Patients with ischemic cardiomyopathy and an impaired LVEF demonstrated a survival benefit after ICD implantation in the Multicenter Automatic Defibrillator Trial (MADIT II) and the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) [
3,
4]. The majority of individuals who suffer from SCD, however, have an LVEF > 35%. Impaired LV global longitudinal strain (GLS) and increased LVMD (Fig.
2) on speckle tracking strain echocardiography have been independently associated with ventricular arrhythmias and SCD in patients with previous myocardial infarction, including those with an LVEF > 35% [
6]. Visualization of LGE on CMR also represents a potential solution to the risk stratification of individuals with an LVEF > 35%, since both the presence and extent of LGE have been independently linked to SCD and ventricular arrhythmias in persons with ischemic cardiomyopathy, regardless of LVEF (Fig.
2; [
7,
8]). Quantification of the grey zone on CMR, in addition to being independent of LVEF for predicting SCD, has been shown to be superior to the LGE burden (Fig.
2; [
9,
10]). As an alternative to echocardiographic LVMD, SPECT has the ability to appraise LV dyssynchrony. In a study of 183 patients with severely impaired LVEF, those with greater SPECT-derived dyssynchrony experienced a higher frequency of ventricular arrhythmias [
11]. Since no multivariable analysis was performed, no firm conclusion can be drawn regarding the additive value of dyssynchrony measured on SPECT for SCD risk estimation [
11]. In a study of > 4500 patients with an LVEF > 35%, the extent of myocardial perfusion defects on SPECT was associated with SCD, demonstrating the potential value of imaging SCD triggers, in addition to the substrate [
12]. Imaging the third limb of Coumel’s triangle, i.e. modulating factors of SCD, is currently the preserve of nuclear medicine. The AdreView Myocardial Imaging for Risk Evaluation in Heart Failure (ADMIRE-HF) trial investigated the role of
123I‑mIBG in predicting outcome in 961 patients with ischemic and non-ischemic cardiomyopathy and an LVEF < 35% [
13]. The occurrence of SCD was associated with myocardial sympathetic dysfunction as part of a combined endpoint [
13]. Similarly, in the Prediction of Arrhythmic Events with Positron Emission Tomography (PAREPET) trial, a greater burden of sympathetic denervation (visualized with
11C‑hydroxyephedrine PET) was associated with SCD in primary prevention ICD candidates with ischemic cardiomyopathy [
14]. The Cardiovascular Magnetic Resonance Guided Management of Mild-Moderate Left Ventricular Systolic Dysfunction (CMR-GUIDE; NCT01918215) trial is a prospective, randomized study which is currently enrolling participants with an LVEF of 36–50%, i.e. persons who would not receive an ICD according to current guidelines [
15]. In the Prediction of Arrhythmic Events With Positron Emission Tomography (PAREPET) II (NCT03493516) trial, the utility of
18F‑LMI1195 (a fluorinated noradrenaline analogue with a longer t
1/2 than
11C‑labelled compounds, having the advantage of allowing delivery from a remote cyclotron) will be evaluated for the prediction of SCD in ischemic cardiomyopathy.