Abstract
Heart failure (HF) admission is a dominant contributor to morbidity and healthcare costs in dilated cardiomyopathy (DCM). Mid-wall striae (MWS) fibrosis by late gadolinium enhancement (LGE) imaging has been associated with elevated arrhythmia risk. However, its capacity to predict HF-specific outcomes is poorly defined. We investigated its role to predict HF admission and relevant secondary outcomes in a large cohort of DCM patients. 719 patients referred for LGE MRI assessment of DCM were enrolled and followed for clinical events. Standardized image analyses and interpretations were conducted inclusive of coding the presence and patterns of fibrosis observed by LGE imaging. The primary clinical outcome was hospital admission for decompensated HF. Secondary heart failure and arrhythmic composite endpoints were also studied. Median age was 57 (IQR 47–65) years and median LVEF 40% (IQR 29–47%). Any fibrosis was observed in 228 patients (32%) with MWS fibrosis pattern present in 178 (25%). At a median follow up of 1044 days, 104 (15%) patients experienced the primary outcome, and 127 (18%) the secondary outcome. MWS was associated with a 2.14-fold risk of the primary outcome, 2.15-fold risk of the secondary HF outcome, and 2.23-fold risk of the secondary arrhythmic outcome. Multivariable analysis adjusting for all relevant covariates, inclusive of LVEF, showed patients with MWS fibrosis to experience a 1.65-fold increased risk (95% CI 1.11–2.47) of HF admission and 1-year event rate of 12% versus 7% without this phenotypic marker. Similar findings were observed for the secondary outcomes. Patients with LVEF > 35% plus MWS fibrosis experienced similar event rates to those with LVEF ≤ 35%. MWS fibrosis is a powerful and independent predictor of clinical outcomes in patients with DCM, identifying patients with LVEF > 35% who experience similar event rates to those with LVEF below this conventionally employed high-risk phenotype threshold.
Highlights
Heart failure (HF) admission is a dominant contributor to morbidity and healthcare costs in dilated cardiomyopathy (DCM)
The latter has led to the identification of DCM sub-cohorts demonstrating advanced degrees of replacement fibrosis on late gadolinium enhancement (LGE) imaging in a septal striae patter, this finding consistently associated with greater risk of sudden cardiac arrest (SCA) or appropriate implantable cardioverter-defibrillator (ICD) therapy[6,7,8,9,10,14,15,16]
The current study provided a sufficient population size with cumulative clinical events to appropriately examine this association in the context of multivariable adjustment, demonstrating that Mid-wall striae (MWS) presence is associated with independent risk of HF admission in this referral cohort
Summary
Heart failure (HF) admission is a dominant contributor to morbidity and healthcare costs in dilated cardiomyopathy (DCM). MWS fibrosis is a powerful and independent predictor of clinical outcomes in patients with DCM, identifying patients with LVEF > 35% who experience similar event rates to those with LVEF below this conventionally employed high-risk phenotype threshold. Mid-wall striae (MWS) fibrosis of the basal septum is observed in approximately one-third of DCM patients referred for LGE-MRI13 Across numerous studies this marker has been associated with elevated risk of allcause death[6,7,10,14] and arrhythmic death or appropriate ICD therapy[7,8,9,10,14,15,16]; these findings confirmed in a multicentre setting[17]. All analyses were stratified for patients with an LVEF above versus below conventional high-risk phenotype thresholds
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