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Time has come to sunset the signal-averaged electrocardiogram for evaluation of patients with suspected arrhythmogenic right ventricular cardiomyopathy

Published:October 27, 2022DOI:https://doi.org/10.1016/j.hrthm.2022.10.022
      Slow conduction within the myocardium can be a substrate for ventricular tachycardia. Signal-averaged electrocardiogram (SAECG) is a method to identify slow conduction manifested as late potential. For arrhythmogenic right ventricular cardiomyopathy (ARVC), late potentials were included in the 1994 diagnostic criteria as a minor criterion,
      • McKenna W.J.
      • Thiene G.
      • Nava A.
      • et al.
      Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy. Task Force of the Working Group Myocardial and Pericardial Disease of the European Society of Cardiology and of the Scientific Council on Cardiomyopathies of the International Society and Federation of Cardiology.
      which was based on an early experience examining 12 patients with ARVC.
      • Blomström-Lundqvist C.
      • Olsson S.B.
      • Edvardsson N.
      Follow-up by repeated signal-averaged surface QRS in patients with the syndrome of arrhythmogenic right ventricular dysplasia.
      Later, in a comparison of 87 ARVC probands to 103 controls, abnormal SAECG (any 1 of 3 components) was reported to have sensitivity of 69% and specificity of 95% in diagnosing ARVC.
      • Kamath G.S.
      • Zareba W.
      • Delaney J.
      • et al.
      Value of the signal-averaged electrocardiogram in arrhythmogenic right ventricular cardiomyopathy/dysplasia.
      In the same report, abnormal SAECG was associated with right ventricular dysfunction and dilation but not with clinical presentation or ventricular arrhythmia. This served as the evidence for SAECG to remain as a minor criterion in the 2010 Task Force Criteria.
      • Marcus F.I.
      • McKenna W.J.
      • Sherrill D.
      • et al.
      Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D).
      However, the evidence for SAECG in the diagnosis of ARVC has never been robust, and the normal value of SAECG in patients with complete or incomplete right bundle branch block (which is common in ARVC patients) is not known. Furthermore, the normal values of SAECG actually were derived from postinfarction patients,
      • Marcus F.I.
      • Zareba W.
      • Sherrill D.
      Evaluation of the normal values for signal-averaged electrocardiogram.
      as SAECG was studied extensively in patients with coronary artery disease. Given the uncertain value of an abnormal SAECG, its use has declined significantly. In 2020, in a 2-center study examining 407 patients referred for ARVC evaluation, abnormal SAECG occurred in 50% of ARVC cases and 50% of non-ARVC cases, lacking both sensitivity and specificity.
      • Bosman L.P.
      • Cadrin-Tourigny J.
      • Bourfiss M.
      • et al.
      Diagnosing arrhythmogenic right ventricular cardiomyopathy by 2010 Task Force Criteria: clinical performance and simplified practical implementation.
      It was suggested that eliminating SAECG from ARVC diagnosis criteria could simplify the diagnosis and improve accuracy. In this context, in a study reported in this issue of Heart Rhythm Journal, Pearman et al

      Pearman, CM, Lee D, Davies B, et al. The incremental value of the signal averaged ECG for diagnosing arrhythmogenic cardiomyopathy. Heart Rhythm 202X;XX:XXX–XXX.

      evaluated the incremental value of the SAECG for diagnosing ARVC from the Canadian ARVC Registry.
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