The need to modify patient selection to improve the benefits of implantable cardioverter-defibrillator for primary prevention of sudden death in non-ischaemic dilated cardiomyopathy

Europace. 2013 Dec;15(12):1693-701. doi: 10.1093/europace/eut228. Epub 2013 Aug 14.


Left ventricular ejection fraction (LVEF) ≤35% is a major determinant for implantable cardioverter-defibrillator (ICD) therapy for primary prevention of sudden death (SD) in patients with non-ischaemic dilated cardiomyopathy (DCM). However, as a risk marker for SD, low LVEF has limited sensibility and specificity. Selecting patients according to the current guidelines shows that most DCM patients do not actually benefit from ICD implantation and may suffer collateral effects and that many patients who are at risk of SD are not identified because a large proportion of SD patients exhibit only mildly depressed LVEF. Identifying patients who are at risk of SD on the sole basis of LVEF appears to be an over-simplification which does not maximize the benefit of ICD therapy. Owing to the complexity of the substrates underlying SD, multiple risk factors used in combination could probably predict the risk of SD better than any individual risk marker. Among non-invasive tests, microvolt T-wave alternans and cardiac magnetic resonance with late gadolinium enhancement may contribute to a better SD risk stratification by their high negative predictive value. Genetics may further contribute because approximately one-third of DCM patients have evidence of familial disease, and mutations in some known disease genes, including LMNA, have been associated with a high risk of SD. In this review, we critically analyse the current indications for ICD implantation and we explore existing knowledge about potentially predicting markers for selecting DCM patients who are at high and low risk of SD.

Keywords: Cardiac magnetic resonance; Cardioverter defibrillator; Dilated cardiomyopathy; Hereditability; Sudden death primary prevention; T-wave alternans.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Algorithms
  • Cardiomyopathy, Dilated / diagnosis
  • Cardiomyopathy, Dilated / genetics
  • Cardiomyopathy, Dilated / mortality
  • Cardiomyopathy, Dilated / physiopathology
  • Cardiomyopathy, Dilated / therapy*
  • DNA Mutational Analysis
  • Death, Sudden, Cardiac / etiology
  • Death, Sudden, Cardiac / prevention & control*
  • Decision Support Techniques
  • Defibrillators, Implantable*
  • Electric Countershock / adverse effects
  • Electric Countershock / instrumentation*
  • Electric Countershock / mortality
  • Electrocardiography
  • Genetic Predisposition to Disease
  • Humans
  • Magnetic Resonance Imaging
  • Patient Selection*
  • Practice Guidelines as Topic
  • Predictive Value of Tests
  • Primary Prevention / instrumentation*
  • Risk Assessment
  • Risk Factors
  • Stroke Volume
  • Treatment Outcome
  • Ventricular Function, Left