Association of fibrosis with mortality and sudden cardiac death in patients with nonischemic dilated cardiomyopathy.

By A. Gulati, A. Jabbour, Tevfik F. Ismail, K. Guha, J. Khwaja, S. Raza, Kishen Morarji, Tristan D. H. Brown, Nizar A. Ismail, M. Dweck and 13 more. Journal of the American Medical Association (JAMA), 2013

1,086 citations recorded by the source corpus.

IMPORTANCE 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. OBJECTIVE 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. DESIGN, SETTING, AND PATIENTS 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. MAIN OUTCOME MEASURES 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. RESULTS 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). CONCLUSIONS AND RELEVANCE 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.

Subfields: Cardiology and Cardiovascular Medicine, Radiology, Nuclear Medicine and Imaging

View Paper: https://www.semanticscholar.org/paper/eeb901d8b21c35feb17253ca7696f140d1b3076b

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In Cardiology and Cardiovascular Medicine

In Radiology, Nuclear Medicine and Imaging

Peter Kellman

Citations in the corpus

Cardiac T1 Mapping and Extracellular Volume (ECV) in clinical practice: a comprehensive review (2016, background): “Late gadolinium enhancement Late Gadolinium Enhancement (LGE) has become the reference standard for non-invasive imaging of myocardial scar and focal fibrosis in both ischaemic [3] and nonischaemic cardiomyopathy [4].”
2016 ESC Position Paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for Practice Guidelines: The Task Force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC). (2016, background): “Late gadolinium imaging may be useful to detect scarring or fibrosis, which may have prognostic implications in the context of impaired LV function.(108,109) Additionally, CMR is an excellent test for the comprehensive evaluation of cardiac masses and infiltrative conditions.”
Myocardial T1 mapping and extracellular volume quantification: a Society for Cardiovascular Magnetic Resonance (SCMR) and CMR Working Group of the European Society of Cardiology consensus statement (2013, background): “While late gadolinium enhancement (LGE) undoubtedly provides important diagnostic and prognostic information [41-47], T1 mapping and ECV may have an advantage over LGE for quantifying the degree of ECM or interstitial expansion.”
2016 ESC Position Paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for Practice Guidelines (2016, background): “Late gadolinium imaging may be useful to detect scarring or fibrosis, which may have prognostic implications in the context of impaired LV function.(108,109) Additionally, CMR is an excellent test for the comprehensive evaluation of cardiac masses and infiltrative conditions.”
Dilated Cardiomyopathy: Genetic Determinants and Mechanisms (2017, neutral): “CMR, especially the identification of delayed enhancement, can help risk stratify for sudden death.(36) Because of increased risk for SCD, there is need for arrhythmia surveillance to more appropriately deploy device management, including pacemakers and implantable cardioverter defibrillators (ICDs)”
Cardiac fibrosis in myocardial infarction—from repair and remodeling to regeneration (2016, background): “to sudden cardiac death and increases overall mortality independently of the ejection fraction (Gulati et al. 2013).”