Absence of myocardial fibrosis predicts favorable long-term survival in new-onset heart failure: a cardiovascular magnetic resonance study

Gulati, A. et al. (2018) Absence of myocardial fibrosis predicts favorable long-term survival in new-onset heart failure: a cardiovascular magnetic resonance study. Circulation: Cardiovascular Imaging, 11(9), e007722. (doi: 10.1161/CIRCIMAGING.118.007722) (PMID:30354674)

Abstract

Background: Myocardial fibrosis, identified by late gadolinium enhancement cardiovascular magnetic resonance, predicts outcomes in chronic heart failure (HF). Its prognostic significance in new-onset HF and reduced left ventricular ejection fraction (LVEF) is unclear. We investigated whether the pattern and extent of fibrosis predict survival in new-onset HF and reduced LVEF of initially uncertain pathogenesis. Methods and Results: Of 120 consecutive patients with new-onset (<6 months) HF and reduced LVEF, 31 (26%) had infarct fibrosis, 25 (21%) had midwall fibrosis, and 64 (53%) had no fibrosis. During median follow-up of 8.9 years, 33 (28%) patients died. Patients with infarct fibrosis (hazard ratios [HR], 3.32; 95% CI, 1.46–7.58; P=0.004) or midwall fibrosis (HR, 2.99; 95% CI, 1.24–7.19; P=0.014) were more likely to die compared with those without fibrosis. On multivariable analysis, the pattern and extent of fibrosis were both associated with all-cause mortality (by fibrosis pattern: infarct: HR, 2.60; 95% CI, 1.08–6.27; P=0.033; midwall: HR, 2.64; 95% CI, 1.08–6.47; P=0.034; by fibrosis extent per 1%: HR, 1.07; 95% CI, 1.03–1.12; P<0.001). Fibrosis pattern also predicted composites of cardiovascular mortality or aborted sudden cardiac death (infarct: HR, 3.45; 95% CI, 1.20–9.90; P=0.022; midwall: HR, 6.59; 95% CI, 2.26–19.22; P<0.001), and all-cause mortality, HF hospitalization, or aborted sudden cardiac death (infarct: HR, 2.69; 95% CI, 1.26–5.76; P=0.011; midwall fibrosis: HR, 2.97; 95% CI, 1.37–6.45; P=0.006). Addition of fibrosis pattern to LVEF improved risk prediction for all-cause mortality (LVEF versus LVEF+fibrosis C statistic: 0.66 versus 0.71; P=0.033). Importantly, the absence of fibrosis heralded a favorable prognosis with an 85% survival rate over the duration of follow-up. Conclusions: The pattern and extent of myocardial fibrosis predict adverse outcomes in new-onset HF and reduced LVEF. In contrast, the absence of fibrosis portends a durable warranty period with a low incidence of adverse events. These findings support a role for late gadolinium enhancement cardiovascular magnetic resonance in the early risk stratification of patients with HF of uncertain pathogenesis.

• Item Type: Articles
• Additional Information: This work was supported by the Cardiovascular Research Centre at the Royal Brompton and Harefield NHS Foundation Trust and Imperial College London. Dr Gulati received grant support from CORDA and the Rosetrees Trust. Dr Japp is supported by a National Research Scotland, Career Research Fellowship. Drs Halliday, Assomull, and Ismail were supported by the British Heart Foundation.
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: Cleland, Professor John
• Authors: Gulati, A., Japp, A. G., Raza, S., Halliday, B. P., Jones, D. A., Newsome, S., Ismail, N. A., Morarji, K., Khwaja, J., Spath, N., Shakespeare, C., Kalra, P. R., Lloyd, G., Mathur, A., Cleland, J. G.F., Cowie, M. R., Assomull, R. G., Pennell, D. J., Ismail, T. F., and Prasad, S. K.
• College/School: College of Medical Veterinary and Life Sciences > School of Cardiovascular & Metabolic Health
• Journal Name: Circulation: Cardiovascular Imaging
• Publisher: American Heart Association
• ISSN: 1941-9651
• ISSN (Online): 1942-0080
• Published Online: 17 September 2018
• Copyright Holders: Copyright © 2018 American Heart Association, Inc.
• First Published: First published in Circulation: Cardiovascular Imaging 11(9): e007722
• Publisher Policy: Reproduced in accordance with the publisher copyright policy