Myocardial Fibrosis Assessment by LGE Is a Powerful Predictor of Ventricular Tachyarrhythmias in Ischemic and Nonischemic LV Dysfunction: A Meta-Analysis.

OBJECTIVES: The authors performed a meta-analysis to evaluate the predictive value of late gadolinium enhancement (LGE) cardiac magnetic resonance for ventricular tachyarrhythmia in ischemic cardiomyopathy (ICM) and nonischemic cardiomyopathy (NICM) patients with ventricular dysfunction. BACKGROUND: The use of LGE to detect myocardial fibrosis and its related arrhythmic substrate is well established. Several recent studies have described the predictive value of LGE for ventricular tachyarrhythmias; however, their validity is limited by small sample size and low number of events. METHODS: MEDLINE and the Cochrane Library electronic databases were systematically searched to identify studies that applied LGE in ICM and NICM patients with ventricular dysfunction and reported arrhythmic clinical outcomes (sudden death, aborted sudden death, ventricular tachycardia, ventricular fibrillation, and appropriate implantable cardioverter-defibrillator [ICD] therapy, including antitachycardia pacing). A meta-analysis was performed to determine pooled odds ratios (ORs) for these arrhythmic events. RESULTS: Nineteen studies that evaluated 2,850 patients with 423 arrhythmic events over a mean/median follow-up of 2.8 years were identified. The composite arrhythmic endpoint was reached in 23.9% of patients with a positive LGE test (annualized event rate of 8.6%) versus 4.9% of patients with a negative LGE test (annualized event rate of 1.7%; p < 0.0001). LGE correlated with arrhythmic events in the different patient groups. In the overall population, the pooled OR was 5.62 (95% confidence interval [CI]: 4.20 to 7.51), with no significant differences between ICM and NICM patients. In a subgroup of 11 studies (1,178 patients) with mean ejection fraction (EF) ≤30%, the pooled OR for the arrhythmic events increased to 9.56 (95% CI: 5.63 to 16.23), with a negative likelihood ratio of 0.13 (95% CI: 0.06 to 0.30). CONCLUSIONS: LGE is a powerful predictor of ventricular arrhythmic risk in patients with ventricular dysfunction, irrespective of ICM and NICM etiology. The prognostic power of LGE is particularly strong in patients with severely depressed EF, which suggests its potential to improve patient selection for ICD implantation.

[Remarks on polyparametric assessment of sudden death risk for primary prevention ICD implantation in patients with left ventricular dysfunction of ischemic and non ischemic etiology. Italian Association of Hospital Cardiologists (ANMCO) Experts Position Paper]. / Considerazioni su una valutazione poliparametrica nella stratificazione del rischio di morte improvvisa per l'indicazione all'impianto di cardioverter-defibrillatore in prevenzione primaria, nella disfunzione ventricolare sinistra di origine ischemica e non ischemica. Position paper dell'Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO).

It is generally recognized that current guidelines, based on ejection fraction criteria, do not allow appropriate selection of patients for implantable cardioverter-defibrillator (ICD) therapy in the primary prevention of sudden death, thus hindering the optimal use of ICD in patients with left ventricular dysfunction of ischemic and nonischemic etiology. Ejection fraction alone has limitations in both sensitivity and specificity. Assessment of the risk for sudden death using a combination of multiple tests (ejection fraction associated with one or more different arrhythmic risk markers) could partially compensate for these limitations. In this position paper, the potential usefulness of a polyparametric assessment using some of the most investigated risk markers of sudden death is discussed, including late gadolinium enhancement cardiac magnetic resonance, programmed ventricular stimulation, T-wave alternans, autonomic tone, biomarkers, and genetic testing.

Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals.

AIMS: The study hypothesis was that a decision-making approach improves diagnostic yield and reduces resource consumption for patients with syncope who present as emergencies at general hospitals. METHODS AND RESULTS: This was a prospective, controlled, multi-centre study. Patients referred from 5 November to 7 December 2001 were managed according to usual practice, whereas those referred from 4 October to 5 November 2004 were managed according to a standardized-care pathway in strict adherence to the recommendations of the guidelines of the European Society of Cardiology. In order to maximize its application, a decision-making guideline-based software was used and trained core medical personnel were designated-both locally in each hospital and centrally-to verify adherence to the diagnostic pathway and give advice on its correct application. The 'usual-care' group comprised 929 patients and the 'standardized-care' group 745 patients. The baseline characteristics of the two study populations were similar. At the end of the evaluation, the standardized-care group was seen to have a lower hospitalization rate (39 vs. 47%, P=0.001), shorter in-hospital stay (7.2+/-5.7 vs. 8.1+/-5.9 days, P=0.04), and fewer tests performed per patient (median 2.6 vs. 3.4, P=0.001) than the usual-care group. More standardized-care patients had a diagnosis of neurally mediated (65 vs. 46%, P=0.001) and orthostatic syncope (10 vs. 6%, P=0.002), whereas fewer had a diagnosis of pseudo-syncope (6 vs. 13%, P=0.001) or unexplained syncope (5 vs. 20%, P=0.001). The mean cost per patient and the mean cost per diagnosis were 19 and 29% lower in the standardized-care group (P=0.001). CONCLUSION: A standardized-care pathway significantly improved diagnostic yield and reduced hospital admissions, resource consumption, and overall costs.

Diagnostic pathway of syncope and analysis of the impact of guidelines in a district general hospital. The ECSIT study (epidemiology and costs of syncope in Trento).

BACKGROUND: The ECSIT study was aimed at evaluating the hospital management of syncope patients, at comparing the appropriateness and costs of the hospital diagnostic pathway before (phase 1) and after (phase 2) the introduction of new guidelines and at analyzing the physicians' compliance to the guidelines. METHODS: All syncope patients admitted to the emergency room between August 1 and October 31, 1999 (phase 1) and between March 1 and May 31, 2000 (phase 2) were enrolled and their clinical records were analyzed in a blind fashion. RESULTS: During the study 538 consecutive patients came to the emergency room for syncope with a hospitalization rate of 53% in phase 1 (n = 151) and of 42% in phase 2 (n = 107). The in-hospital stay increased from 9 days in phase 1 to 11.3 days in phase 2 and diagnostic tests from 2.6 per patient (phase 1) to 2.9 per patient (phase 2) with total costs that rose from [symbol: see text] 3,474 to [symbol: see text] 3,647. Patients with no diagnosis decreased from 51 to 45.8% and the principal causes were identified as vascular brain disease (36.1 vs 33.7%) and neurally-mediated mechanisms (35.3 vs 42.2%). CONCLUSIONS: Despite the high costs of syncope management, the appropriateness and efficacy of the hospital diagnostic pathway remains far from ideal and simply introducing new guidelines seems unable to modify clinical practice.