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Cardiac magnetic resonance infarct heterogeneity: is it ready to be used on patients for the prevention of sudden cardiac death?

Numerous advancements in the treatment of acute myocardial infarction (MI), from reperfusion therapy to coronary care units, have markedly reduced 30-day patient mortality. Despite optimal therapy, a significant proportion of patients remain at high risk for sudden cardiac death (SCD), particularly in the first 6 months.1 The absence of herald symptoms and the catastrophic outcomes from arrhythmia-related SCD have led to the investigation of the prophylactic role of implantable cardioverter-defibrillators (ICDs) following acute MI. Two large-scale, randomized clinical trials (DINAMIT, IRIS) of early ICD implantation failed to demonstrate a benefit in all-cause mortality, despite a reduction in arrhythmia-related deaths.2,3 These studies highlight that despite the availability of an effective therapy for the prevention of SCD, we still lack the clinical risk-stratifying tools to identify patients at highest risk who may benefit from ICD therapy.

Unlike other post-infarct complications that are related to the extent of myocardial injury and left ventricular (LV) systolic failure, the development of arrhythmia-related SCD often occurs in patients with medium-to-small infarcts.4 Electrophysiological studies (EPS) have implicated heterogeneity of depolarization and dispersion of repolarization within the border zones of the infarcted myocardium as key substrates in arrhythmia-related SCD.5 It is postulated that these ‘peri-infarct zones’ (PIZs) represent an admixture of fibrotic and …