{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T18:50:26Z","timestamp":1792003826057,"version":"4.4.0"},"reference-count":49,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T00:00:00Z","timestamp":1779235200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Cardiovasc. Med."],"abstract":"<jats:p>Risk stratification for sudden cardiac death (SCD) in non-ischemic dilated cardiomyopathy (NICM) and a left ventricular ejection fraction (LVEF) \u226435%. remains controversial. The value of a low LVEF alone is limited, as it cannot distinguish between arrhythmic and nonarrhythmic mortality. This led to further investigation into markers of electrical instability. Prior studies have evaluated noninvasive and invasive markers, including ambient arrhythmias, signal-averaged ECG, QT dispersion, T-wave alternans, heart rate variability, and programmed ventricular stimulation. None of these markers have consistently improved the predictive accuracy for SCD beyond LVEF. Cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE) has emerged as a tool for substrate characterization, with myocardial fibrosis burden and LGE patterns associated with SCD, arrhythmic events, as well as appropriate therapies in patients with implantable cardioverter-defibrillators. Quantitative LGE thresholds and integrated CMR-based models may enhance SCD risk discrimination, although methodological heterogeneity, scanner-dependent quantification, and lack of randomized trials challenge the inclusion of CMR parameters in current guidelines. Emerging tiered approaches like the ReCONSIDER framework, combining noninvasive markers, CMR tissue characterization, and electrophysiologic testing to capture the heterogeneity of NICM, may also be of value. However, at the present time, no single imaging, clinical, or electrophysiologic marker has achieved guideline-level validation as an adjunct or a replacement for LVEF. Future studies may focus on standardizing CMR acquisition and quantification, prospective validation of multimodal risk models, and assessment of dynamic, serial biomarkers to establish a more accurate approach to SCD risk stratification in NICM.<\/jats:p>","DOI":"10.3389\/fcvm.2026.1766952","type":"journal-article","created":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T04:43:11Z","timestamp":1779252191000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Risk stratification for sudden cardiac death in nonischemic dilated cardiomyopathy: a moving target?"],"prefix":"10.3389","volume":"13","author":[{"given":"Laura","family":"Bradel","sequence":"first","affiliation":[{"name":"Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital","place":["Brooklyn, NY, United States"]},{"name":"Department of Medicine, Weill Cornell Medicine","place":["New York, NY, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katherine","family":"Kovrizhkin","sequence":"additional","affiliation":[{"name":"Department of Medicine, Albert Einstein College of Medicine","place":["New York, NY, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Harout","family":"Yacoub","sequence":"additional","affiliation":[{"name":"Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital","place":["Brooklyn, NY, United States"]},{"name":"Department of Medicine, Weill Cornell Medicine","place":["New York, NY, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gioia","family":"Turitto","sequence":"additional","affiliation":[{"name":"Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital","place":["Brooklyn, NY, United States"]},{"name":"Department of Medicine, Weill Cornell Medicine","place":["New York, NY, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,5,20]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"270","DOI":"10.1093\/eurheartj\/ehm342","article-title":"Classification of the cardiomyopathies: a position statement from the European Society of Cardiology working group on myocardial and pericardial diseases","volume":"29","author":"Elliott","year":"2008","journal-title":"Eur Heart J"},{"key":"B2","doi-asserted-by":"publisher","first-page":"1361","DOI":"10.1111\/jce.13284","article-title":"Sudden cardiac death in nonischemic cardiomyopathy: refining risk assessment","volume":"28","author":"Zipse","year":"2017","journal-title":"J Cardiovasc Electrophysiol"},{"key":"B3","doi-asserted-by":"publisher","first-page":"1113","DOI":"10.1046\/j.1540-8167.2003.03204.x","article-title":"Risk stratification and management of sudden cardiac death: a new paradigm","volume":"14","author":"El-Sherif","year":"2003","journal-title":"J Cardiovasc Electrophysiol"},{"key":"B4","doi-asserted-by":"publisher","first-page":"1097","DOI":"10.1002\/ejhf.181532","article-title":"The electrocardiogram in the diagnosis and management of patients with dilated cardiomyopathy","volume":"22","author":"Finocchiaro","year":"2020","journal-title":"Eur J Heart Fail"},{"key":"B5","doi-asserted-by":"publisher","first-page":"770","DOI":"10.1016\/0002-9149(94)90879-6","article-title":"Incidence and prediction of induced ventricular tachyarrhythmias in idiopathic dilated cardiomyopathy","volume":"73","author":"Turitto","year":"1994","journal-title":"Am J Cardiol"},{"key":"B6","doi-asserted-by":"publisher","first-page":"1523","DOI":"10.1016\/0735-1097(94)90149-X","article-title":"Risk stratification for arrhythmic events in patients with nonischemic dilated cardiomyopathy and nonsustained ventricular tachycardia: role of programmed stimulation and the signal-averaged electrocardiogram","volume":"24","author":"Turitto","year":"1994","journal-title":"J Am Coll Cardiol"},{"key":"B7","doi-asserted-by":"publisher","first-page":"105","DOI":"10.1002\/joa3.12253","article-title":"Association of QT dispersion with mortality and arrhythmic events\u2014a meta-analysis of observational studies","volume":"36","author":"Bazoukis","year":"2019","journal-title":"J Arrhythm"},{"key":"B8","doi-asserted-by":"publisher","first-page":"323","DOI":"10.1111\/j.1542-474x.2001.tb00126.x","article-title":"T-wave alternans and arrhythmia risk stratification","volume":"6","author":"El-Sherif","year":"2001","journal-title":"Ann Noninvasive Electrocardiol"},{"key":"B9","doi-asserted-by":"publisher","first-page":"1879","DOI":"10.1016\/j.jacc.2013.12.02133","article-title":"Sudden cardiac death risk stratification in patients with nonischemic dilated cardiomyopathy","volume":"63","author":"Goldberger","year":"2014","journal-title":"J Am Coll Cardiol"},{"key":"B10","doi-asserted-by":"publisher","first-page":"281","DOI":"10.1016\/j.hrthm.2005.11.028","article-title":"Preserved heart rate variability identifies low-risk patients with nonischemic dilated cardiomyopathy: results from the DEFINITE trial","volume":"3","author":"Rashba","year":"2006","journal-title":"Heart Rhythm J"},{"key":"B11","doi-asserted-by":"publisher","first-page":"1449","DOI":"10.1016\/j.ijcard.2014.08.06835","article-title":"Prognostic value of programmed ventricular stimulation for sudden death in selected high-risk patients with structural heart disease and preserved systolic function","volume":"176","author":"Gatzoulis","year":"2014","journal-title":"Int J Cardiol"},{"key":"B12","doi-asserted-by":"publisher","first-page":"169","DOI":"10.1016\/j.hjc.2020.03.008","article-title":"Arrhythmic risk stratification in nonischemic dilated cardiomyopathy: the ReCONSIDER study design - A two-step, multifactorial, electrophysiology-inclusive approach","volume":"62","author":"Gatzoulis","year":"2021","journal-title":"Hellenic J Cardiol"},{"key":"B13","doi-asserted-by":"publisher","first-page":"899","DOI":"10.1038\/s41436-018-0039-z","article-title":"Genetic evaluation of cardiomyopathy: a clinical practice resource of the American college of medical genetics and genomics (ACMG)","volume":"20","author":"Hershberger","year":"2018","journal-title":"Genet Med"},{"key":"B14","doi-asserted-by":"publisher","first-page":"3503","DOI":"10.1093\/eurheartj\/ehad194","article-title":"2023 ESC guidelines for the management of cardiomyopathies: developed by the task force on the management of cardiomyopathies of the European Society of Cardiology (ESC)","volume":"44","author":"Arbelo","year":"2023","journal-title":"Eur Heart J"},{"key":"B15","doi-asserted-by":"publisher","first-page":"2340","DOI":"10.1016\/j.hrthm.2025.01.003","article-title":"Late-gadolinium enhancement predicts appropriate device therapies in nonischemic recipients of primary prevention implantable cardioverter-defibrillators","volume":"22","author":"Kiang","year":"2025","journal-title":"Heart Rhythm J"},{"key":"B16","doi-asserted-by":"publisher","first-page":"2184","DOI":"10.1002\/ehf2.12865","article-title":"Left ventricular midwall fibrosis as a predictor of sudden cardiac death in non-ischaemic dilated cardiomyopathy: a meta-analysis","volume":"7","author":"Wang","year":"2020","journal-title":"ESC Heart Failure"},{"key":"B17","doi-asserted-by":"publisher","first-page":"18e017246","DOI":"10.1161\/CIRCIMAGING.124.017246","article-title":"Prognosis and risk stratification in dilated cardiomyopathy with LVEF\u226435%: cardiac MRI insights for better outcomes","volume":"18","author":"Zhou","year":"2025","journal-title":"Circ Cardiovasc Imaging"},{"key":"B18","doi-asserted-by":"publisher","first-page":"28","DOI":"10.1016\/j.jchf.2016.09.017","article-title":"Late gadolinium enhancement and the risk for ventricular arrhythmias or sudden death in dilated cardiomyopathy: systematic review and meta-analysis","volume":"5","author":"Di Marco","year":"2017","journal-title":"JACC Heart Fail"},{"key":"B19","doi-asserted-by":"publisher","first-page":"1046","DOI":"10.1016\/j.jcmg.2016.01.033","article-title":"Myocardial fibrosis assessment by LGE is a powerful predictor of ventricular tachyarrhythmias in ischemic and nonischemic LV dysfunction: a meta-analysis","volume":"9","author":"Disertori","year":"2016","journal-title":"JACC Cardiovasc Imaging"},{"key":"B20","doi-asserted-by":"publisher","first-page":"e010105","DOI":"10.1161\/CIRCIMAGING.119.010105","article-title":"Prognostic value of late gadolinium enhancement for the prediction of cardiovascular outcomes in dilated cardiomyopathy: an international, multi-institutional study of the MINICOR group","volume":"13","author":"Alba","year":"2020","journal-title":"Circ Cardiovasc Imaging"},{"key":"B21","doi-asserted-by":"publisher","first-page":"1343","DOI":"10.1161\/CIRCULATIONAHA.120.04847","article-title":"Relationship of LVEF and myocardial scar to long-term mortality risk and mode of death in patients with nonischemic cardiomyopathy","volume":"143","author":"Klem","year":"2021","journal-title":"Circulation"},{"key":"B22","doi-asserted-by":"publisher","first-page":"e272","DOI":"10.1161\/CIR.0000000000000549","article-title":"2017 AHA\/ACC\/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology\/American Heart Association task force on clinical practice guidelines and the heart rhythm society","volume":"138","author":"Al-Khatib","year":"2018","journal-title":"Circulation"},{"key":"B23","doi-asserted-by":"publisher","first-page":"1601","DOI":"10.1093\/europace\/euv319","article-title":"2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: the task force for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death of the European Society of Cardiology.","volume":"11","author":"Priori","year":"2015","journal-title":"Europace"},{"key":"B24","doi-asserted-by":"publisher","first-page":"1221","DOI":"10.1056\/NEJMoa1608029","article-title":"Defibrillator implantation in patients with nonischemic systolic heart failure","volume":"375","author":"K\u00f8ber","year":"2016","journal-title":"N Engl J Med"},{"key":"B25","doi-asserted-by":"publisher","first-page":"1179","DOI":"10.1161\/circulationaha.123.065560","article-title":"Implantable cardioverter defibrillator in patients with nonischemic systolic heart failure with and without cardiac resynchronization therapy: extended follow-up study of the DANISH trial","volume":"148","author":"Butt","year":"2023","journal-title":"Circulation"},{"key":"B26","doi-asserted-by":"publisher","first-page":"1530","DOI":"10.1161\/CIRCULATIONAHA.119.043012","article-title":"Association between use of primary-prevention implantable cardioverter-defibrillators and mortality in patients with heart failure: a prospective propensity score-matched analysis from the Swedish heart failure registry","volume":"140","author":"Schrage","year":"2019","journal-title":"Circulation"},{"key":"B27","doi-asserted-by":"publisher","first-page":"245","DOI":"10.1111\/pace.13869","article-title":"Long-term follow-up of implantable cardioverter defibrillator patients with regard to appropriate therapy, complications, and mortality","volume":"43","author":"Mattsson","year":"2020","journal-title":"Pacing Clin Electrophysiol"},{"key":"B28","doi-asserted-by":"publisher","first-page":"685","DOI":"10.1001\/jamacardio.2017.0630","article-title":"Primary prevention implantable cardioverter defibrillators in patients with nonischemic cardiomyopathy: a meta-analysis","volume":"2","author":"Al-Khatib","year":"2017","journal-title":"JAMA Cardiol"},{"key":"B29","doi-asserted-by":"publisher","first-page":"201","DOI":"10.1161\/CIRCULATIONAHA.116.026056","article-title":"Implantable cardioverter-defibrillator for nonischemic cardiomyopathy: an updated meta-analysis","volume":"135","author":"Golwala","year":"2017","journal-title":"Circulation"},{"key":"B30","doi-asserted-by":"publisher","first-page":"103","DOI":"10.7326\/M17-0120","article-title":"Implantable cardioverter-defibrillators for primary prevention in patients with ischemic or nonischemic cardiomyopathy: a systematic review and meta-analysis","volume":"167","author":"Kolodziejczak","year":"2017","journal-title":"Ann Intern Med"},{"key":"B31","doi-asserted-by":"publisher","first-page":"1196","DOI":"10.1007\/s00380-018-01337-2","article-title":"Can we rely on DANISH? Real-world data on patients with nonischemic cardiomyopathy from the German device registry","volume":"34","author":"Frommeyer","year":"2019","journal-title":"Heart Vessels"},{"key":"B32","doi-asserted-by":"publisher","first-page":"297","DOI":"10.1002\/ehf2.12407","article-title":"Association between mortality and implantable cardioverter-defibrillators by aetiology of heart failure: a propensity-matched analysis of the WARCEF trial","volume":"6","author":"Lee","year":"2019","journal-title":"ESC Heart Fail"},{"key":"B33","doi-asserted-by":"publisher","first-page":"803","DOI":"10.1111\/echo.12142","article-title":"Independent role of left ventricular global longitudinal strain in predicting prognosis of chronic heart failure patients","volume":"30","author":"Iacovello","year":"2013","journal-title":"Echocardiography"},{"key":"B34","doi-asserted-by":"publisher","first-page":"2956","DOI":"10.1002\/ehf2.12910","article-title":"Global longitudinal strain for prediction of ventricular arrhythmia in patients with heart failure","volume":"7","author":"Nikoo","year":"2020","journal-title":"ESC Heart Fail"},{"key":"B35","doi-asserted-by":"publisher","first-page":"448","DOI":"10.1001\/jamacardio.2020.7184","article-title":"Association of global longitudinal strain with clinical status and mortality in patients with chronic heart failure","volume":"6","author":"Trobs","year":"2021","journal-title":"JAMA Cardiology"},{"key":"B36","doi-asserted-by":"publisher","first-page":"721","DOI":"10.1111\/pace.14706","article-title":"Reduced inferior wall longitudinal strain is associated with malignant arrhythmias in non-ischemic heart failure","volume":"46","author":"Winslow","year":"2023","journal-title":"Pacing Clin Electrophysiol"},{"key":"B37","doi-asserted-by":"publisher","first-page":"667","DOI":"10.1016\/j.echo.2012.02.004","article-title":"Risk assessment of ventricular arrhythmias in patients with nonischemic dilated cardiomyopathy by strain echocardiography","volume":"25","author":"Haugaa","year":"2012","journal-title":"J Am Soc Echocardiogr"},{"key":"B38","doi-asserted-by":"publisher","first-page":"7115","DOI":"10.3390\/ijms22137115","article-title":"CMR-based risk stratification of sudden cardiac death and use of implantable cardioverter\u2013defibrillator in non-ischemic cardiomyopathy","volume":"22","author":"Keil","year":"2021","journal-title":"Int J Mol Sci"},{"key":"B39","doi-asserted-by":"publisher","first-page":"2890","DOI":"10.1016\/j.jacc.2021.04.030","article-title":"Improved risk stratification for ventricular arrhythmias and sudden death in patients with nonischemic dilated cardiomyopathy","volume":"77","author":"Di Marco","year":"2021","journal-title":"J Am Coll Cardiol"},{"key":"B40","doi-asserted-by":"publisher","first-page":"523","DOI":"10.1007\/s10840-021-01027-6","article-title":"the prognostic role of late gadolinium enhancement on cardiac magnetic resonance in patients with nonischemic cardiomyopathy and reduced ejection fraction, implanted with cardioverter defibrillators for primary prevention. A systematic review and meta-analysis","volume":"63","author":"Anagnostopoulos","year":"2022","journal-title":"J Interv Card Electrophysiol"},{"key":"B41","doi-asserted-by":"publisher","first-page":"2906","DOI":"10.1016\/j.jacc.2021.04.031","article-title":"Refining the approach to risk stratification in patients with dilated cardiomyopathy","volume":"77","author":"Curtis","year":"2021","journal-title":"J Am Coll Cardiol"},{"key":"B42","doi-asserted-by":"publisher","first-page":"1609","DOI":"10.1093\/ehjci\/jeaf198","article-title":"Redefining the risk of major arrhythmic events in non-ischaemic cardiomyopathy: insights from the DERIVATE-NICM study","volume":"26","author":"Guaricci","year":"2025","journal-title":"Eur Heart J Cardiovasc Imaging"},{"key":"B43","doi-asserted-by":"publisher","first-page":"895","DOI":"10.3390\/jcm14030895","article-title":"Late gadolinium enhancement magnetic resonance imaging (MRI) for predicting left ventricular reverse remodeling in non-ischemic cardiomyopathy: a systematic review and meta-analysis","volume":"14","author":"Teraoka","year":"2025","journal-title":"J Clin Med"},{"key":"B44","doi-asserted-by":"publisher","first-page":"e040517","DOI":"10.1161\/JAHA.124.040517","article-title":"Fibrosis entropy is associated with life-threatening arrhythmia in nonischemic cardiomyopathy","volume":"14","author":"Hammersley","year":"2025","journal-title":"J Am Heart Assoc"},{"key":"B45","doi-asserted-by":"publisher","first-page":"475","DOI":"10.1016\/j.jcmg.2012.08.019","article-title":"Native T1 mapping in differentiation of normal myocardium from diffuse disease in hypertrophic and dilated cardiomyopathy","volume":"6","author":"Puntmann","year":"2013","journal-title":"JACC Cardiovasc Imaging"},{"key":"B46","doi-asserted-by":"publisher","first-page":"75","DOI":"10.1186\/s12968-017-0389-8","article-title":"Clinical recommendations for cardiovascular magnetic resonance mapping of T1, T2, T2*, and ECV","volume":"19","author":"Messroghli","year":"2017","journal-title":"J Cardiovasc Magn Reson"},{"key":"B47","doi-asserted-by":"publisher","first-page":"3555","DOI":"10.1093\/eurheartj\/ehaf464","article-title":"Late gadolinium enhancement imaging and sudden cardiac death","volume":"46","author":"Prasad","year":"2025","journal-title":"Eur Heart J"},{"key":"B48","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.jchf.2024.09.014","article-title":"Revisiting ICD therapy for primary prevention in patients with heart failure and reduced ejection fraction","volume":"13","author":"Yehya","year":"2025","journal-title":"Heart Fail"},{"key":"B49","doi-asserted-by":"publisher","first-page":"1040","DOI":"10.1016\/j.hrthm.2024.10.078","article-title":"Reassessing the need for primary prevention implantable cardioverter\u2013defibrillators in contemporary patients with heart failure","volume":"22","author":"Goldenberg","year":"2025","journal-title":"Heart Rhythm"}],"container-title":["Frontiers in Cardiovascular Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2026.1766952\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T04:43:23Z","timestamp":1779252203000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2026.1766952\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,20]]},"references-count":49,"alternative-id":["10.3389\/fcvm.2026.1766952"],"URL":"https:\/\/doi.org\/10.3389\/fcvm.2026.1766952","relation":{},"ISSN":["2297-055X"],"issn-type":[{"value":"2297-055X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,20]]},"article-number":"1766952"}}