Performance of 2020 AHA/ACC HCM Guidelines and Incremental Value of Myocardial Strain for Predicting SCD

Abstract

Background: The 2020 American Heart Association (AHA)/American College of Cardiology (ACC) guidelines for sudden cardiac death (SCD) risk stratification in hypertrophic cardiomyopathy (HCM) need further international validation.

Objectives: Performance of the guidelines and the incremental value of myocardial strain for predicting SCD in HCM were investigated.

Methods: In 1,416 HCM patients, SCD risk was stratified according to the 2020 AHA/ACC and 2014 European Society of Cardiology (ESC) guidelines. Left ventricular (LV) global longitudinal strain (GLS) and left atrial reservoir strain (LARS) were measured. The main outcome consisted of SCD events.

Results: Overall, 29.1% had major risk factors (RFs), and 14.7% had nonmajor RFs in the absence of major RFs; estimated 5-year SCD event rates were 6.8% and 2.3%, respectively. SCD risk was significantly increased in the former group but not in the latter. When stratified by the number of RFs, 5-year SCD event rates were 1.9%, 3.0%, 4.9%, and 18.4% for patients with 0, 1, 2, and 3 or more RFs, respectively. SCD risk was elevated in patients with multiple RFs but not in those with a single RF. Performance of the AHA/ACC and ESC guidelines did not differ significantly over 10 years (5-year time-dependent area under the curve: 0.677 vs 0.724; P = 0.235). Decreased LV GLS and LARS were independently associated with SCD events with optimal cutoffs of LV GLS <13% and LARS <21%. Adding LV GLS and LARS to the guidelines had incremental predictive value.

Conclusions: The 2020 AHA/ACC guidelines were predictive of SCD events with modest power in a large Asian HCM cohort. Implantable cardioverter-defibrillators are reasonable in patients with multiple RFs, and consideration of myocardial strain can improve SCD prediction.