The Combined Incremental Prognostic Value of LVEF, Late Gadolinium Enhancement, and Global Circumferential Strain Assessed by CMR

JACC Cardiovasc Imaging. 2015 May;8(5):540-549. doi: 10.1016/j.jcmg.2015.02.005. Epub 2015 Apr 15.


Objectives: This study aimed to assess the incremental prognostic value of global circumferential strain (GCS), as measured using cardiac magnetic resonance (CMR) tagging, in addition to baseline clinical characteristics, left ventricular ejection fraction (LVEF), and late gadolinium enhancement (LGE), in the prediction of major adverse cardiovascular events (MACE) in an unselected cohort of patients.

Background: LVEF is a powerful predictor of mortality and is used for guiding treatment decisions. It is, however, subject to limitations. The value of GCS measured by CMR tagging in patients with suspected cardiac disease has not been fully explored despite its being considered as the gold standard noninvasive method of assessment of LV deformation.

Methods: We prospectively evaluated data from 539 consecutive patients referred for CMR who underwent a CMR protocol that included cine imaging, tagging, and LGE. The primary endpoint was the prevalence of MACE, defined as a composite of all-cause mortality, heart failure-related hospitalization, and aborted sudden cardiac death.

Results: MACE occurred in 62 of 539 patients (11.5%) over a mean follow-up period of 2.2 years. History of ischemic heart disease (IHD) and beta-blocker use were both significant clinical predictors of adverse outcomes. All 3 CMR parameters were significant multivariate predictors of the primary outcome when added to significant clinical predictors (LVEF, hazard ratio [HR]: 0.96 [95% confidence interval [CI]: 0.94 to 0.99; p = 0.005]; presence of LGE, HR: 2.07 [95% CI: 1.03 to 4.14; p = 0.04]; GCS, HR: 1.11 [95% CI: 1.02 to 1.21; p = 0.041]). Global chi-square increased significantly with the addition of both LGE and GCS. Both the presence of LGE and reduced GCS had independent prognostic value in the overall cohort. Patients with LVEF ≥35% but LGE present and reduced GCS had a poor outcome similar to that in those with LVEF <35%.

Conclusions: We found, in a large-scale cohort of patients, that GCS, in addition to clinical variables, LVEF, and LGE, had incremental independent prognostic value. This measure could provide further risk stratification, especially in patients with mild LV impairment.

Keywords: cardiac magnetic resonance; late gadolinium enhancement; strain; tagging.

MeSH terms

  • Adult
  • Biomechanical Phenomena
  • Chi-Square Distribution
  • Contrast Media*
  • Death, Sudden, Cardiac / epidemiology
  • Death, Sudden, Cardiac / prevention & control
  • Disease Progression
  • Female
  • Gadolinium DTPA*
  • Heart Diseases / diagnosis*
  • Heart Diseases / mortality
  • Heart Diseases / physiopathology
  • Heart Diseases / therapy
  • Heart Failure / diagnosis
  • Heart Failure / mortality
  • Heart Failure / physiopathology
  • Humans
  • Kaplan-Meier Estimate
  • Magnetic Resonance Imaging, Cine*
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Myocardial Contraction*
  • Predictive Value of Tests
  • Prevalence
  • Prognosis
  • Proportional Hazards Models
  • Prospective Studies
  • Risk Factors
  • Stroke Volume*
  • Time Factors
  • Ventricular Dysfunction, Left / diagnosis
  • Ventricular Dysfunction, Left / mortality
  • Ventricular Dysfunction, Left / physiopathology
  • Ventricular Function, Left*


  • Contrast Media
  • Gadolinium DTPA