Myocardial damage detected by late gadolinium enhancement cardiovascular magnetic resonance is associated with subsequent hospitalization for heart failure

Abstract

Background: Hospitalization for heart failure (HHF) is among the most important problems confronting medicine. Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) robustly identifies intrinsic myocardial damage. LGE may indicate inherent vulnerability to HHF, regardless of etiology, across the spectrum of heart failure stage or left ventricular ejection fraction (LVEF).

Methods and results: We enrolled 1068 consecutive patients referred for CMR where 448 (42%) exhibited LGE. After a median of 1.4 years (Q1 to Q3: 0.9 to 2.0 years), 57 HHF events occurred, 15 deaths followed HHF, and 43 deaths occurred without antecedent HHF (58 total deaths). Using multivariable Cox regression adjusting for LVEF, heart failure stage, and other covariates, LGE was associated with first HHF after CMR (HR: 2.70, 95% CI: 1.32 to 5.50), death (HR: 2.13, 95% CI: 1.08 to 4.21), or either death or HHF (HR: 2.52, 95% CI: 1.49 to 4.25). Quantifying LGE extent yielded similar results; more LGE equated higher risks. LGE improved model discrimination (IDI: 0.016, 95% CI: 0.005 to 0.028, P=0.002) and reclassification of individuals at risk (continuous NRI: 0.40, 95% CI: 0.05 to 0.70, P=0.024). Adjustment for competing risks of death that shares common risk factors with HHF strengthened the LGE and HHF association (HR: 4.85, 95% CI: 1.40 to 16.9).

Conclusions: The presence and extent of LGE is associated with vulnerability for HHF, including higher risks of HHF across the spectrum of heart failure stage and LVEF. Even when LVEF is severely decreased, those without LGE appear to fare reasonably well. LGE may enhance risk stratification for HHF and may enhance both clinical and research efforts to reduce HHF through targeted treatment.

Keywords: late gadolinium enhancement; magnetic resonance imaging; myocardial delayed enhancement; myocardial fibrosis; myocardial infarction.

Figure 1.

The distribution of left ventricular ejection fraction (LVEF) measures by cardiovascular magnetic resonance (CMR) (n=214) in those with heart failure approximates a bimodal distribution (shown by the moving average trend line) observed in previous reports from community‐based epidemiologic studies.

Figure 2.

Clinical examples of significant late gadolinium enhancement (LGE) are shown, including: normal myocardium without significant LGE (A); inferior wall transmural myocardial infarction (B); midwall fibrosis following anthracycline chemotherapy (C); cardiac amyloidosis pattern from light chain (AL) systemic amyloidosis with brighter signal in the myocardium compared to blood pool from diffuse myocardial LGE and rapid gadolinium contrast clearance from the blood (D).

Figure 3.

Kaplan‐Meier curves for those with or without late gadolinium enhancement (LGE) showing time to event for: hospitalization for heart failure (top row), all cause mortality (middle row), or either event (bottom row). The cohort is also stratified according to whether preserved left ventricular ejection fraction (LVEF) is preserved (≥55%, middle column), or not (<55%, right column). LGE was significantly associated with adverse events for all outcomes, even when LVEF was preserved (≥55%) or reduced (<55%). CMR indicates cardiovascular magnetic resonance.

Figure 4.

Kaplan‐Meier curves for those with or without late gadolinium enhancement (LGE) where the cohort is further stratified according to the presence of myocardial infarction (excluding those with nonischemic myocardial scar, middle column) or according to the presence of nonischemic myocardial scar (excluding those with myocardial infarction, right column). The curves show time to event for: hospitalization for heart failure (top row), all cause mortality (middle row), or either event (bottom row). Risks of adverse events were similar for the presence myocardial infarction and nonischemic scar based on their log rank statistics. CMR indicates cardiovascular magnetic resonance.

Figure 5.

More extensive LGE is associated with higher risks of adverse outcomes demonstrating a dose–response relationship. CMR indicates cardiovascular magnetic resonance; LGE, late gadolinium enhancement; LV, left ventricle.

Figure 6.

Among 102 (of 1068) patients with severely reduced systolic function (LVEF ≤30%), of whom 73 were hospitalized, absence of LGE was prognostically favorable where no events occurred during follow‐up, except in 1 of the 2 remaining patients still being followed after 2 years who experienced HHF. In contrast, those with LGE were a very high‐risk group with 1‐year event rates of 28% for HHF, 22% for mortality, and 42% for either HHF or mortality. LGE was prevalent when LVEF was ≤30%; 46 had nonischemic scar and 44 had MI (8 had both). CMR indicates cardiovascular magnetic resonance; HHF, hospitalization for heart failure; LGE, late gadolinium enhancement; LVEF, left ventricular ejection fraction; MI, myocardial infarction.