Arrhythmic risk stratification in non-ischemic dilated cardiomyopathy: Where do we stand after DANISH?

Publication of the DANISH randomized trial led to considerable debate, given that it demonstrated no survival benefit stemming from current implantable cardioverter-defibrillator (ICD) allocation criteria in patients with non-ischemic dilated cardiomyopathy (NIDCM). Consequently, a thorough reconsideration of our approach to sudden cardiac death (SCD)-risk stratification appears to be in order. NIDCM encompasses a wide spectrum of disease entities, often with differing arrhythmogenicity; however, in its kernel, is still defined by the fundamentals of electrophysiology that dictate that abnormal tissue, exhibiting altered electrophysiological properties is necessary for arrhythmogenesis, but not enough, given that formation of functional circuits is required. In this review article, we will attempt a presentation of the current status in SCD-risk stratification in NIDCM and introduce the concept of multifactorial tiered approach, bringing together non-invasive indices of arrhythmic potential and programmed ventricular stimulation, as an alternative approach, in order to finally delineate a potential basis for the design and realization of trials necessary to achieve a paradigm shift and improvement in NIDCM SCD-risk stratification.