Document Detail

Association of fibrosis with mortality and sudden cardiac death in patients with nonischemic dilated cardiomyopathy.
MedLine Citation:
PMID:  23462786     Owner:  NLM     Status:  MEDLINE    
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.
Ankur Gulati; Andrew Jabbour; Tevfik F Ismail; Kaushik Guha; Jahanzaib Khwaja; Sadaf Raza; Kishen Morarji; Tristan D H Brown; Nizar A Ismail; Marc R Dweck; Elisa Di Pietro; Michael Roughton; Ricardo Wage; Yousef Daryani; Rory O'Hanlon; Mary N Sheppard; Francisco Alpendurada; Alexander R Lyon; Stuart A Cook; Martin R Cowie; Ravi G Assomull; Dudley J Pennell; Sanjay K Prasad
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Publication Detail:
Type:  Journal Article; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  JAMA     Volume:  309     ISSN:  1538-3598     ISO Abbreviation:  JAMA     Publication Date:  2013 Mar 
Date Detail:
Created Date:  2013-03-06     Completed Date:  2013-03-08     Revised Date:  2014-09-17    
Medline Journal Info:
Nlm Unique ID:  7501160     Medline TA:  JAMA     Country:  United States    
Other Details:
Languages:  eng     Pagination:  896-908     Citation Subset:  AIM; IM    
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MeSH Terms
Cardiomyopathy, Dilated / mortality*,  pathology*
Cause of Death
Death, Sudden, Cardiac / epidemiology*
Defibrillators, Implantable
Gadolinium / diagnostic use
Great Britain / epidemiology
Magnetic Resonance Imaging
Middle Aged
Myocardium / pathology*
Patient Selection
Predictive Value of Tests
Prospective Studies
Risk Assessment
Stroke Volume
Ventricular Function, Left*
Grant Support
FS/11/67/28954//British Heart Foundation
Reg. No./Substance:
Comment In:
Rev Cardiovasc Med. 2014;15(1):73   [PMID:  24762471 ]
JAMA. 2013 Mar 6;309(9):929-30   [PMID:  23462791 ]
JAMA. 2013 Jun 26;309(24):2548-9   [PMID:  23800927 ]
JAMA. 2013 Jun 26;309(24):2547   [PMID:  23800925 ]
JAMA. 2013 Jun 26;309(24):2547-8   [PMID:  23800926 ]
Erratum In:
JAMA. 2013 Jul 3;310(1):99

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