Review ArticleMolecular imaging to predict ventricular arrhythmia in heart failure
Section snippets
Clinical Case Highlight
Case 1 A patient with history of stable coronary artery disease (CAD) has a single unexplained syncope. Acute myocardial infarction and regional myocardial ischemia are ruled out by electrocardiogram, serial troponin and stress myocardial perfusion imaging. His LVEF is determined to be 32% on gated SPECT and 30% on echocardiography. He is determined to be in NYHA class II and receives an implantable cardioverter-defibrillator (ICD). During further follow up of 3 years, his LVEF is stable under
Scope of the Problem and Diagnostic Gaps
Approximately, 1%–2% of the adult population in developed countries suffer from heart failure (HF), with prevalence up to 10% above 70 years of age and CAD as the most frequent cause.1 In the US, incidence has largely remained stable over the past several decades with over 650,000 newly diagnosed cases per year.2 Approximately, 50% of HF patients die within 5 years after diagnosis.3 In the “Metoprolol Randomised Intervention Trial in Congestive Heart Failure” (MERIT-HF) trial, 50% of deaths
Brief Review of the Biology of the Cardiac Sympathetic Nervous System in Heart Failure
An intact autonomic nervous system is essential for the adaptation of heart rate and contractile function to different loads. Autonomic innervation of the heart occurs via sympathetic nerve fibers of the cervical ganglia (Nervi cardiaci), and parasympathetic fibers of the vagal nerve. Sympathetic efferents originate from the locus coerulus. Preganglionic sympathetic fibers are located in the lateral column of the spinal cord and synapse via the T1-T5 rami with sympathetic efferent
Current State of the Art in Arrhythmia Prediction by Molecular Cardiac Neuronal Imaging
Imaging of the cardiac nervous system has emerged as an important diagnostic tool for identifying patients at increased risk for arrhythmic events. Several SPECT and PET tracers may be used for imaging of pre- and post-synaptic function.40 The most widespread and recently FDA-approved agent is 123I-metaiodobenzylguanidine (MIBG). This norepinephrine analog, a derivative of the adrenergic neuron blocking agent guanethidine, is selectively taken up into the pre-synaptic sympathetic nerve endings
Systemic Biomarkers
The prognostic value of systemic catecholamines in HF has been established long ago, but this difficult to measure systemic marker is not incremental to direct cardiac assessment of innervation,45,46 and it has not been proven clinically useful for the prediction of arrhythmia. A more robust systemic marker for risk stratification is B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP), which are released in response to myocardial stretch. Several studies
Action Item 1: Define Multi-parametric Algorithms Which Incorporate Imaging and Other Markers for Optimal Noninvasive Risk Stratification in HF
The development of life-threatening arrhythmia in HF is most likely a multi-factorial process which involves various systemic, global, and regional myocardial mechanisms. It is, therefore, likely that the risk of arrhythmia is best described by a multi-factorial model which incorporates multiple parameters including systemic biomarkers, electrophysiologic, and imaging test results. Various larger studies have already suggested that a combination of test results is superior over the use of a
Clinical Case Discussion
The initially highlighted cases described 2 situations where ICD was indicated according to current guidelines and appropriateness criteria, but unnecessary in the individual case, and where ICD was not indicated according to current guidelines and appropriateness criteria, but probably necessary in the individual case. Speculatively, cardiac neuronal imaging would have provided incremental information in both cases. In case 1, cardiac cateholamine uptake would be expected to be globally
Disclosure
The authors declare that there are no conflicts of interest.
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