LGE and NT-proBNP Identify Low Risk of Death or Arrhythmic Events in Patients With Primary Prevention ICDs

Study Questions:

Does late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) or N-terminal pro–B-type natriuretic peptide (NT-proBNP) identify patients with a low risk of death or use of implantable cardioverter-defibrillator (ICD) in patients receiving a primary prevention ICD?


A total of 157 patients with heart failure (61 with ischemic cardiomyopathy and 96 with dilated cardiomyopathy; mean age 50.5 years; 78% male) underwent primary prevention ICD implantation. Presence and volume of LGE were assessed, and serum NT-proBNP level was measured before implantation. The combined primary endpoint was cardiovascular death or appropriate ICD therapy (either appropriate shock or antitachycardia pacing).


The primary outcome occurred in 32 patients (20.4%) over a median follow-up period of 915 days. Percentage of LGE (hazard ratio [HR] per 1% increase, 1.06; 95% confidence interval [CI], 1.04-1.09; p < 0.001) and (ln) NT-proBNP (HR, 1.44; 95% CI, 1.04-1.98; p = 0.027) were predictors of death or appropriate ICD activation, and remained significant when entered into multivariable analysis. When the cohort was stratified into tertiles based on LGE percentage and NT-proBNP, a low-risk group was identified (event rate 3% per year), compared with the intermediate- and high-risk groups (6% and 10% per year, respectively).


Both percentage of LGE and NT-proBNP were associated with higher risk of death or appropriate ICD activation. The use of these markers in combination may be useful in identifying individuals most likely to benefit from this costly intervention, and more specifically, in the identification of a group at lower risk in whom ICD implantation may be deferred.


LGE-MRI and NT-proBNP have separately been shown to be associated with adverse outcomes in patients with cardiomyopathy. The current study suggests that combining these two markers may improve risk stratification of patients presenting for primary prevention ICD implantation. It may be possible to identify a low-risk group of patients with EF <35% that are not likely to benefit from ICD implantation. Given that most sudden cardiac deaths occur in patients with EF >35%, it would be interesting to explore whether LGE with or without NT-proBNP may identify a high-risk group that might benefit from a primary prevention ICD despite preserved LV function.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Magnetic Resonance Imaging

Keywords: Biological Markers, Gadolinium, Heart Failure, Peptide Fragments, Magnetic Resonance Imaging, Defibrillators, Implantable, Cardiomyopathy, Dilated, Natriuretic Peptide, Brain

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