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Prognostic Value of Multiple Parameters Assessed by CMR to Predict MACE | Journal Scan
Study Questions:
What is the prognostic value of multiple parameters determined by cardiac magnetic resonance imaging (CMR) for predicting major adverse cardiovascular events (MACE)?
Methods:
MACE occurred in 62 of the 539 patients (11.5%) and included 20 deaths (16 cardiac), 30 congestive heart failure admissions, and 12 aborted sudden cardiac deaths. The post-CMR diagnosis was ischemic cardiomyopathy in 90 [26 of whom had MACE (28.9%)], dilated cardiomyopathy in 159 [16 of whom had MACE (10.1%)], and no abnormality in 184, 5 of whom sustained MACE (2.7%). On univariate analysis, age, ischemic heart disease, angiotensin-converting enzyme (ACE) inhibitor or beta-blocker, or statin or aspirin use were predictors of MACE. On multivariate analysis, only presence of ischemic heart disease (hazard ratio [HR], 3.58; p < 0.001) was an independent predictor of MACE among the multiple clinical variables. All three CMR parameters were significant univariate predictors of MACE (LVEF, HR, 0.892; LGE, HR, 5.47; and GCS, HR, 1.21 [all p < 0.001]). Each of the CMR parameters remained an independent predictor of MACE when added to the clinical predictors. In the subset of patients with nonischemic cardiomyopathy, LGE (HR, 2.65) and GCS (HR, 1.13) remained significant multivariable predictors of outcome. LVEF >35% was noted in 473 patients, 35 of whom experienced MACE (7.4%). LGE (HR, 3.88; p < 0.001) and GCS (HR, 1.09; p = 0.046) were multivariate predictors of MACE when added to LVEF. For the subset of patients with LVEF ≥35% but LGE present and GCS ≥12.1%, outcome was similar to patients with LVEF <35%.
Results:
MACE occurred in 62 of the 539 patients (11.5%) and included 20 deaths (16 cardiac), 30 congestive heart failure admissions, and 12 aborted sudden cardiac deaths. The post-CMR diagnosis was ischemic cardiomyopathy in 90 [26 of whom had MACE (28.9%)], dilated cardiomyopathy in 159 [16 of whom had MACE (10.1%)], and no abnormality in 184, five of whom sustained MACE (2.7%). On univariate analysis, age, ischemic heart disease, ACE inhibitor or beta-blocker, or statin or aspirin use were predictors of MACE. On multivariate analysis, only presence of ischemic heart disease (hazard ratio [HR], 3.58; p < 0.001) was an independent predictor of MACE among the multiple clinical variables. All three CMR parameters were significant univariate predictors of MACE (LVEF; HR, 0.892; LGE, HR, 5.47; and GCS, HR, 1.21 [all p < 0.001]). Each of the CMR parameters remained an independent predictor of MACE when added to the clinical predictors. In the subset of patients with nonischemic cardiomyopathy, LGE (HR, 2.65) and GCS (HR, 1.13) remained significant multivariable predictors of outcome. LVEF >35% was noted in 473 patients, 35 of whom experienced MACE (7.4%). LGE (HR, 3.88; p < 0.001) and GCS (HR, 1.09; p = 0.046) were multivariate predictors of MACE when added to LVEF. For the subset of patients with LVEF ≥35% but LGE present and GCS ≥12.1%, outcome was similar to patients with LVEF <35%.
Conclusions:
The authors concluded that CMR parameters of LVEF, LGE, and GCS have incremental prognostic value in predicting outcome independently and when added to clinical variables.
Perspective:
Multiple smaller-scale studies have demonstrated the prognostic value of imaging parameters in both the general population as well as specific disease states such as ischemic heart disease and cardiomyopathy. This is the largest study to date examining consecutive series of patients with a broad range of indications for CMR, subsequently followed for adverse events. The authors have nicely demonstrated the expected relationship between LVEF and MACE, which has been reported with CMR and other imaging techniques, but also the added value of circumferential strain and detection of scar and fibrosis by means of LGE. The incremental prognostic value of the CMR parameters was evident for the population as a whole as well as for the subset with both ischemic and nonischemic etiologies, and importantly provided prognostic information in patients with LVEF ≥35%, which has been a traditional cutoff for a presumed favorable outcome. Each of the evaluated parameters has previously been reported as a prognostic indicator. This study, however, nicely confirms the earlier observations in a large population and suggests a significant role for CMR in determining patient prognosis.
Keywords: Angiotensin-Converting Enzyme Inhibitors, Aspirin, Cardiomyopathies, Cardiomyopathy, Dilated, Coronary Artery Disease, Death, Sudden, Cardiac, Diagnostic Imaging, Heart Failure, Magnetic Resonance Imaging, Multivariate Analysis, Myocardial Ischemia, Prognosis
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