Key result
In patients with hypertrophic cardiomyopathy and primary prevention ICDs, a 1% decrease in LVEF was associated with an 8% increased risk of appropriate ICD activation (HR 0.92).
Why the study?
ESC guidelines have broadened primary prevention ICD recommendations in HCM, but how these evolving criteria translate into real-world eligibility, clinical outcomes, and event detection remained unclear.
How do evolving ESC guidelines impact ICD eligibility, and what are the predictors of appropriate ICD activation in patients with hypertrophic cardiomyopathy?
Cohort (n=52)
No
How do evolving ESC guidelines impact ICD eligibility, and what are the predictors of appropriate ICD activation in patients with hypertrophic cardiomyopathy?
Hazard Ratio: 0.92 (95% CI 0.85–0.99)
p-value: p=0.03
Successive updates to ESC guidelines have significantly increased ICD eligibility for primary prevention in HCM patients; however, some individuals deemed ineligible still experience arrhythmic events, highlighting the continued need for individualized risk assessment.
Background: Sudden cardiac death (SCD) remains a major concern in hypertrophic cardiomyopathy (HCM). Over recent years, European Society of Cardiology (ESC) guidelines have broadened recommendations for implantable cardioverter defibrillator (ICD) implantation in primary prevention. We aimed to evaluate clinical outcomes and event detection in an HCM primary prevention cohort, while assessing how these evolving criteria translate into real-world ICD eligibility and event detection. Methods: We conducted a single-centre retrospective study including 52 consecutive HCM patients who received an ICD for primary prevention between 2014 and 2024. Baseline clinical, imaging, and follow-up data were collected. The primary endpoint was appropriate ICD therapy for ventricular tachycardia or fibrillation. Patients were classified according to the 2014, 2022, and 2023 ESC guidelines. Time-to-event analyses using univariate Cox regression were performed to identify predictors of ICD activation. Results: Over a median follow-up of 2.2 years, 6 patients (12%) experienced appropriate ICD therapy. According to ESC classifications, the 2022/2023 guidelines would have increased ICD eligibility by about 50% compared with the 2014 guideline, mainly due to the inclusion of extensive late gadolinium enhancement on CMR and reduced LVEF (<50%) as risk enhancers. However, no guideline set identified all patients who developed ventricular arrhythmias, and a subset of patients with events would not have been eligible for ICD implantation under any ESC recommendation. Lower LVEF was associated with higher risk of ICD activation. Conclusions: Successive ESC guidelines have lowered the threshold for ICD implantation in HCM, increasing eligibility but also implantations in event-free patients. Persistent event occurrence in ineligible individuals highlights the need for refined prediction models and individualized clinical judgment, including complementary tools such as ILR monitoring.
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Antunes et al. (2026) conducted a cohort in Hypertrophic cardiomyopathy (HCM) (n=52). Left ventricular ejection fraction (LVEF) was evaluated on Appropriate ICD therapy (shock delivery or anti-tachycardia pacing for VT or VF) (HR 0.92, 95% CI 0.85-0.99, p=0.03). In patients with hypertrophic cardiomyopathy and primary prevention ICDs, a 1% decrease in LVEF was associated with an 8% increased risk of appropriate ICD activation (HR 0.92).
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