study. CONCLUSIONS: Albuminuria increases within the normal range in hypertensive individuals with OSA compared with those without OSA proportionally to OSA severity independently of confounders. The association of upper-airway dysfunction with albuminuria and pulsatile hemodynamic load may provide an explanatory mechanism for the OSA-related risk in hypertension.

Multiple cardiac metastases from a malignant melanoma.

Metastatic tumors in the pericardium or the heart are more common than primary tumors and their incidence has increased during the last decades due to the prolonged survival of patients with cancer and the increased prevalence of the disease in the general population. We present the case of a 36-year-old patient admitted to our hospital due to fatigue, dyspnea, and episodes of dizziness and fainting during the last month. He had a history of a malignant skin melanoma surgically removed 4 years ago. The echo study identified multiple metastases in the heart involving the pericardium, the myocardium and the right atrium, where the tumor was mobile creating mechanical tricuspid valve stenosis. Malignant metastasis was confirmed by pericardiocentesis and, although treatment with chemotherapy was promptly initiated, the patient died 4 months later. Despite the difficulty in clinical diagnosis of cardiac melanoma, early detection has important therapeutic and prognostic implications. Echocardiography is the most common diagnostic modality and transesophageal approach may be the technique of choice to image intracardiac metastatic tumors.

Myocardial and aortic stiffening in the early course of primary aldosteronism.

BACKGROUND: Primary aldosteronism (PA) has been experimentally and clinically linked to myocardial and vascular fibrosis, and it has been further associated with left ventricular (LV) structural adaptations. HYPOTHESIS: Functional cardiovascular adaptations in hypertensive patients with PA precede structural alterations in the early stages of the disease. METHODS: We studied 17 hypertensive subjects with a recent diagnosis of PA (10 male patients, aged approximately 55 y, with office blood pressure [BP] of 137/88 mm Hg), and 30 essential hypertensives matched for age, sex, office BP levels, treatment status, and LV mass index (LVMI). Apart from standard 2-Dimensional (2-D) and conventional Doppler parameters, tissue Doppler imaging (TDI) methodology was used to assess LV diastolic function; averaging early and late diastolic mitral annular peak velocities (Emav/, Amav, Emav/Amav ratio) from 4 separate sites of measurement (septal, lateral, anterior, and inferior walls). Aortic stiffness was evaluated by means of carotid-femoral pulse wave velocity (cf-PWV) measurements. RESULTS: Although transmitral E/A ratio was similar in both groups (0.95+/-0.26 versus 0.98+/-0.24, p=0.66), hypertensive subjects with PA compared with essential hypertensives are characterized by significantly higher relative wall thickness (0.50+/-0.07 versus 0.41+/-0.06, p

Estrogen-induced improvement in coronary flow responses during atrial pacing in relation to endothelin-1 levels in postmenopausal women without coronary disease.

BACKGROUND: The cardioprotective role of hormonal replacement therapy remains in doubt, but interest is increasing in the vascular effects of estrogens especially in coronary circulation. METHODS: Coronary blood flow (CBF) was measured in 24 postmenopausal women (age 55+/-3 years), whose coronary arteries appeared angiographically normal, during incremental atrial pacing (AP) before and 20 minutes after intracoronary administration of either 75 ng/mL 17-beta estradiol (treated group, n=18) or 0.9% saline (controls, n=6). RESULTS: Before estrogen, no differences in the coronary vasomotor responses at AP between the two groups (p=NS) could be detected. After estrogen, in the treated group, at the peak of the second AP, the coronary artery diameter decreased by 0.17 mm (p<0.005) while the CBF increased by 61 mL/min (p<0.05). These changes differed significantly from those observed at the peak of first AP (p<0.001 for both cases). In contrast, in the control group no such changes were observed. The endothelin-1 (ET-1) levels in the coronary sinus were significantly reduced after estrogen infusion, which was negatively correlated with the degree of coronary artery constriction (r= -0.40, p=0.03) and positively correlated with the increase in CBF (r=0.54, p=0.01). CONCLUSIONS: In postmenopausal women without coronary artery disease, the intracoronary estrogen infusion mediates a greater increase in CBF and is positively correlated with the reduction of the coronary sinus ET-1 levels at the peak of AP.

Renal resistive index in hypertensive patients.

Spectral Doppler ultrasonography provides the evaluation of renal resistive index (RRI), a noninvasive and reproducible measure to investigate arterial compliance and/or resistance. RRI seems to possess an important role in the evaluation of diverse cases of secondary hypertension. In essential hypertension, RRI is associated with subclinical markers of target organ damage and reflects renal disease progression beyond albuminuria and creatinine clearance. Also, RRI can estimate cardiovascular and renal risk. The evaluation of RRI may also help the therapeutic decisions. Given its simple assessment, RRI emerges as a simple method and a "multifunctional" tool that could help on the cardiovascular risk evaluation of the hypertensive patient.

Programmed ventricular stimulation predicts arrhythmic events and survival in hypertrophic cardiomyopathy.

BACKGROUND: Sudden cardiac death (SCD) risk stratification in hypertrophic cardiomyopathy (HCM) in the context of primary prevention remains suboptimal. The purpose of this study was to examine the additional contribution of programmed ventricular stimulation (PVS) on established risk assessment. METHODS: Two-hundred-and-three consecutive patients with diagnosed HCM and ≥1 noninvasive risk factors were prospectively enrolled over 19years. Patients were risk stratified, submitted to PVS and received an implantable cardioverter-defibrillator (ICD) according to then-current American Heart Association (AHA) guidelines and inducibility. Participants were prospectively followed-up for primary endpoint occurrence (appropriate ICD therapy or SCD). Contemporary (2015) AHA and European Society of Cardiology (ESC) guidelines were retrospectively assessed. RESULTS: During a median follow-up period of 60months the primary endpoint occurred in 20 patients, 19 of whom were inducible and received an ICD. Overall, 79 patients (38.9%) were inducible and 92 patients (45.3%) received an ICD (PVS sensitivity=95%, specificity=67.2%, positive predictive value=24%, negative predictive value=99.2%). AHA and ESC guidelines application misclassified 3 and 9 primary endpoint-meeting patients, respectively. Inducibility was the most important determinant of event-free survival in multivariate Cox regression (hazard ratio=33.3). A combined approach of ESC score≥6% or AHA indication for ICD with PVS inducibility yielded absolute sensitivity and negative predictive value, the former at a more cost-effective and specific way. CONCLUSIONS: Inducibility at PVS predicts SCD or appropriate device therapy in HCM. Non-inducibility is associated with prolonged event-free survival, while the procedure was proven safe. Reintegration of PVS into established risk stratification models in HCM may improve patient assessment.