Elsevier

American Heart Journal

Volume 168, Issue 2, August 2014, Pages 220-228.e1
American Heart Journal

Clinical Investigation
Imaging and Diagnostic Testing
Is there a role for diastolic function assessment in era of delayed enhancement cardiac magnetic resonance imaging?: A multimodality imaging study in patients with advanced ischemic cardiomyopathy

https://doi.org/10.1016/j.ahj.2014.04.004Get rights and content

Background

Cardiac magnetic resonance (CMR) identifies important prognostic variables in ischemic cardiomyopathy (ICM) patients such as left ventricular (LV) volumes, LV ejection fraction (LVEF), peri-infarct zone, and myocardial scar burden (MSB). It is unknown whether Doppler-based diastolic dysfunction (DDF) retains its prognostic value in ICM patients, in the context of current imaging, medical, and device therapies.

Methods

Diastolic function was evaluated in ICM patients (LVEF ≤40% and ≥70% stenosis in ≥1 coronary artery) who underwent transthoracic echocardiogram and delayed hyperenhancement CMR studies within 7 days. The association of DDF with the combined end point was assessed after risk-adjustment using Cox proportional hazards models.

Results

A total of 360 patients with severe LV dysfunction (LVEF = 24±9%) and extensive MSB (31±17%) were evaluated; DDF was present in all patients (stage 1%-44%, stage 2%-25%, stage 3%-31%). There were 130 events (124 deaths and 6 heart transplants) over a median follow-up of 5.8 years (IQR, 3.7-7.4 years). On multivariable analysis, DDF > stage 1 (HR, 1.37; P = .007) was associated with the combined end-point, independent of clinical risk score (HR, 2.40; P < .0001), implantable cardioverter defibrillator implantation (HR, 0.60; P = .009), incomplete revascularization (HR, 1.32; P = .003), mitral regurgitation (HR, 3.37; P = .01), peri-infarct zone area (HR, 1.04; P = 0.02), and MSB (HR, 1.02; P = .01). DDF had incremental prognostic value for the combined end-point (model χ2 increased from 89 to 95, P = .02).

Conclusion

DDF is a powerful predictor of mortality in ICM patients with significant LV dysfunction, independent of clinical and CMR data. DDF assessment provides incremental value, improving risk stratification.

Section snippets

Patient population and study design

We examined 459 consecutive patients with the diagnosis of ICM (LVEF ≤40% with ≥70% stenosis in ≥1 epicardial coronary vessel on angiography and/or history of MI or coronary revascularization,10) who were referred for clinically indicated myocardial viability assessment with CMR between January 2002 and December 2006. All transthoracic echocardiograms (TTE) obtained within a maximum of 7 days from the index CMR study were used for the analysis detailed below. Patients with standard CMR

Patient characteristics

Our study cohort (n = 360) was middle aged (62 ± 11 years) and predominantly male (76%) with a high prevalence of cardiovascular risk factors. A total of 43% had prior revascularization and majority received optimal medical therapies including β-blockers, angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker and statin. A small percentage (17%) was on aldosterone blockage therapy. Patients with worse DDF (stage >1) were younger, had lower systolic blood pressure, higher

Discussion

In patients with advanced ICM, DDF remains an independent predictor of all-cause mortality and heart transplantation, despite coronary revascularization and optimal contemporary medical and device therapies. DDF was found to be powerful prognostic indicator, even after adjusting for baseline clinical risk score, LVEF, MSB, and LV remodeling characteristics in this high risk population. Furthermore, our study is the first to demonstrate that diastolic function assessment provided incremental

Limitations

Although our patient cohort represents a patient population seen at a tertiary referral center, the impact of selection biases and missing/unmeasured variables may affect the findings in this study. For example, CMR was performed for clinically indicated myocardial viability assessment, thus patients with renal impairment, non-sinus rhythm/tachycardia, implanted devices (ICD/CRT/CRT-D) are not represented in the population and results may not be generally applicable. This might in part explain

Conclusions

DDF remains an independent predictor of all-cause mortality and heart transplantation in this population with advanced ICM, even after adjusting for clinical risk factors, optimal medical therapy, device therapies, coronary revascularization, and CMR-derived MSB and peri-infarct zone area. Diastolic function assessment provides incremental prognostic value to the baseline clinical characteristics and CMR data, improving risk stratification. This suggests a functional association with outcome

Disclosures

Funding: No extramural funding was used to support this work.

References (18)

There are more references available in the full text version of this article.

Cited by (6)

  • The prognostic value of right ventricular ejection fraction by cardiovascular magnetic resonance in heart failure: A systematic review and meta-analysis

    2022, International Journal of Cardiology
    Citation Excerpt :

    After removal of duplicates, 2237 studies were excluded based on title and abstract, resulting in 64 studies eligible for full-text assessment. Finally, 46 studies enrolling 14,344 patients were included in the review [6,10,11,13–55]. Detailed flow diagram is presented in Fig. 1.

  • Management of asymptomatic (occult) feline cardiomyopathy: Challenges and realities

    2015, Journal of Veterinary Cardiology
    Citation Excerpt :

    Similarly, diastolic dysfunction has prognostic importance in human patients with both preserved and depressed left ventricular systolic function.23 Comprehensive Doppler echocardiography can provide information regarding diastolic function and filling pressures.24,26 In patients with ischemic cardiomyopathy, Doppler-based diagnosis of diastolic dysfunction provides strong prediction for adverse outcome when evaluating transmitral Doppler flow patterns including isovolumic relaxation time, early peak (E wave), and late (A wave) phases of diastole; deceleration time; and mitral annular velocities using tissue Doppler imaging.24

Presented in part at the 2012 American Heart Association meeting in Los Angeles, CA, November 3 to 7, 2012.

View full text