Non-invasive imaging for prediction of ventricular arrhythmias

Ventricular tachyarrhythmias (VA) remain a major cause of sudden cardiac death (SCD) and can present as a first manifestation of coronary artery disease (CAD) or in patients with known CAD. In the population with known CAD, therapies for the prevention of SCD include medication, implantable devices, and catheter ablation. As the latter two represent invasive interventions carrying their own substantial risk, therapeutic decisions should be based on accurate risk assessment for the prediction of VA. One of the major shortcomings of the current guidelines for device-based therapy in the primary prevention of SCD in CAD is the notion that the decision for an implantable cardioverter-defibrillator (ICD) implantation is based on two simple criteria, that is, a cutoff for a left ventricular (LV)- ejection fraction (EF) ≤35% and an assessment of the clinical severity of heart failure (NYHA Class).1 With this background, it appears evident that a crude measure of LV-EF and a subjective estimation of the NYHA class alone cannot satisfy the complexity behind the far-reaching decision for a drastic and expensive treatment strategy with multiple consequences for the patient. Up to 9.5% of all patients will suffer from at least one complication after cardiac electronic device implantation such as psychological stigmatisation as device carrier, periprocedural complications, device-related endocarditis often requiring lead extraction and long-term antibiotic treatment and last but not least inappropriate shocks, all associated with an important morbidity and mortality.2 The fact that not more than about one third of the patients who receive an ICD benefit from an appropriate shock while the large majority does not require …