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Editorials

Prediction of Sudden Cardiac Death in Patients With Coronary Heart Disease

The Challenge Ahead

Christine M. Albert, MD, MPH

From the Center for Arrhythmia Prevention, Division of Preventive Medicine and Cardiovascular Division, Brigham and Women’s Hospital, Boston, Mass.

Correspondence to Christine M. Albert, MD, MPH, Center for Arrhythmia Prevention, Division of Preventive Medicine and Cardiovascular Division, Brigham and Women’s Hospital, 900 Commonwealth Ave East, Boston, MA 02215-1204. E-mail calbert@partners.org

Key Words: coronary disease • death, sudden • nuclear medicine • prevention • risk factors

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Despite widespread advances in coronary heart disease (CHD) treatment and the growing use of implantable cardioverter-defibrillators (ICDs), sudden cardiac death (SCD) remains a major cause of CHD death in the United States,¹ and identification of patients at risk for SCD remains a challenge. Left ventricular ejection fraction (LVEF) has been found to be the strongest independent predictor of SCD among traditional clinical markers,² and risk of SCD exponentially increases as LVEF decreases.³ Based on data from observational studies, clinical trials were designed to test the hypothesis that ICD therapy would prolong life in patients with clinically recognized left ventricular dysfunction. Although these trials have demonstrated convincing survival benefits,^4,5 there continues to be great debate regarding the overall effectiveness, and in particular cost-effectiveness, of the current strategy of allocating ICD therapy on the basis of LVEF.^6,7

Article see p 180

Stratifying SCD risk based solely on LVEF has 2 important well-recognized limitations. First, LVEF lacks specificity in that it not only predicts SCD but other modes of cardiovascular death as well.⁸ Indeed, most current clinical predictors, with the possible exception of invasive electrophysiological testing,⁹ predict cardiovascular death in general rather than mode of death. Thus, these predictors in isolation are unable to discriminate those who will die suddenly from those who will die from other causes. Although defibrillators are highly effective at terminating potentially lethal ventricular arrhythmias, recent estimates suggest that allocating ICD therapy on the basis of LVEF may not be cost-effective until 8 years after implantation,¹⁰ a timeline that . . . [Full Text of this Article]

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