Elsevier

International Journal of Cardiology

Volume 296, 1 December 2019, Pages 164-171
International Journal of Cardiology

Prognostic value of cardiac metaiodobenzylguanidine imaging and QRS duration in implantable cardioverter defibrillator patients with and without heart failure

https://doi.org/10.1016/j.ijcard.2019.07.068Get rights and content

Highlights

  • Combination of MIBG imaging and QRS duration could predict appropriate ICD therapy.

  • Highest rate of the therapy was seen in the intermediate decrease in MIBG uptake.

  • The therapy was more frequent in patients with than without prolonged QRS duration.

  • This combination was useful even in patients with and without heart failure.

Abstract

Background

Cardiac metaiodobenzylguanidine (MIBG) imaging provides prognostic information in patients with heart failure (HF). Recent studies showed that the highest rate of ventricular tachyarrhythmias (VTs) is seen in HF patients with an intermediate decrease in MIBG uptake, rather than in those with the lowest values. However, prolonged QRS duration (QRSd) has been shown to be associated with VTs in HF patients. This study assessed the prognostic value of the combination of an intermediate decrease in MIBG uptake and prolonged QRSd for predicting VTs in patients with implantable cardioverter defibrillators (ICDs) in relation to the presence of heart failure (HF).

Methods and results

A total of 196 outpatients with ICDs (age: 64 ± 14 years, male: 81%, left ventricular ejection fraction [LVEF]: 49% ± 16%) were prospectively enrolled; 135 had HF (NYHA class: 2.0 ± 0.6). At entry, cardiac MIBG imaging was performed, and QRSd was measured on standard 12‑lead electrocardiography. An intermediate decrease in the heart-to-mediastinum ratio on the delayed planar image (ID-H/M) was defined as 1.40–1.89. During the 3.3 ± 2.2-year follow-up, 59 patients had appropriate ICD discharges (ATx) for VTs. On multivariate Cox analysis, ID-H/M and prolonged QRSd (≥147 ms) were significantly and independently associated with ATx. In both patients with and without HF, ATx were significantly more frequent in patients with ID-H/M and/or prolonged QRSd than in those with neither (with HF: 40% vs. 14%, p = 0.020; without HF: 43% vs. 10%, p = 0.0028).

Conclusions

The combination of ID-H/M and prolonged QRSd provided more prognostic information for predicting VTs in ICD patients, with and without HF.

Introduction

Despite recent advances in the diagnosis and management of patients with cardiac disease, sudden cardiac death remains a leading cause of cardiovascular death [1]. According to the current guidelines, the use of implantable cardioverter defibrillators (ICDs) for the primary prevention of sudden cardiac death (SCD) is recommended only in patients with ischemic and non-ischemic cardiomyopathy (CM) whose left ventricular ejection fraction (LVEF) is <35% [2,3]. However, in a community-wide study, only approximately one-third of patients who died from SCD had an LVEF that met the LVEF-based criteria for prophylactic ICD implantation under the current guidelines, and the major burden of SCD occurs in patients with less severe LV impairment [4]. The need to identify the subgroup of patients with mild and moderate reductions in LVEF or patients without chronic heart failure (CHF) at high risk for SCD has also been highlighted by the guidelines and statements [[1], [2], [3],5]. Furthermore, ICD discharges are linked to significant mortality and impairment of quality of life (QoL) of patients with ICD implants [[6], [7], [8], [9]]. Therefore, it is clinically relevant to identify those patients with cardiac disease, with or without CHF, at greatest risk for ventricular tachyarrhythmias and who would benefit most from ICD therapy.

The autonomic nervous system plays a major role in the pathophysiology of arrhythmias leading to SCD [10]. Cardiac metaiodobenzylguanidine (MIBG) imaging, which is useful for evaluating cardiac adrenergic nervous system activity [11], provides prognostic information in CHF patients with a reduced LVEF [[12], [13], [14], [15], [16], [17]]. Recent studies have shown that the highest rate of severe arrhythmic events is seen in CHF patients with an intermediate decrease (ID) in MIBG uptake, rather than in those with the lowest values; however, there is a progressive increase in the all-cause mortality rate as cardiac uptake decreases [[18], [19], [20]]. On the other hand, prolonged QRS duration (pQRSd) on the resting 12‑lead electrocardiogram (ECG) has been shown to be associated with SCD not only in CHF patients, but also in the general population [[21], [22], [23], [24]]. Therefore, the goal of this study was to investigate the prognostic value of the combination of ID in MIBG uptake and pQRSd for the prediction of ventricular tachyarrhythmias in patients with ICDs with and without CHF.

Section snippets

Study patients

A total of 217 consecutive outpatients with ICDs who were followed-up at our hospital between January 2012 and September 2018 were enrolled. Patients were excluded from this study if they withdrew informed consent (n = 2) or were judged as inappropriate for the study due to difficulty in follow-up by primary care physicians (n = 19). Therefore, 196 patients were analyzed. Heart failure was diagnosed by a history of worsening heart failure, symptoms due to heart failure according to the

Patient characteristics

The subjects were 158 men and 38 women (mean age, 64 ± 14 years); 135 were diagnosed with CHF. An ICD was implanted, according to the Japanese Circulation Society Guidelines, for primary prevention in 75 patients and secondary prevention in 121 patients at 0.2 [0–1.8] years before study enrollment. As for primary prevention, 50 patients had ischemic (n = 19) and non-ischemic CM (n = 31), 9 had hypertrophic cardiomyopathy (HCM), and 8 had Brugada syndrome, 8 had arrhythmogenic right ventricular

Discussion

This study demonstrated that ID-H/M and pQRSd were independently associated with appropriate ICD discharge, and the combination of the two indices provided more prognostic information to predict ventricular tachyarrhythmias in ICD patients, regardless of the presence of CHF.

Conclusion

To the best of our knowledge, this was the first study to show that a combination of an intermediate decrease in the late H/M and prolonged QRSd provided more prognostic information to help predict ventricular tachyarrhythmias in ICD patients, regardless of the presence of CHF.

Acknowledgments

The authors would like to thank Ms. Yumiko Sugie and Ms. Kanako Ueda for caring for the patients and Ms. Hiroko Maekawa for the data acquisition and analysis.

Declaration of Competing Interest

We have no financial conflict of interest to disclose concerning this study.

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  • 1

    All authors have made an important contribution to the study and are thoroughly familiar with the primary data. TM, YF, ST, YI, AK, TK, MS, HK, and YS contributed to the conception and design of this study. TY contributed to both the conception and design of this study, and the analysis and interpretation of the data. MF gave the final approval of the manuscript to be submitted.

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