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World J Cardiol. Mar 26, 2022; 14(3): 139-151
Published online Mar 26, 2022. doi: 10.4330/wjc.v14.i3.139
Arrhythmic risk stratification in ischemic, non-ischemic and hypertrophic cardiomyopathy: A two-step multifactorial, electrophysiology study inclusive approach
Petros Arsenos, Konstantinos A Gatzoulis, Dimitrios Tsiachris, Polychronis Dilaveris, Skevos Sideris, Ilias Sotiropoulos, Stefanos Archontakis, Christos-Konstantinos Antoniou, Athanasios Kordalis, Ioannis Skiadas, Konstantinos Toutouzas, Charalambos Vlachopoulos, Dimitrios Tousoulis, Konstantinos Tsioufis
Petros Arsenos, Konstantinos A Gatzoulis, Polychronis Dilaveris, Athanasios Kordalis, Konstantinos Toutouzas, Charalambos Vlachopoulos, Dimitrios Tousoulis, Konstantinos Tsioufis, First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
Dimitrios Tsiachris, Christos-Konstantinos Antoniou, Athens Heart Center, Athens Medical Center, Athens 15125, Attika, Greece
Skevos Sideris, Ilias Sotiropoulos, Stefanos Archontakis, Department of Cardiology, Hippokration Hospital, Athens 11527, Attika, Greece
Ioannis Skiadas, Fifth Department of Cardiology, Hygeia Hospital, Marousi 15123, Attika, Greece
Author contributions: Arsenos P and Gatzoulis KA wrote the article; Dilaveris P, Kordalis A, Tsiachris D, Antoniou CK, Sideris S, Sotiropoulos I, Archontakis S and Skiadas I made critical revisions related to the important intellectual content of the manuscript; Toutouzas K, Vlachopoulos C, Tousoulis D, Tsioufis K and Gatzoulis KA approved the final manuscript for publication.
Conflict-of-interest statement: Authors declare no conflict of interests for this article. PRESERVE EF is a physician-initiated study that received unrestricted funding by Medtronic Hellas SA.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution-Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Konstantinos A Gatzoulis, MD, PhD, Professor, First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Avenue, Athens 11527, Attika, Greece. kgatzoul@med.uoa.gr
Received: March 18, 2021
Peer-review started: March 18, 2021
First decision: September 29, 2021
Revised: October 28, 2021
Accepted: February 23, 2022
Article in press: February 23, 2022
Published online: March 26, 2022
Processing time: 368 Days and 22.6 Hours
Abstract

Annual arrhythmic sudden cardiac death ranges from 0.6% to 4% in ischemic cardiomyopathy (ICM), 1% to 2% in non-ischemic cardiomyopathy (NICM), and 1% in hypertrophic cardiomyopathy (HCM). Towards a more effective arrhythmic risk stratification (ARS) we hereby present a two-step ARS with the usage of seven non-invasive risk factors: Late potentials presence (≥ 2/3 positive criteria), premature ventricular contractions (≥ 30/h), non-sustained ventricular tachycardia (≥ 1episode/24 h), abnormal heart rate turbulence (onset ≥ 0% and slope ≤ 2.5 ms) and reduced deceleration capacity (≤ 4.5 ms), abnormal T wave alternans (≥ 65μV), decreased heart rate variability (SDNN < 70ms), and prolonged QTc interval (> 440 ms in males and > 450 ms in females) which reflect the arrhythmogenic mechanisms for the selection of the intermediate arrhythmic risk patients in the first step. In the second step, these intermediate-risk patients undergo a programmed ventricular stimulation (PVS) for the detection of inducible, truly high-risk ICM and NICM patients, who will benefit from an implantable cardioverter defibrillator. For HCM patients, we also suggest the incorporation of the PVS either for the low HCM Risk-score patients or for the patients with one traditional risk factor in order to improve the inadequate sensitivity of the former and the low specificity of the latter.

Keywords: Arrhythmic sudden cardiac death; Risk stratification; Non-invasive risk factors; Electrophysiology study; Two-step approach; Arrhythmias in cardiomyopathy

Core Tip: An effective arrhythmic risk stratification approach based on two steps is proposed for the detection of truly high arrhythmic risk patients among ischemic and non-ischemic cardiomyopathy groups: In the first step, patients are screened for several non-invasive risk factors (NIRFs). When even one of these NIRFs is present, patients proceed to the second step, i.e., an electrophysiological study with programmed ventricular stimulation. An implantable cardiac defibrillator is offered to the inducible patients. We also suggest the incorporation of an electrophysiological study in the arrhythmic risk stratification approach among low-risk groups of hypertrophic cardiomyopathy patients.