Cardiac Magnetic Resonance GUIDEd Management of Mild-moderate Left Ventricular Systolic Dysfunction.

  • STATUS
    Recruiting
  • End date
    Dec 26, 2024
  • participants needed
    1055
  • sponsor
    Flinders University
Updated on 26 January 2021
medical therapy
ejection fraction
ace inhibitor
cardiomyopathy
systolic dysfunction
angiotensin
beta-adrenergic blocking agents
sudden cardiac death
left ventricular systolic dysfunction

Summary

Contemporary heart failure (HF) guidelines recommend insertion of a primary prevention implantable defibrillator (ICD) in patients with left ventricular ejection fraction less than 35% (LVEF < 35%) on maximally tolerated medical therapy. Nevertheless, there are a substantial number of HF patients who have LVEF>35% and hence do not qualify for ICD, who succumb to sudden cardiac death (SCD). At present our tools to reliably risk stratify these patients with mild-moderate systolic dysfunction (LVEF 36-50%) are poor. It is likely that these patients have ventricular scar and/or replacement fibrosis as a substrate for their malignant arrhythmia. Cardiovascular magnetic resonance imaging (CMR) can reliably identify and quantify both ventricular scar (seen in Ischaemic cardiomyopathy, ICM) and replacement myocardial fibrosis (seen in Non-Ischemic Cardiomyopathy, NICM).

Methods/Design: A multi-centre randomised controlled trial in which 428 patients with mild-moderate left-ventricular systolic dysfunction (either ICM or NICM) and ventricular scar/fibrosis on cardiovascular magnetic resonance are randomized to either ICD or implantable loop recorder (ILR) insertion and are followed up until the last patient recruited has been in the study for 3 years.

Potentially eligible patients will have a screening CMR and will be enrolled into the device arm of study based on the presence of any ventricular scar/fibrosis (CMR +). Patients who do not have ventricular scar/fibrosis will be followed up in an observational registry, and will not be randomised.

In both the device and registry arms, we aim to enrol 700 patients in Australia and 355 in Europe.

The primary hypothesis is that among patients with mild-moderate left ventricular systolic dysfunction, a routine CMR guided management strategy of ICD insertion is superior to a conservative strategy of standard care.

Details
Condition Heart failure, Congestive Heart Failure, Heart failure, Heart disease, Heart disease, Cardiac Disease, Left Ventricular Systolic Dysfunction, Congestive Heart Failure, Cardiac Disease, cardiac failure, congestive heart disease
Treatment ICD, ILR
Clinical Study IdentifierNCT01918215
SponsorFlinders University
Last Modified on26 January 2021

Eligibility

Yes No Not Sure

Inclusion Criteria

Age equal or greater than 18 years
Patients with coronary artery disease (CAD) or dilated cardiomyopathy (DCM) of the idiopathic, chronic post myocarditis or familial type
Left ventricular systolic impairment as defined by left ventricular ejection fraction 36-50% by any current standard technique (echocardiogram, multiple gated acquisition scan (MUGA), angiography or CMR taken in the last six months. If a LGE CMR has been taken within 2 months this scan can be used for inclusion
Able and willing to comply with all pre-, post- and follow-up testing, and requirements
On maximum tolerated doses of ACE inhibitors (or Angiotensin and Receptor Blockers if intolerant of ACE) and Beta Blockers

Exclusion Criteria

History of cardiac arrest or spontaneous or inducible sustained ventricular tachycardia or ventricular fibrillation unless within 48 hours of an acute MI
Cardiomyopathy related to sarcoidosis
Standard Cardiac Magnetic Resonance imaging contraindications (e.g. severe claustrophobia)
Currently implanted permanent pacemaker and/or pacemaker/ICD lead
Clinical indication for ICD or Pacemaker or cardiac resynchronisation therapy
CMR LVEF 35% or>50%
Severe renal insufficiency (eGFR< 30mls/min/1.73m2)
Recent Myocardial Infarction (MI) (<40 days) or cardiac revascularization (<90 days)
New York Heart Association HF functional class IV at baseline
Conditions associated with life expectancy <1 year
Pregnancy or in females of child-bearing potential, the non-use of accepted forms of contraception
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