Purpose

To explore individual weight of cardiac magnetic resonance (CMR) metrics to predict short-term outcomes in patients with dilated cardiomyopathy (DCM), and develop a risk algorithm for short-term outcome based on CMR biomarkers.

Method

A total of 407 consecutive patients with DCM (48.1±13.8 years, 311men) who underwent cardiac magnetic resonance with a 3.0-T contrast-enhanced magnetic resonance scanner were prospectively enrolled in this study. The primary endpoint was a composite of heart failure death, sudden cardiac death (SCD), aborted SCD, and heart transplantation. Survival estimates were calculated by receiver operating characteristic analyses, competing risk regression analyses, and Cox regression analyses. Furthermore, risk factors were used to build personalizing risk stratification model.

Result

During a mean follow-up of 22.0 months (range 0.5-35.5 months), 63 patients reached the primary endpoint. NYHA (hazard ratio, HR=2.327), left ventricular ejection fraction (LVEF) (HR=0.941), late gadolinium enhancement (LGE) >0.9% & ≤6.6% (HR=3.512), LGE>6.6% (HR=5.908), and mean extracellular volume (ECV) fraction≥32.8% (HR: 5.944) had a significant prognostic association with the primary end points (C statistic:0.851) (all p<0.05). Competing risk regression analyses showed that patients with mean ECV fraction ≥32.8% (SHR: 31.215, p<0.001), LGE≥5.9% (SHR: 16.421, p<0.001) or global circumferential strain ≥-5.6% (SHR: 15.218, p<0.001) had significantly shorter event-free survival due to heart failure death and heart transplantation. Patients with mean ECV fraction ≥32.8% (SHR: 8.912, p=0.003), LGE≥5.9% (SHR: 13.154, p<0.001) had significantly shorter event-free survival due to SCD or aborted SCD. The model showed great agreement in calibration plot and contributed to clinical decision making in decision curve analysis.

Discussion

In this study, we comprehensively assessed the prognostic value of CMR conventional (EF, LGE) and novel parameters (native T1, ECV fraction, strain) for patients with DCM. We demonstrated that these parameters were more associated with cardiac-related death, aborted SCD and heart transplantation, comparing with the risk factors in the current guideline 6. In addition, competing risk regression analysis indicated that patients with ECVmean≥32.8% had markedly strong association with heart failure death and heart transplantation as a consequent of advanced heart failure, while LGE≥5.9% showed the highest SHR to predict SCD and aborted SCD as a consequent of malignant ventricular arrhythmia. However, patients with GCS≥-5.6%, or who accorded with the guideline criteria of ICDs implantation, had not significantly association with SCD and aborted SCD. Finally, we developed a CMR-based personalized risk stratification model to predict the 1- and 2-year probability of major cardiac adverse events. Patients who had ECVmean≥32.8% or LGE≥6.6% showed a 1.78-fold increased risk of death, aborted SCD, and heart transplantation, which showed better performance than model without novel CMR metric and current guideline.

Conclusion

ECV fraction may be the best independently risk factor for the short-term outcomes in patients with DCM, surpassing LVEF and LGE. However, LGE has better prognostic value than other CMR metrics for SCD and aborted SCD. The risk stratification model we developed may be a promising non-invasive tool for decision making and prognosis.

Acknowledgements

Not application.

References

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