Arq. Bras. Cardiol. 2021; 117(1): 157-159
Risk Stratification for Primary Prevention of Sudden Cardiac Death in Hypertrophic Cardiomyopathy
Styliani Vakrou
, Charalampos Vlachopoulos, Konstantinos A. Gatzoulis
Reply
Sudden cardiac death (SCD) is considered the most dramatic complication of hypertrophic cardiomyopathy (HCM) with an estimated annual incidence of 0.5–1%. Over the years, the ACC/AHA and the ESC have published consensus guidelines providing different approaches for SCD risk stratification based on independent clinical predictors. Despite the relatively low accuracy of these markers, current strategies are considered to have a reasonable discriminatory power for the recognition of high-risk patients. However, prognostic assessment is challenging in HCM, especially in low to moderate risk patients. SCD may arise in the absence of known risk factors and some approaches show conflicting results in different populations. Moreover, methodological discrepancies between the North American and the European guidelines may determine discordant levels of recommendation regarding implantable cardioverter defibrillator (ICD) in primary prevention. Therefore, risk stratification is still imprecise and requires further investigation.
The 2018 manuscript of Gatzoulis et al. reevaluates the role of electrophysiological study for prognostic assessment in a low to intermediate risk single-center HCM cohort stratified according to contemporary guidelines. The authors conclude that programmed ventricular stimulation (PVS) combined with current models add sensitivity and negative predictive value to risk stratification. Results are interesting but need to be confirmed in larger prospective trials. PVS has been downgraded to class III in current guidelines due to the low sensitivity and potential risks. Similarly, fractionation of right ventricle electrograms has been related to SCD but was not assimilated due to the invasive nature of the procedure, which may impact feasibility in some settings. Electrical instability is transitory in HCM and should be periodically evaluated such as other predictors with dynamic characteristics. , The guidelines recommend the reassessment of SCD risk during follow-up. Clinical and more easily acquired non-invasive approaches favor routine patient evaluation.
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