Implantable cardioverter defibrillator use in arrhythmogenic right ventricular cardiomyopathy in North America and Europe
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic heart disease that increases the risk of sudden cardiac death due to life-threatening arrhythmias. Implantable cardioverter-defibrillators (ICDs) are commonly used to prevent such events, especially in patients who have never had a serious arrhythmia but are considered at risk. Since ARVC often affects young individuals, clinicians must carefully weigh the potential benefits of an ICD against the risks and complications that can arise from device therapy.
In this study, researchers analyzed 1,098 patients with a confirmed ARVC diagnosis from both North America and Europe. The goal of the study was to compare utilization of ICD use in North America and Europe. None of the patients had experienced a sustained arrhythmia at the time of diagnosis. Each patient’s risk of future arrhythmic events was calculated using the ARVC risk calculator (www.arvcrisk.com), which estimates the likelihood of a life-threatening arrhythmia occurring within the next five years. Based on these predictions, patients were divided into three groups: low risk (with less than a 10% five-year risk); intermediate risk (with a 10% to 25% five-year risk); and high risk (with greater than 25% five-year risk).
Over a median follow-up of 5.1 years, the study found that North American patients were more than three times as likely to receive an ICD compared to European patients. This was consistently found in all three risk groups. Despite this more aggressive approach, the rate of arrhythmic events among patients who did not receive an ICD was not higher in Europe. In fact, “unprotected” patients in North America (i.e. those who did not receive an ICD) had more arrhythmias than their unprotected European counterparts, particularly in the high-risk group. This shows that a more selective ICD implantation strategy, as practiced in Europe, did not result in worse outcomes, even for patients at higher baseline risk.
The study also found a sex difference in arrhythmic risk: men had nearly double the rate of arrhythmias compared to women. Nevertheless, ICD implantation rates were similar between men and women, especially in European centers, suggesting that male sex may not be fully appreciated as an independent risk factor when making treatment decisions.
These findings support the importance of personalized care in ARVC. Rather than relying on broad regional practice patterns, clinicians should use individualized risk tools, such as the ARVC risk calculator, to guide ICD decisions. A more conservative, risk-based approach can safely reduce unnecessary ICD use while ensuring that patients who need protection receive it.
Carrick RT, De Marco C, Gasperetti A, Bosman LP, Gourraud JB, Trancuccio A, Mazzanti A, Murray B, Pendleton C, Tichnell C, Tandri H, Zeppenfeld K, Wilde AAM, Davies B, Seifer C, Roberts JD, Healey JS, MacIntyre C, Alqarawi W, Tadros R, Cutler MJ, Targetti M, Calò L, Vitali F, Bertini M, Compagnucci P, Casella M, Dello Russo A, Cappelletto C, De Luca A, Stolfo D, Duru F, Jensen HK, Svensson A, Dahlberg P, Hasselberg NE, Di Marco A, Jordà P, Arbelo E, Moreno Weidmann Z, Borowiec K, Delinière A, Biernacka EK, van Tintelen JP, Platonov PG, Olivotto I, Saguner AM, Haugaa KH, Cox M, Tondo C, Merlo M, Krahn AD, Te Riele ASJM, Wu KC, Calkins H, James CA, Cadrin-Tourigny J. Implantable cardioverter defibrillator use in arrhythmogenic right ventricular cardiomyopathy in North America and Europe.
Eur Heart J 45, 538-548, 2024. PMID: 38195003
Translated by Laurens Bosman and Ruth Biller