Author + information
- Received February 16, 2018
- Revision received May 31, 2018
- Accepted June 2, 2018
- Published online September 17, 2018.
- Ankur Gupta, MD, PhDa,
- Meagan Harrington, BSa,
- Christine M. Albert, MD, MPHb,
- Navkaranbir S. Bajaj, MD, MPHa,
- Jon Hainer, BSa,
- Victoria Morgan, BSa,
- Courtney F. Bibbo, MSca,
- Paco E. Bravo, MDa,
- Michael T. Osborne, MDc,
- Sharmila Dorbala, MDa,
- Ron Blankstein, MDa,
- Viviany R. Taqueti, MD, MPHa,
- Deepak L. Bhatt, MD, MPHd,
- William G. Stevenson, MDb and
- Marcelo F. Di Carli, MDa,∗ ()
- aDivision of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- bDivision of Preventive Medicine and Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- cCardiac MR/PET/CT Program, Department of Radiology, Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- dBrigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
- ↵∗Address for correspondence:
Dr. Marcelo F. Di Carli, Noninvasive Cardiovascular Imaging Program, Brigham and Women’s Hospital, ASB-L1 037C, 75 Francis Street, Boston, Massachusetts 02115.
Objectives This study sought to investigate the association of myocardial scar and ischemia with major arrhythmic events (MAEs) in patients with left ventricular ejection fraction (LVEF) ≤35%.
Background Although myocardial scar is a known substrate for ventricular arrhythmias, the association of myocardial ischemia with ventricular arrhythmias in stable patients with left ventricular dysfunction is less clear.
Methods A total of 439 consecutive patients (median age, 70 years; 78% male; 55% with implantable cardioverter defibrillator [ICD]) referred for stress/rest positron emission tomography (PET) and resting LVEF ≤35% were included. Primary outcome was time-to-first MAE defined as sudden cardiac death, resuscitated sudden cardiac death, or appropriate ICD shocks for ventricular tachyarrhythmias ascertained by blinded adjudication of hospital records, Social Security Administration’s Death Masterfile, National Death Index, and ICD vendor databases.
Results Ninety-one MAEs including 20 sudden cardiac deaths occurred in 75 (17%) patients during a median follow-up of 3.2 years. Transmural myocardial scar was strongly associated with MAEs beyond age, sex, cardiovascular risk factors, beta-blocker therapy, and resting LVEF (adjusted hazard ratio per 10% increase in scar, 1.48 [95% confidence interval: 1.22 to 1.80]; p < 0.001). However, non transmural scar/hibernation or markers of myocardial ischemia on PET including global or peri-infarct ischemia, coronary flow reserve, and resting or hyperemic myocardial blood flows were not associated with MAEs in univariable or multivariable analysis. These findings remained robust in subgroup analyses of patients with ICD (n = 223), with ischemic cardiomyopathy (n = 287), and in patients without revascularization after the PET scan (n = 365).
Conclusions Myocardial scar but not ischemia was associated with appropriate ICD shocks and sudden cardiac death in patients with LVEF ≤35%. These findings have implications for risk-stratification of patients with left ventricular dysfunction who may benefit from ICD therapy.
- heart failure
- implantable cardioverter-defibrillator
- positron emission tomography
- sudden cardiac death
- ventricular arrhythmias
This study was supported in part by grants 5T32HL094301 (Drs. Gupta, Bajaj, and Bravo) and 5T32076136-12 (Dr. Osborne) from the National Institutes of Health. Dr. Bhatt is on the Advisory Board for Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; is on the Board of Directors for Boston VA Research Institute and the Society of Cardiovascular Patient Care; is Chair for the American Heart Association Quality Oversight Committee; is on the Data Monitoring Committees of Cleveland Clinic, Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine, Population Health Research Institute; has received honoraria from the American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); has received research funding from Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Ironwood, Ischemix, Lilly, Medtronic, Pfizer, Roche, Sanofi Aventis, The Medicines Company; Royalties, Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); Site Co-Investigator, Biotronik, Boston Scientific, St. Jude Medical (now Abbott); is a trustee for the American College of Cardiology; and has received unfunded research from FlowCo, Merck, PLx Pharma, Takeda. Dr. Dorbala is a member of an advisory board for General Electric Health Care. Dr. Di Carli has received consulting fees from Sanofi and General Electric. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received February 16, 2018.
- Revision received May 31, 2018.
- Accepted June 2, 2018.
- 2018 American College of Cardiology Foundation
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