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Risk stratification of ventricular arrhythmias and use of ICDs in dilated cardiomyopathy
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Orientador(es)
Resumo(s)
Miocardiopatia dilatada (MCD) é uma etiologia prevalente de insuficiência cardíaca não isquémica. A MCD compreende um espectro heterogéneo de condições que afetam o tecido miocárdio e consiste na dilatação do ventrículo esquerdo ou de ambos os ventrículos, com disfunção sistólica, que não é explicada por doença arterial coronária significativa ou condições de sobrecarga.
Embora tenham ocorrido melhorias significativas no prognóstico da MCD nas últimas décadas, com avanços significativos no tratamento da insuficiência cardíaca, a previsão de arritmias ventriculares e a subsequente morte súbita cardíaca (MSC) ainda representam um grande desafio.
A utilização de desfibriladores cardioversores-desfibrilhadores implantáveis (CDIs) tem se mostrado eficaz no tratamento dos pacientes de alto risco. No entanto, devido às limitações atuais na identificação dos indivíduos de alto risco, muitos pacientes são submetidos a implante desnecessário de CDIs, levando a morbidade associada, enquanto outros em risco, não são reconhecidos, resultando em mortalidade evitável.
Esta revisão fornece uma visão geral das características da MCD, incluindo etiologia, diagnóstico, progressão e prognóstico, salientando como uma avaliação diagnóstica precisa e a compreensão da etiologia subjacente são fundamentais para uma estratificação de risco eficaz. Além disso, esta revisão tem como objetivo fornecer uma análise abrangente das evidências disponíveis que apoiam os marcadores das atuais guidelines para avaliar o risco de MSC e a utilização de CDIs na prevenção primária. Por fim, este trabalho explora os novos marcadores de risco com o potencial de prever o risco de arritmias ventriculares e MSC em pacientes com MCD, marcadores que reconhecem que, ao longo do tempo, tanto a natureza dinâmica da patologia quanto o risco arrítmico associado mudam.
Dilated cardiomyopathy (DCM) is a prevalent etiology of non-ischemic heart failure. DCM comprises a heterogeneous spectrum of conditions that affect the myocardial tissue, and it is defined as a left or both ventricles dilatation and systolic dysfunction not explained by significant coronary artery disease or abnormal loading conditions such as hypertensive, valvular, or congenital heart disease. While there have been notable improvements in DCM prognosis over the last few decades, with significant advancements in managing heart failure, the prediction of ventricular arrhythmias and subsequent sudden cardiac death (SCD) still poses a major challenge. The utilization of implantable cardioverter defibrillators (ICDs) has proven effective in managing high-risk patients. However, due to the current limitations in identifying high-risk individuals, many patients undergo unnecessary ICD implantation, leading to associated morbidity, while others at risk go unrecognized, resulting in preventable mortality. This review provides an overview of the fundamentals of DCM, including its etiology, diagnosis, progression, and prognosis, focusing on how a precise diagnostic evaluation and understanding of the underlying etiology are the foundation for effective risk stratification. Additionally, this review aims to provide a comprehensive analysis of the available evidence supporting current guideline-directed markers for assessing the risk of SCD and the utilization of ICDs in primary prevention. Finally, this work explores novel imaging, genetic, electrophysiological, and serological markers that have the potential to predict the risk of ventricular arrhythmias and SCD in patients with DCM, recognizing that, over time, both the dynamic nature of the pathology and the associated arrhythmic risk change.
Dilated cardiomyopathy (DCM) is a prevalent etiology of non-ischemic heart failure. DCM comprises a heterogeneous spectrum of conditions that affect the myocardial tissue, and it is defined as a left or both ventricles dilatation and systolic dysfunction not explained by significant coronary artery disease or abnormal loading conditions such as hypertensive, valvular, or congenital heart disease. While there have been notable improvements in DCM prognosis over the last few decades, with significant advancements in managing heart failure, the prediction of ventricular arrhythmias and subsequent sudden cardiac death (SCD) still poses a major challenge. The utilization of implantable cardioverter defibrillators (ICDs) has proven effective in managing high-risk patients. However, due to the current limitations in identifying high-risk individuals, many patients undergo unnecessary ICD implantation, leading to associated morbidity, while others at risk go unrecognized, resulting in preventable mortality. This review provides an overview of the fundamentals of DCM, including its etiology, diagnosis, progression, and prognosis, focusing on how a precise diagnostic evaluation and understanding of the underlying etiology are the foundation for effective risk stratification. Additionally, this review aims to provide a comprehensive analysis of the available evidence supporting current guideline-directed markers for assessing the risk of SCD and the utilization of ICDs in primary prevention. Finally, this work explores novel imaging, genetic, electrophysiological, and serological markers that have the potential to predict the risk of ventricular arrhythmias and SCD in patients with DCM, recognizing that, over time, both the dynamic nature of the pathology and the associated arrhythmic risk change.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2023
Palavras-chave
Cardiomiopatia dilatada Estratificação de risco Arritmia ventricular Morte súbita cardíaca Cardioversor-desfibrilhador implantável Cardiologia