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Eichhorn C, Koeckerling D, Reddy RK, Ardissino M, Rogowski M, Coles B, Hunziker L, Greulich S, Shiri I, Frey N, Eckstein J, Windecker S, Kwong RY, Siontis GCM, Gräni C. Risk Stratification in Nonischemic Dilated Cardiomyopathy Using CMR Imaging: A Systematic Review and Meta-Analysis. JAMA 2024:2823869. [PMID: 39298146 PMCID: PMC11413760 DOI: 10.1001/jama.2024.13946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 06/25/2024] [Indexed: 09/25/2024]
Abstract
Importance Accurate risk stratification of nonischemic dilated cardiomyopathy (NIDCM) remains challenging. Objective To evaluate the association of cardiac magnetic resonance (CMR) imaging-derived measurements with clinical outcomes in NIDCM. Data Sources MEDLINE, Embase, Cochrane Library, and Web of Science Core Collection databases were systematically searched for articles from January 2005 to April 2023. Study Selection Prospective and retrospective nonrandomized diagnostic studies reporting on the association between CMR imaging-derived measurements and adverse clinical outcomes in NIDCM were deemed eligible. Data Extraction and Synthesis Prespecified items related to patient population, CMR imaging measurements, and clinical outcomes were extracted at the study level by 2 independent reviewers. Random-effects models were fitted using restricted maximum likelihood estimation and the method of Hartung, Knapp, Sidik, and Jonkman. Main Outcomes and Measures All-cause mortality, cardiovascular mortality, arrhythmic events, heart failure events, and major adverse cardiac events (MACE). Results A total of 103 studies including 29 687 patients with NIDCM were analyzed. Late gadolinium enhancement (LGE) presence and extent (per 1%) were associated with higher all-cause mortality (hazard ratio [HR], 1.81 [95% CI, 1.60-2.04]; P < .001 and HR, 1.07 [95% CI, 1.02-1.12]; P = .02, respectively), cardiovascular mortality (HR, 2.43 [95% CI, 2.13-2.78]; P < .001 and HR, 1.15 [95% CI, 1.07-1.24]; P = .01), arrhythmic events (HR, 2.69 [95% CI, 2.20-3.30]; P < .001 and HR, 1.07 [95% CI, 1.03-1.12]; P = .004) and heart failure events (HR, 1.98 [95% CI, 1.73-2.27]; P < .001 and HR, 1.06 [95% CI, 1.01-1.10]; P = .02). Left ventricular ejection fraction (LVEF) (per 1%) was not associated with all-cause mortality (HR, 0.99 [95% CI, 0.97-1.02]; P = .47), cardiovascular mortality (HR, 0.97 [95% CI, 0.94-1.00]; P = .05), or arrhythmic outcomes (HR, 0.99 [95% CI, 0.97-1.01]; P = .34). Lower risks for heart failure events (HR, 0.97 [95% CI, 0.95-0.98]; P = .002) and MACE (HR, 0.98 [95% CI, 0.96-0.99]; P < .001) were observed with higher LVEF. Higher native T1 relaxation times (per 10 ms) were associated with arrhythmic events (HR, 1.07 [95% CI, 1.01-1.14]; P = .04) and MACE (HR, 1.06 [95% CI, 1.01-1.11]; P = .03). Global longitudinal strain (GLS) (per 1%) was not associated with heart failure events (HR, 1.06 [95% CI, 0.95-1.18]; P = .15) or MACE (HR, 1.03 [95% CI, 0.94-1.14]; P = .43). Limited data precluded definitive analysis for native T1 relaxation times, GLS, and extracellular volume fraction (ECV) with respect to mortality outcomes. Conclusion The presence and extent of LGE were associated with various adverse clinical outcomes, whereas LVEF was not significantly associated with mortality and arrhythmic end points in NIDCM. Risk stratification using native T1 relaxation times, extracellular volume fraction, and global longitudinal strain requires further evaluation.
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Affiliation(s)
- Christian Eichhorn
- Division of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Private University in the Principality of Liechtenstein, Triesen
- Department of Internal Medicine, See-Spital, Horgen, Switzerland
| | - David Koeckerling
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Rohin K. Reddy
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Maddalena Ardissino
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Marek Rogowski
- Private University in the Principality of Liechtenstein, Triesen
- Agaplesion General Hospital, Hagen, Germany
| | - Bernadette Coles
- Velindre University NHS Trust Library & Knowledge Service, Cardiff University, Cardiff, Wales
| | - Lukas Hunziker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon Greulich
- Department of Cardiology and Angiology, University of Tübingen, Tübingen, Germany
| | - Isaac Shiri
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Norbert Frey
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jens Eckstein
- Division of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raymond Y. Kwong
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - George C. M. Siontis
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Ma HY, Xie GY, Tao J, Li ZZ, Liu P, Zheng XJ, Wang RP. Identification of patients with nonischemic dilated cardiomyopathy at risk of malignant ventricular arrhythmias: insights from cardiac magnetic resonance feature tracking. BMC Cardiovasc Disord 2024; 24:29. [PMID: 38172720 PMCID: PMC10765793 DOI: 10.1186/s12872-023-03655-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 12/04/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Patients with nonischemic dilated cardiomyopathy (NIDCM) are prone to arrhythmias, and the cause of mortality in these patients is either end-organ dysfunction due to pump failure or malignant arrhythmia-related death. However, the identification of patients with NIDCM at risk of malignant ventricular arrhythmias (VAs) is challenging in clinical practice. The aim of this study was to evaluate whether cardiovascular magnetic resonance feature tracking (CMR-FT) could help in the identification of patients with NIDCM at risk of malignant VAs. METHODS A total of 263 NIDCM patients who underwent CMR, 24-hour Holter electrocardiography (ECG) and inpatient ECG were retrospectively evaluated. The patients with NIDCM were allocated to two subgroups: NIDCM with VAs and NIDCM without VAs. From CMR-FT, the global peak radial strain (GPRS), global longitudinal strain (GPLS), and global peak circumferential strain (GPCS) were calculated from the left ventricle (LV) model. We investigated the possible predictors of NIDCM combined with VAs by univariate and multivariate logistic regression analyses. RESULTS The percent LGE (15.51 ± 3.30 vs. 9.62 ± 2.18, P < 0.001) was higher in NIDCM patients with VAs than in NIDCM patients without VAs. Furthermore, the NIDCM patients complicated with VAs had significantly lower GPCS than the NIDCM patients without VAs (- 5.38 (- 7.50, - 4.22) vs.-9.22 (- 10.73, - 8.19), P < 0.01). Subgroup analysis based on LGE negativity showed that NIDCM patients complicated with VAs had significantly lower GPRS, GPCS, and GPLS than NIDCM patients without VAs (P < 0.05 for all). Multivariate analysis showed that both GPCS and %LGE were independent predictors of NIDCM combined with VAs. CONCLUSIONS CMR global strain can be used to identify NIDCM patients complicated with VAs early, specifically when LGE is not present. GPCS < - 13.19% and %LGE > 10.37% are independent predictors of NIDCM combined with VAs.
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Affiliation(s)
- Hai-Yan Ma
- Department of Radiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Guang-You Xie
- Department of Radiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Jian Tao
- Department of Radiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Zong-Zhuang Li
- Department of Cardiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Pan Liu
- Department of Radiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Xing-Ju Zheng
- Department of Radiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Rong-Pin Wang
- Department of Radiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China.
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Feng XY, He WF, Zhang TY, Wang LL, Yang F, Feng YL, Li CP, Li R. Association between late gadolinium enhancement and outcome in dilated cardiomyopathy: A meta-analysis. World J Radiol 2023; 15:324-337. [PMID: 38058605 PMCID: PMC10696187 DOI: 10.4329/wjr.v15.i11.324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/29/2023] [Accepted: 10/23/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND The prognostic value of late gadolinium enhancement (LGE) derived from cardiovascular magnetic resonance (CMR) is well studied, and several new metrics of LGE have emerged. However, some controversies remain; therefore, further discussion is needed, and more precise risk stratification should be explored. AIM To investigate the associations between the positivity, extent, location, and pattern of LGE and multiple outcomes in dilated cardiomyopathy (DCM). METHODS PubMed, Ovid MEDLINE, and Cochrane Library were searched for studies that investigated the prognostic value of LGE in patients with DCM. Pooled hazard ratios (HRs) and 95% confidence intervals were calculated to assess the role of LGE in the risk stratification of DCM. RESULTS Nineteen studies involving 7330 patients with DCM were included in this meta-analysis and covered a wide spectrum of DCM, with a mean left ventricular ejection fraction between 21% and 50%. The meta-analysis revealed that the presence of LGE was associated with an increased risk of multiple adverse outcomes (all-cause mortality, HR: 2.14; arrhythmic events, HR: 5.12; and composite endpoints, HR: 2.38; all P < 0.001). Furthermore, every 1% increment in the extent of LGE was associated with an increased risk of all-cause mortality. Analysis of a subgroup revealed that the prognostic value varied based on different location and pattern of LGE. Additionally, we found that LGE was a stronger predictor of arrhythmic events in patients with greater left ventricular ejection fraction. CONCLUSION LGE by CMR in patients with DCM exhibited a substantial value in predicting adverse outcomes, and the extent, location, and pattern of LGE could provide additional information for risk stratification.
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Affiliation(s)
- Xin-Yi Feng
- Department of Radiology, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Wen-Feng He
- Department of Cardiology, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Tian-Yue Zhang
- Department of Radiology, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Ling-Li Wang
- Department of Radiology, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Fan Yang
- Department of Radiology, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Yu-Ling Feng
- Department of Radiology, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Chun-Ping Li
- Department of Radiology, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Rui Li
- Department of Radiology, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
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Theerasuwipakorn N, Chokesuwattanaskul R, Phannajit J, Marsukjai A, Thapanasuta M, Klem I, Chattranukulchai P. Impact of late gadolinium-enhanced cardiac MRI on arrhythmic and mortality outcomes in nonischemic dilated cardiomyopathy: updated systematic review and meta-analysis. Sci Rep 2023; 13:13775. [PMID: 37612359 PMCID: PMC10447440 DOI: 10.1038/s41598-023-41087-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 08/22/2023] [Indexed: 08/25/2023] Open
Abstract
Risk stratification based mainly on the impairment of left ventricular ejection fraction has limited performance in patients with nonischemic dilated cardiomyopathy (NIDCM). Evidence is rapidly growing for the impact of myocardial scar identified by late gadolinium enhancement (LGE) cardiac magnetic resonance imaging (CMR) on cardiovascular events. We aim to assess the prognostic value of LGE on long-term arrhythmic and mortality outcomes in patients with NIDCM. PubMed, Scopus, and Cochrane databases were searched from inception to January 21, 2022. Studies that included disease-specific subpopulations of NIDCM were excluded. Data were independently extracted and combined via random-effects meta-analysis using a generic inverse-variance strategy. Data from 60 studies comprising 15,217 patients were analyzed with a 3-year median follow-up. The presence of LGE was associated with major ventricular arrhythmic events (pooled OR: 3.99; 95% CI 3.08, 5.16), all-cause mortality (pooled OR: 2.14; 95% CI 1.81, 2.52), cardiovascular mortality (pooled OR 2.83; 95% CI 2.23, 3.60), and heart failure hospitalization (pooled OR: 2.53; 95% CI 1.78, 3.59). Real-world evidence suggests that the presence of LGE on CMR was a strong predictor of adverse long-term outcomes in patients with NIDCM. Scar assessment should be incorporated as a primary determinant in the patient selection criteria for primary prophylactic implantable cardioverter-defibrillator placement.
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Affiliation(s)
- Nonthikorn Theerasuwipakorn
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Ronpichai Chokesuwattanaskul
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Jeerath Phannajit
- Division of Clinical Epidemiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Apichai Marsukjai
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Mananchaya Thapanasuta
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Igor Klem
- Duke Cardiovascular Magnetic Resonance Center, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Pairoj Chattranukulchai
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand.
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De Lio F, Andreis A, De Lio G, Bellettini M, Pidello S, Raineri C, Gallone G, Alunni G, Frea S, Imazio M, Castagno D, De Ferrari GM. Cardiac imaging for the prediction of sudden cardiac arrest in patients with heart failure. Heliyon 2023; 9:e17710. [PMID: 37456051 PMCID: PMC10338975 DOI: 10.1016/j.heliyon.2023.e17710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/11/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023] Open
Abstract
The identification of heart failure (HF) patients at risk for arrhythmic sudden cardiac arrest (SCA) is a major challenge in the cardiovascular field. In addition to optimal medical treatment for HF, implantable cardioverter defibrillator (ICD) is currently recommended to prevent SCA in patients with reduced left ventricular ejection fraction (LVEF). The indication for an ICD implantation, in addition to HF etiology, New York Health Association (NYHA) class and life expectancy, mainly depends on LVEF value at echocardiography. However, the actual role of LVEF in the prediction of SCA has recently been debated, while newer multimodality imaging techniques with increased prognostic accuracy have been developed. Speckle tracking imaging allows the quantification of mechanical dispersion, a marker of electrophysiological heterogeneity predisposing to malignant arrhythmias, while advanced cardiac magnetic resonance techniques such as myocardial T1-mapping and extracellular volume fraction assessment allow the evaluation of interstitial diffuse fibrosis. Nuclear imaging is helpful for the appraisal of sympathetic nervous system dysfunction, while newer computed tomography techniques assessing myocardial delayed enhancement allow the identification of focal myocardial scar. This review will focus on the most modern advances in the field of cardiovascular imaging along with its applications for the prediction of SCA in patients with HF. Modern artificial intelligence applications in cardiovascular imaging will also be discussed.
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Affiliation(s)
- Francesca De Lio
- Division of Cardiology, Città della Salute e della Scienza di Torino University Hospital, University of Torino, Turin, Italy
| | - Alessandro Andreis
- Division of Cardiology, Città della Salute e della Scienza di Torino University Hospital, University of Torino, Turin, Italy
| | - Giulia De Lio
- Division of Cardiology, Città della Salute e della Scienza di Torino University Hospital, University of Torino, Turin, Italy
| | - Matteo Bellettini
- Division of Cardiology, Città della Salute e della Scienza di Torino University Hospital, University of Torino, Turin, Italy
| | - Stefano Pidello
- Division of Cardiology, Città della Salute e della Scienza di Torino University Hospital, University of Torino, Turin, Italy
| | - Claudia Raineri
- Division of Cardiology, Città della Salute e della Scienza di Torino University Hospital, University of Torino, Turin, Italy
| | - Guglielmo Gallone
- Division of Cardiology, Città della Salute e della Scienza di Torino University Hospital, University of Torino, Turin, Italy
| | - Gianluca Alunni
- Division of Cardiology, Città della Salute e della Scienza di Torino University Hospital, University of Torino, Turin, Italy
| | - Simone Frea
- Division of Cardiology, Città della Salute e della Scienza di Torino University Hospital, University of Torino, Turin, Italy
| | - Massimo Imazio
- Cardiology Unit, Cardiothoracic Department, University Hospital “Santa Maria della Misericordia”, Udine, Italy
| | - Davide Castagno
- Division of Cardiology, Città della Salute e della Scienza di Torino University Hospital, University of Torino, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Città della Salute e della Scienza di Torino University Hospital, University of Torino, Turin, Italy
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Al-Sadawi M, Aslam F, Tao M, Fan R, Singh A, Rashba E. Association of Late-Gadolinium Enhancement in Cardiac Magnetic Resonance with Mortality, Ventricular Arrhythmias, and Heart Failure in Patients with Non-Ischemic Cardiomyopathy: A Systematic Review and Meta-Analysis. Heart Rhythm O2 2023; 4:241-250. [PMID: 37124560 PMCID: PMC10134398 DOI: 10.1016/j.hroo.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background Late gadolinium enhancement (LGE) on cardiac magnetic resonance is a predictor of adverse events in patients with nonischemic cardiomyopathy (NICM). Objective This meta-analysis evaluated the correlation between LGE and mortality, ventricular arrhythmias (VAs) and sudden cardiac death (SCD), and heart failure (HF) outcomes. Methods A literature search was conducted for studies reporting the association between LGE in NICM and the study endpoints. The primary endpoint was mortality. Secondary endpoints included VA and SCD, HF hospitalization, improvement in left ventricular ejection fraction (LVEF) to >35%, and heart transplantation referral. The search was not restricted to time or publication status. The minimum follow-up duration was 1 year. Results A total of 46 studies and 10,548 NICM patients (4610 with LGE, 5938 without LGE) were included; mean follow-up was 3 years (range 13-71 months). LGE was associated with increased mortality (odds ratio [OR] 2.9; 95% confidence interval [CI] 2.3-3.8; P < .01) and VA and SCD (OR 4.6; 95% CI 3.5-6.0; P < .01). LGE was associated with an increased risk of HF hospitalization (OR 3.4; 95% CI 2.3-5.0; P < .01), referral for transplantation (OR 5.1; 95% CI 2.5-10.4; P < .01), and decreased incidence of LVEF improvement to >35% (OR 0.2; 95% CI 0.03-0.85; P = .03). Conclusion LGE in NICM patients is associated with increased mortality, VA and SCD, and HF hospitalization and heart transplantation referral during long-term follow up. Given these competing risks of mortality and HF progression, prospective randomized controlled trials are required to determine if LGE is useful for guiding prophylactic implantable cardioverter-defibrillator placement in NICM patients.
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Affiliation(s)
| | | | | | | | | | - Eric Rashba
- Address reprint requests and correspondence: Dr Eric Rashba, Stony Brook Heart Rhythm Center, Stony Brook Medicine, 101 Nicolls Road, Stony Brook, NY 11794.
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CMR-Based Risk Stratification of Sudden Cardiac Death and Use of Implantable Cardioverter-Defibrillator in Non-Ischemic Cardiomyopathy. Int J Mol Sci 2021; 22:ijms22137115. [PMID: 34281168 PMCID: PMC8268120 DOI: 10.3390/ijms22137115] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/27/2021] [Accepted: 06/29/2021] [Indexed: 01/04/2023] Open
Abstract
Non-ischemic cardiomyopathy (NICM) is one of the most important entities for arrhythmias and sudden cardiac death (SCD). Previous studies suggest a lower benefit of implantable cardioverter–defibrillator (ICD) therapy in patients with NICM as compared to ischemic cardiomyopathy (ICM). Nevertheless, current guidelines do not differentiate between the two subgroups in recommending ICD implantation. Hence, risk stratification is required to determine the subgroup of patients with NICM who will likely benefit from ICD therapy. Various predictors have been proposed, among others genetic mutations, left-ventricular ejection fraction (LVEF), left-ventricular end-diastolic volume (LVEDD), and T-wave alternans (TWA). In addition to these parameters, cardiovascular magnetic resonance imaging (CMR) has the potential to further improve risk stratification. CMR allows the comprehensive analysis of cardiac function and myocardial tissue composition. A range of CMR parameters have been associated with SCD. Applicable examples include late gadolinium enhancement (LGE), T1 relaxation times, and myocardial strain. This review evaluates the epidemiological aspects of SCD in NICM, the role of CMR for risk stratification, and resulting indications for ICD implantation.
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Marrow BA, Cook SA, Prasad SK, McCann GP. Emerging Techniques for Risk Stratification in Nonischemic Dilated Cardiomyopathy: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 75:1196-1207. [PMID: 32164893 DOI: 10.1016/j.jacc.2019.12.058] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/04/2019] [Indexed: 02/06/2023]
Abstract
Dilated cardiomyopathy (DCM) is a common condition, which carries significant mortality from sudden cardiac death and pump failure. Left ventricular ejection fraction has conventionally been used as a risk marker for sudden cardiac death, but has performed poorly in trials. There have been significant advances in the areas of cardiac magnetic resonance imaging and genetics, which are able to provide useful rick prediction in DCM. Biomarkers and cardiopulmonary exercise testing are well validated in the prediction of risk in heart failure; however, they have been tested less specifically in the DCM setting. This review will discuss these methods with a view toward multiparametric risk assessment in DCM with the hope of creating parametric risk models to predict sudden cardiac death and pump failure in the DCM population.
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Affiliation(s)
- Benjamin A Marrow
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Stuart A Cook
- Department of Cardiovascular Medicine, National Heart & Lung Institute, Imperial College, London, United Kingdom; Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Sanjay K Prasad
- Department of Cardiovascular Medicine, National Heart & Lung Institute, Imperial College, London, United Kingdom
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom.
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Centurión OA, Alderete JF, Torales JM, García LB, Scavenius KE, Miño LM. Myocardial Fibrosis as a Pathway of Prediction of Ventricular Arrhythmias and Sudden Cardiac Death in Patients With Nonischemic Dilated Cardiomyopathy. Crit Pathw Cardiol 2020; 18:89-97. [PMID: 31094736 DOI: 10.1097/hpc.0000000000000171] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The mechanism of sudden cardiac death (SCD) in patients with nonischemic dilated cardiomyopathy (NIDCM) is mostly due to sustained ventricular tachycardia and ventricular fibrillation. The clinical guidelines for the therapeutic management of this set of patients are mostly based on left ventricular ejection fraction value which has a low specificity to differentiate the risk of SCD from the risk of mortality associated with heart failure or other comorbidities. Moreover, since SCD can occur in patients with normal or mildly depressed ejection fraction, it is necessary to identify new markers to improve the prognostic stratification of SCD. Several studies that analyzed the ventricular arrhythmia substrate found that myocardial fibrosis plays an important role in the genesis of ventricular arrhythmias in patients with NIDCM. The surrounding zone of the area of fibrosis is a heterogeneous medium, where tissue with different levels of fibrosis coexists, resulting in both viable and nonviable myocardium. This myocardial fibrosis may constitute a substrate for ventricular arrhythmias, where slow and heterogeneous conduction may favor the genesis of reentry mechanism increasing the chance to develop sustained ventricular tachycardia or ventricular fibrillation. Therefore, the evaluation of ventricular fibrosis by late gadolinium enhancement (LGE) cardiac magnetic resonance imaging has been suggested as an indicator for SCD risk stratification. Indeed, LGE in patients with NIDCM is associated with increased risk of all-cause mortality, heart failure hospitalization, and SCD. Detection of myocardial fibrosis as LGE by cardiac magnetic resonance imaging can be considered as a useful pathway of prediction of malignant ventricular arrhythmias since it has excellent prognostic characteristics and may help guide risk stratification and management in patients with NIDCM.
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Affiliation(s)
- Osmar Antonio Centurión
- From the Division of Cardiovascular Medicine, Clinic Hospital, Asuncion National University (UNA), San Lorenzo, Paraguay.,Department of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de la Mora, Paraguay
| | - José Fernando Alderete
- From the Division of Cardiovascular Medicine, Clinic Hospital, Asuncion National University (UNA), San Lorenzo, Paraguay
| | - Judith María Torales
- From the Division of Cardiovascular Medicine, Clinic Hospital, Asuncion National University (UNA), San Lorenzo, Paraguay.,Department of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de la Mora, Paraguay
| | - Laura Beatriz García
- From the Division of Cardiovascular Medicine, Clinic Hospital, Asuncion National University (UNA), San Lorenzo, Paraguay.,Department of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de la Mora, Paraguay
| | - Karina Elizabeth Scavenius
- From the Division of Cardiovascular Medicine, Clinic Hospital, Asuncion National University (UNA), San Lorenzo, Paraguay
| | - Luis Marcelo Miño
- From the Division of Cardiovascular Medicine, Clinic Hospital, Asuncion National University (UNA), San Lorenzo, Paraguay
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Kawashima K, Hirashiki A, Nomoto K, Kokubo M, Shimizu A, Sakurai T, Kondo I, Washimi Y, Arai H, Toba K, Murohara T. Peak Work Rate during Exercise Could Detect Frailty Status in Elderly Patients with Stable Heart Failure. Int Heart J 2019; 60:1366-1372. [PMID: 31735775 DOI: 10.1536/ihj.19-120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Kihon Checklist (KCL) is a reliable tool for determining frailty status in the elderly. However, there is no information in the literature about the relationship between frailty status and exercise capacity. Here, we examined the associations between cardiopulmonary exercise testing parameters and frailty status in elderly patients with stable heart failure (HF).Ninety-two elderly patients with stable HF were evaluated using cardiopulmonary exercise testing and the KCL. A KCL score of 0-3 was classified as robust, 4-7 as pre-frail, and ≥ 8 as frail.Mean age, peak VO2, and KCL score were 81.7 years, 13.2 mL/kg/minute, and 10.7, respectively. KCL score was significantly correlated with peak VO2 (r = -0.527, P < 0.001) and peak work rate (r = -0.632, P < 0.001). In patients with frailty (n = 63), the peak work rate (WR) was significantly lower than it was in patients without frailty (n = 29; 39.9 versus 69.5 W, respectively; P < 0.001). Multivariate analysis revealed that peak WR and peak systolic blood pressure were significant, independent predictors of frailty (β = -0.108 and -0.045, respectively). In a diagnostic performance plot analysis, a cutoff value for peak WR of 51.9 W was the best predictor of frailty.Frailty status was significantly associated with peak WR and peak systolic blood pressure in elderly patients with stable HF. Therefore, cardiopulmonary exercise testing may be useful for assessing frailty status in this patient population.
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Affiliation(s)
- Kazuhiro Kawashima
- Department of Cardiology, National Center for Geriatrics and Gerontology
| | - Akihiro Hirashiki
- Department of Cardiology, National Center for Geriatrics and Gerontology.,Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kenichiro Nomoto
- Department of Cardiology, National Center for Geriatrics and Gerontology
| | - Manabu Kokubo
- Department of Cardiology, National Center for Geriatrics and Gerontology
| | - Atsuya Shimizu
- Department of Cardiology, National Center for Geriatrics and Gerontology
| | - Takashi Sakurai
- Department of Cardiology, National Center for Geriatrics and Gerontology
| | - Izumi Kondo
- Department of Cardiology, National Center for Geriatrics and Gerontology
| | - Yukihiko Washimi
- Department of Cardiology, National Center for Geriatrics and Gerontology
| | - Hidenori Arai
- Department of Cardiology, National Center for Geriatrics and Gerontology
| | - Kenji Toba
- Department of Cardiology, National Center for Geriatrics and Gerontology
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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Predicción del riesgo de muerte súbita cardiaca: el papel de la resonancia magnética cardiaca. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2018.04.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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12
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van der Bijl P, Podlesnikar T, Bax JJ, Delgado V. Sudden Cardiac Death Risk Prediction: The Role of Cardiac Magnetic Resonance Imaging. ACTA ACUST UNITED AC 2018; 71:961-970. [PMID: 29970349 DOI: 10.1016/j.rec.2018.05.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 05/07/2018] [Indexed: 02/06/2023]
Abstract
Sudden cardiac death (SCD) accounts for more than 4 million global deaths per year. While it is most commonly caused by coronary artery disease, a final common pathway of ventricular arrhythmias is shared by different etiologies. The most effective primary and secondary prevention strategy is an implantable cardioverter-defibrillator (ICD). The decision to implant an ICD for primary prevention is largely based on a left ventricular ejection fraction ≤ 35%, but this criterion in isolation is neither sensitive nor specific. Novel imaging parameters hold promise to improve ICD candidate selection. Cardiac magnetic resonance (CMR) imaging is a powerful and versatile technique, with the ability to comprehensively assess cardiac structure and function. A range of variables based on CMR techniques (late gadolinium enhancement, T1 mapping, T2* relaxometry, deformation imaging) have been associated with ventricular arrhythmias and SCD risk. The role of CMR in the estimation of ventricular arrhythmias and SCD risk in coronary artery disease, nonischemic cardiomyopathies, cardiac transplant, iron-overload cardiomyopathy and valvular heart disease is reviewed in this article. Prospective, randomized trials and standardization of CMR techniques are required before its routine use can be recommended for guiding SCD prevention strategies.
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Affiliation(s)
- Pieter van der Bijl
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tomaž Podlesnikar
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
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13
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Becker MAJ, Cornel JH, van de Ven PM, van Rossum AC, Allaart CP, Germans T. The Prognostic Value of Late Gadolinium-Enhanced Cardiac Magnetic Resonance Imaging in Nonischemic Dilated Cardiomyopathy: A Review and Meta-Analysis. JACC Cardiovasc Imaging 2018; 11:1274-1284. [PMID: 29680351 DOI: 10.1016/j.jcmg.2018.03.006] [Citation(s) in RCA: 188] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/23/2018] [Accepted: 03/01/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This review and meta-analysis reviews the prognostic value of cardiac magnetic resonance (CMR) in nonischemic dilated cardiomyopathy (DCM). BACKGROUND Late gadolinium-enhanced (LGE) CMR is a noninvasive method to determine the underlying cause of DCM and previous studies reported the prognostic value of the presence of LGE to identify patients at risk of major adverse cardiovascular events. METHODS PubMed was searched for studies describing the prognostic implication of LGE in patients with DCM for the specified endpoints cardiovascular mortality, major ventricular arrhythmic events including appropriate implantable cardioverter-defibrillator therapy, rehospitalization for heart failure, and left ventricular reverse remodeling. RESULTS Data from 34 studies were included, with a total of 4,554 patients. Contrast enhancement was present in 44.8% of DCM patients. Patients with LGE had increased cardiovascular mortality (odds ratio [OR]: 3.40; 95% confidence interval [CI]: 2.04 to 5.67), ventricular arrhythmic events (OR: 4.52; 95% CI: 3.41 to 5.99), and rehospitalization for heart failure (OR: 2.66; 95% CI: 1.67 to 4.24) compared with those without LGE. Moreover, the absence of LGE predicted left ventricular reverse remodeling (OR: 0.15; 95% CI: 0.06 to 0.36). CONCLUSIONS The presence of LGE on CMR substantially worsens prognosis for adverse cardiovascular events in DCM patients, and the absence indicates left ventricular reverse remodeling.
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Affiliation(s)
- Marthe A J Becker
- Department of Cardiology, Northwest Clinics, Alkmaar, the Netherlands; Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands.
| | - Jan H Cornel
- Department of Cardiology, Northwest Clinics, Alkmaar, the Netherlands
| | - Peter M van de Ven
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Albert C van Rossum
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Cornelis P Allaart
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Tjeerd Germans
- Department of Cardiology, Northwest Clinics, Alkmaar, the Netherlands; Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
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15
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Di Marco A, Anguera I, Schmitt M, Klem I, Neilan TG, White JA, Sramko M, Masci PG, Barison A, Mckenna P, Mordi I, Haugaa KH, Leyva F, Rodriguez Capitán J, Satoh H, Nabeta T, Dallaglio PD, Campbell NG, Sabaté X, Cequier Á. Late Gadolinium Enhancement and the Risk for Ventricular Arrhythmias or Sudden Death in Dilated Cardiomyopathy: Systematic Review and Meta-Analysis. JACC-HEART FAILURE 2016; 5:28-38. [PMID: 28017348 DOI: 10.1016/j.jchf.2016.09.017] [Citation(s) in RCA: 240] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/29/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the association between late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging and ventricular arrhythmias or sudden cardiac death (SCD) in patients with dilated cardiomyopathy (DCM). BACKGROUND Risk stratification for SCD in DCM needs to be improved. METHODS A systematic review and meta-analysis were conducted. A systematic search of PubMed and Ovid was performed, and observational studies that analyzed the arrhythmic endpoint (sustained ventricular arrhythmia, appropriate implantable cardioverter-defibrillator [ICD] therapy, or SCD) in patients with DCM, stratified by the presence or absence of LGE, were included. RESULTS Twenty-nine studies were included, accounting for 2,948 patients. The studies covered a wide spectrum of DCM, with a mean left ventricular ejection fraction between 20% and 43%. LGE was significantly associated with the arrhythmic endpoint both in the overall population (odds ratio: 4.3; p < 0.001) and when including only those studies that performed multivariate analysis (hazard ratio: 6.7; p < 0.001). The association between LGE and the arrhythmic endpoint remained significant among studies with mean left ventricular ejection fractions >35% (odds ratio: 5.2; p < 0.001) and was maximal in studies that included only patients with primary prevention ICDs (odds ratio: 7.8; p = 0.008). CONCLUSIONS Across a wide spectrum of patients with DCM, LGE is strongly and independently associated with ventricular arrhythmia or SCD. LGE could be a powerful tool to improve risk stratification for SCD in patients with DCM. These results raise 2 major questions to be addressed in future studies: whether patients with LGE could benefit from primary prevention ICDs irrespective of their left ventricular ejection fractions, while patients without LGE might not need preventive ICDs despite having severe left ventricular dysfunction.
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Affiliation(s)
- Andrea Di Marco
- Arrhythmia Unit, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain.
| | - Ignasi Anguera
- Arrhythmia Unit, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
| | | | - Igor Klem
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina
| | - Tomas G Neilan
- Division of Cardiology and Cardiac MR PET CT Program, Massachusetts General Hospital, Boston, Massachusetts
| | - James A White
- Stephenson CMR Centre at the Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
| | - Marek Sramko
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Pier Giorgio Masci
- Centre for Cardiovascular Magnetic Resonance, Lausanne University Hospital, Lausanne, Switzerland
| | - Andrea Barison
- Fondazione "G. Monasterio," CNR-Regione Toscana, Pisa, Italy
| | - Peter Mckenna
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain
| | - Ify Mordi
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | | | - Francisco Leyva
- Department of Cardiology, The Queen Elizabeth Hospital, Birmingham, United Kingdom
| | | | - Hiroshi Satoh
- Division of Cardiology, Internal Medicine III, Hamamatsu University Hospital, Hamamatsu, Japan
| | - Takeru Nabeta
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Tokyo, Japan
| | | | | | - Xavier Sabaté
- Arrhythmia Unit, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
| | - Ángel Cequier
- Arrhythmia Unit, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain
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16
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Tateishi E, Noguchi T, Goto Y, Morita Y, Ishibashi-Ueda H, Yamada N, Kanzaki H, Nishimura K, Miyamoto Y, Anzai T, Ogawa H, Yasuda S. Prognostic impact of blood pressure response plus gadolinium enhancement in dilated cardiomyopathy. Heart 2015; 101:774-80. [PMID: 25761994 PMCID: PMC4431328 DOI: 10.1136/heartjnl-2014-307007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Accepted: 02/11/2015] [Indexed: 02/03/2023] Open
Abstract
Objective Late gadolinium enhancement (LGE) is not necessarily ideal for detecting diffuse myocardial fibrosis in idiopathic dilated cardiomyopathy (DCM). Since systolic blood pressure response (SBPR) during exercise has been proposed to reflect cardiac pump reserve in patients with heart failure, we wished to determine whether LGE plus SBPR is a better prognostic factor in patients with DCM. Methods LGE and cardiopulmonary exercise testing results in consecutive 207 patients with DCM were examined. Patients were divided into four groups according to the presence or absence of LGE and the SBPR cut-off value of +40 mm Hg according to receiver operating characteristic curve analysis: LGE-positive+SBPR <40 mm Hg (n=65), LGE-positive+SBPR ≥40 mm Hg (n=40), LGE-negative+SBPR <40 mm Hg (n=33) and LGE-negative+SBPR ≥40 mm Hg (n=69). The composite end point was cardiac death, cardiac transplantation, LV assist device implantation, life-threatening arrhythmia or heart failure. Results Forty-two (20%) patients developed the composite end point, with rates of 35%, 20%, 21% and 6% in patients with LGE-positive+SBPR <40 mm Hg, LGE-positive+SBPR ≥40 mm Hg, LGE-negative+SBPR <40 mm Hg and LGE-negative+SBPR ≥40 mm Hg status, respectively. Multivariable Cox regression analysis identified LGE-positive and SBPR <40 mm Hg as a significant independent predictor of cardiac events (HR 2.08, 95% CI 1.06 to 4.11, p=0.034). Of note, there was no significant difference in the cardiac event-free survival rate between the LGE-positive+SBPR ≥40 mm Hg and LGE-negative+SBPR <40 mm Hg groups (p=0.736). Conclusions The combination of LGE and SBPR provides more clinically relevant information for assessing the risk of cardiac events in patients with DCM than LGE status alone.
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Affiliation(s)
- Emi Tateishi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoichi Goto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshiaki Morita
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hatsue Ishibashi-Ueda
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Naoaki Yamada
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiro Miyamoto
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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