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      Prognostic value of myocardial strain and late gadolinium enhancement on cardiovascular magnetic resonance imaging in patients with idiopathic dilated cardiomyopathy with moderate to severely reduced ejection fraction

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          Abstract

          Background

          It has been reported that left ventricular (LV) myocardial strain and late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) imaging have prognostic value in patients with heart failure (HF). However, previous studies included patients with various systolic functions. This study aimed to investigate the prognostic value of LV myocardial strain and LGE on CMR imaging in patients with idiopathic dilated cardiomyopathy (DCM) with reduced ejection fraction (EF < 40%).

          Methods

          From a prospectively followed cohort who underwent CMR between November 2008 and December 2015, subjects with LV EF < 40% and a diagnosis of idiopathic DCM were eligible for this study. The CMR images were analyzed for LV and right ventricular (RV) function, presence and extent of LGE, and LV myocardial strain. The primary outcome was a composite of all-cause death and heart transplantation. The secondary outcome was hospitalization for HF.

          Results

          A total of 172 patients were included, in whom mean LV EF was 23.7 ± 7.9% (EF 30–40% n = 47; EF < 30% n = 125). During a median follow-up of 47 months, the primary outcome occurred in 43 patients (16 heart transplantations, 29 all-cause deaths), and there were 41 hospitalizations for HF. Univariate Cox proportional hazard regression analysis showed that mean arterial pressure, serum sodium concentration, log of plasma NT-proBNP level, and presence of LGE (HR 2.277, 95% CI: 1.221–4.246) were significantly associated with the primary outcome. However, LV strain had no significant association (HR 1.048, 95% CI: 0.945–1.163). Multivariable analysis showed that presence of LGE (HR 4.73, 95% CI: 1.11–20.12) and serum sodium (HR 0.823, 95% CI: 0.762–0.887) were independently associated with the primary outcome.

          Conclusions

          LGE in CMR imaging was a good predictor of adverse outcomes for patients with idiopathic DCM and reduced EF. Identification of LGE could thus improve risk stratification in high-risk patients. LV strain had no significant prognostic value in patients with moderate to severe systolic dysfunction.

          Electronic supplementary material

          The online version of this article (10.1186/s12968-018-0466-7) contains supplementary material, which is available to authorized users.

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          Most cited references31

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          Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention.

          Barry J Maron, Jeffrey A. Towbin, Gaetano Thiene … (2006)
          Classifications of heart muscle diseases have proved to be exceedingly complex and in many respects contradictory. Indeed, the precise language used to describe these diseases is profoundly important. A new contemporary and rigorous classification of cardiomyopathies (with definitions) is proposed here. This reference document affords an important framework and measure of clarity to this heterogeneous group of diseases. Of particular note, the present classification scheme recognizes the rapid evolution of molecular genetics in cardiology, as well as the introduction of several recently described diseases, and is unique in that it incorporates ion channelopathies as a primary cardiomyopathy.
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            Association of fibrosis with mortality and sudden cardiac death in patients with nonischemic dilated cardiomyopathy.

            Ankur Gulati, Andrew Jabbour, Tevfik Ismail … (2013)
            Risk stratification of patients with nonischemic dilated cardiomyopathy is primarily based on left ventricular ejection fraction (LVEF). Superior prognostic factors may improve patient selection for implantable cardioverter-defibrillators (ICDs) and other management decisions. To determine whether myocardial fibrosis (detected by late gadolinium enhancement cardiovascular magnetic resonance [LGE-CMR] imaging) is an independent and incremental predictor of mortality and sudden cardiac death (SCD) in dilated cardiomyopathy. Prospective, longitudinal study of 472 patients with dilated cardiomyopathy referred to a UK center for CMR imaging between November 2000 and December 2008 after presence and extent of midwall replacement fibrosis were determined. Patients were followed up through December 2011. Primary end point was all-cause mortality. Secondary end points included cardiovascular mortality or cardiac transplantation; an arrhythmic composite of SCD or aborted SCD (appropriate ICD shock, nonfatal ventricular fibrillation, or sustained ventricular tachycardia); and a composite of HF death, HF hospitalization, or cardiac transplantation. Among the 142 patients with midwall fibrosis, there were 38 deaths (26.8%) vs 35 deaths (10.6%) among the 330 patients without fibrosis (hazard ratio [HR], 2.96 [95% CI, 1.87-4.69]; absolute risk difference, 16.2% [95% CI, 8.2%-24.2%]; P < .001) during a median follow-up of 5.3 years (2557 patient-years of follow-up). The arrhythmic composite was reached by 42 patients with fibrosis (29.6%) and 23 patients without fibrosis (7.0%) (HR, 5.24 [95% CI, 3.15-8.72]; absolute risk difference, 22.6% [95% CI, 14.6%-30.6%]; P < .001). After adjustment for LVEF and other conventional prognostic factors, both the presence of fibrosis (HR, 2.43 [95% CI, 1.50-3.92]; P < .001) and the extent (HR, 1.11 [95% CI, 1.06-1.16]; P < .001) were independently and incrementally associated with all-cause mortality. Fibrosis was also independently associated with cardiovascular mortality or cardiac transplantation (by fibrosis presence: HR, 3.22 [95% CI, 1.95-5.31], P < .001; and by fibrosis extent: HR, 1.15 [95% CI, 1.10-1.20], P < .001), SCD or aborted SCD (by fibrosis presence: HR, 4.61 [95% CI, 2.75-7.74], P < .001; and by fibrosis extent: HR, 1.10 [95% CI, 1.05-1.16], P < .001), and the HF composite (by fibrosis presence: HR, 1.62 [95% CI, 1.00-2.61], P = .049; and by fibrosis extent: HR, 1.08 [95% CI, 1.04-1.13], P < .001). Addition of fibrosis to LVEF significantly improved risk reclassification for all-cause mortality and the SCD composite (net reclassification improvement: 0.26 [95% CI, 0.11-0.41]; P = .001 and 0.29 [95% CI, 0.11-0.48]; P = .002, respectively). Assessment of midwall fibrosis with LGE-CMR imaging provided independent prognostic information beyond LVEF in patients with nonischemic dilated cardiomyopathy. The role of LGE-CMR in the risk stratification of dilated cardiomyopathy requires further investigation.
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              Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators.

              S Yusuf (1991)
              Patients with congestive heart failure have a high mortality rate and are also hospitalized frequently. We studied the effect of an angiotensin-converting-enzyme inhibitor, enalapril, on mortality and hospitalization in patients with chronic heart failure and ejection fractions less than or equal to 0.35. Patients receiving conventional treatment for heart failure were randomly assigned to receive either placebo (n = 1284) or enalapril (n = 1285) at doses of 2.5 to 20 mg per day in a double-bind trial. Approximately 90 percent of the patients were in New York Heart Association functional classes II and III. The follow-up averaged 41.4 months. There were 510 deaths in the placebo group (39.7 percent), as compared with 452 in the enalapril group (35.2 percent) (reduction in risk, 16 percent; 95 percent confidence interval, 5 to 26 percent; P = 0.0036). Although reductions in mortality were observed in several categories of cardiac deaths, the largest reduction occurred among the deaths attributed to progressive heart failure (251 in the placebo group vs. 209 in the enalapril group; reduction in risk, 22 percent; 95 percent confidence interval, 6 to 35 percent). There was little apparent effect of treatment on deaths classified as due to arrhythmia without pump failure. Fewer patients died or were hospitalized for worsening heart failure (736 in the placebo group and 613 in the enalapril group; risk reduction, 26 percent; 95 percent confidence interval, 18 to 34 percent; P less than 0.0001). The addition of enalapril to conventional therapy significantly reduced mortality and hospitalizations for heart failure in patients with chronic congestive heart failure and reduced ejection fractions.
              Article 0 comments Cited 333 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Seung-Hoon Pi: shpv86@gmail.com
                Sung Mok Kim: sm5040.kim@samsung.com
                Jin-Oh Choi:
                ORCID: http://orcid.org/0000-0002-2441-2267
                82-2-3410-3391 , choijean5@gmail.com
                Eun Kyoung Kim: ekbobi.kim@samsung.com
                Sung-A Chang: sunga.chang@samsung.com
                Yeon Hyeon Choe: yh.choe@samsung.com
                Sang-Chol Lee: sc.lea@samsung.com
                Eun-Seok Jeon: eunseok.jeon@samsung.com
                Journal
                Journal ID (nlm-ta): J Cardiovasc Magn Reson
                Journal ID (iso-abbrev): J Cardiovasc Magn Reson
                Title: Journal of Cardiovascular Magnetic Resonance
                Publisher: BioMed Central (London )
                ISSN (Print): 1097-6647
                ISSN (Electronic): 1532-429X
                Publication date (Electronic): 14 June 2018
                Publication date PMC-release: 14 June 2018
                Publication date Collection: 2018
                Volume: 20
                Electronic Location Identifier: 36
                Affiliations
                [1 ]ISNI 0000 0001 2181 989X, GRID grid.264381.a, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, , Sungkyunkwan University School of Medicine, ; 81 Irwon-ro, Gangnam-gu, Seoul, 06351 Republic of Korea
                [2 ]ISNI 0000 0001 2181 989X, GRID grid.264381.a, Department of Radiology, Cardiovascular Imaging Center, Samsung Medical Center, , Sungkyunkwan University School of Medicine, ; Seoul, Republic of Korea
                Author information
                http://orcid.org/0000-0002-2441-2267
                Article
                Publisher ID: 466
                DOI: 10.1186/s12968-018-0466-7
                PMC ID: 6001169
                PubMed ID: 29898740
                SO-VID: bee77666-5bcf-4468-bb81-28e1d92619a6
                Copyright © © The Author(s). 2018
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 11 October 2017
                Date accepted : 25 May 2018
                Categories
                Subject: Research
                Custom metadata
                issue-copyright-statement © The Author(s) 2018

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: cardiovascular magnetic resonance imaging,myocardial strain,prognosis,late gadolinium enhancement,idiopathic dilated cardiomyopathy
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: cardiovascular magnetic resonance imaging, myocardial strain, prognosis, late gadolinium enhancement, idiopathic dilated cardiomyopathy

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