Quantifying late gadolinium enhancement on CMR provides additional prognostic information in early risk-stratification of nonischemic cardiomyopathy: a cohort study

Suspected nonischemic cardiomyopathy (NICM) is a common clinical setting with highly variable prognosis. Early noninvasive risk-stratification is important for justification of invasive examinations, specific treatment and patient surveillance. We studied the additional prognostic value of late gadolinium enhancement (LGE) and segmental wall motion abnormality (SWMA) extent on cardiovascular magnetic resonance (CMR) compared to traditional risk factors in suspected NICM.

In this observational cohort study, we enrolled 86 consecutive patients referred for CMR due to suspected NICM. Patients with ischemic cardiomyopathy were excluded. CMR images were analysed for left ventricular LGE and SWMA extents and patients were followed-up for major adverse cardiac events (MACE), including cardiovascular death, aborted sudden death and cardiac transplantation.

Of 86 patients (median age: 53 years, 45% female), mainly presenting with ventricular arrhythmias (40%) and congestive heart failure (44%), 76% were finally diagnosed with NICM, 17% with left ventricle hypertrophy and 7% with idiopathic arrhythmia. On CMR, 61 patients (71%) had LGE and 56 (65%) SWMA. During median follow-up of 835 days, 15 patients (17%) reached MACE. In univariant analysis, LGE volume (hazard ratio [HR] 1.028 per 1% increase in LGE, p < 0.001), left ventricular ejection fraction (LVEF) (HR 0.959, p = 0.009) and SWMA score (HR 1.067, p = 0.012) had strongest associations with MACE. In multivariate analysis, the best overall model for event prediction included LGE volume (HR 1.027, p = 0.003), sustained ventricular tachycardia (HR 4.7, p = 0.011) and LVEF (HR 0.962, p = 0.034). Among patients with LGE, there was an event rate of 26% (14 of 61) versus 4% (1 of 25) in patients without LGE (p = 0.041, Log-rank). The highest event rate was observed in patients with LGE volume of ≥17%. Patients without SWMA did not experience MACE (p = 0.002, Log-rank), giving additional information in the subgroup of patients with preserved LVEF (≥50%).

In suspected NICM, presenting with ventricular arrhythmias or heart failure, LGE extent gives additional prognostic information compared to traditional risk factors, while the absence of SWMA may give prognostic information beyond normal LVEF. Even though the final diagnosis is uncertain in NICM, extensive amount of LGE should be considered as a sign of poor prognosis.