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. 2022 Feb 2;12(1):1739.
doi: 10.1038/s41598-022-05790-y.

Mid-wall striae fibrosis predicts heart failure admission, composite heart failure events, and life-threatening arrhythmias in dilated cardiomyopathy

Yanish Purmah  1 , Aidan Cornhill  1 , Lucy Y Lei  1 , Steven Dykstra  1 , Yoko Mikami  1 , Alessandro Satriano  1 , Dina Labib  1 , Jacqueline Flewitt  1 , Sandra Rivest  1 , Rosa Sandonato  1 , Michelle Seib  1 , Andrew G Howarth  1   2 , Carmen P Lydell  1   3 , Bobak Heydari  1   2 , Naeem Merchant  1   3 , Michael Bristow  1   3 , Louis Kolman  1   2 , Nowell M Fine  1   2 , James A White  4   5   6
Affiliations

Mid-wall striae fibrosis predicts heart failure admission, composite heart failure events, and life-threatening arrhythmias in dilated cardiomyopathy

Yanish Purmah et al. Sci Rep. .

Abstract

Heart failure (HF) admission is a dominant contributor to morbidity and healthcare costs in dilated cardiomyopathy (DCM). Mid-wall striae (MWS) fibrosis by late gadolinium enhancement (LGE) imaging has been associated with elevated arrhythmia risk. However, its capacity to predict HF-specific outcomes is poorly defined. We investigated its role to predict HF admission and relevant secondary outcomes in a large cohort of DCM patients. 719 patients referred for LGE MRI assessment of DCM were enrolled and followed for clinical events. Standardized image analyses and interpretations were conducted inclusive of coding the presence and patterns of fibrosis observed by LGE imaging. The primary clinical outcome was hospital admission for decompensated HF. Secondary heart failure and arrhythmic composite endpoints were also studied. Median age was 57 (IQR 47-65) years and median LVEF 40% (IQR 29-47%). Any fibrosis was observed in 228 patients (32%) with MWS fibrosis pattern present in 178 (25%). At a median follow up of 1044 days, 104 (15%) patients experienced the primary outcome, and 127 (18%) the secondary outcome. MWS was associated with a 2.14-fold risk of the primary outcome, 2.15-fold risk of the secondary HF outcome, and 2.23-fold risk of the secondary arrhythmic outcome. Multivariable analysis adjusting for all relevant covariates, inclusive of LVEF, showed patients with MWS fibrosis to experience a 1.65-fold increased risk (95% CI 1.11-2.47) of HF admission and 1-year event rate of 12% versus 7% without this phenotypic marker. Similar findings were observed for the secondary outcomes. Patients with LVEF > 35% plus MWS fibrosis experienced similar event rates to those with LVEF ≤ 35%. MWS fibrosis is a powerful and independent predictor of clinical outcomes in patients with DCM, identifying patients with LVEF > 35% who experience similar event rates to those with LVEF below this conventionally employed high-risk phenotype threshold.

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Conflict of interest statement

Dr James White is a shareholder of Cohesic Inc and has received research funding from Siemens Healthineers. The remaining authors have nothing to disclose.

Figures

Figure 1
Figure 1
Example late gadolinium enhancement (LGE) reporting of mid-wall striae (MWS) pattern fibrosis in a 38-year-old female with dilated cardiomyopathy. Concurrent inferior right ventricular insert site fibrosis is also noted.
Figure 2
Figure 2
Kaplan–Meier event free survival curve for the primary outcome of heart failure hospitalization in patients with and without (a) mid-wall striae (MWS) fibrosis, and (b) LVEF ≤ 35%.
Figure 3
Figure 3
Kaplan–Meier event free survival curve for the primary outcome of heart failure hospitalization stratified by the combined presence or absence of mid-wall striae (MWS) fibrosis and LVEF ≤ 35%.
Figure 4
Figure 4
Hazard ratios provided by each of four DCM phenotypes defined using the combined presence or absence of mid-wall striae (MWS) fibrosis and LVEF ≤ 35%.
Figure 5
Figure 5
Kaplan–Meier event free survival curve for the secondary heart failure composite outcome of heart failure hospitalization in patients with and without (a) mid-wall striae (MWS) fibrosis, and (b) LVEF ≤ 35%.
Figure 6
Figure 6
Kaplan–Meier event free survival curve for the secondary heart failure outcome of HF admission, left ventricular assist device (LVAD) implantation, cardiac transplantation or all-cause mortality stratified by the combined presence or absence of mid-wall striae (MWS) fibrosis and LVEF ≤ 35%.
Figure 7
Figure 7
Kaplan–Meier event free survival curve for the secondary arrhythmic composite outcome of appropriate ICD therapy, sudden cardiac death (SCD), survived sudden cardiac arrest (SCA), or sustained VT requiring cardioversion with and without (a) mid-wall striae (MWS) fibrosis, and (b) LVEF ≤ 35%.
Figure 8
Figure 8
Kaplan–Meier event free survival curve for the secondary arrhythmic outcome of appropriate ICD therapy, sudden cardiac death (SCD), survived sudden cardiac arrest (SCA), or sustained VT requiring cardioversion stratified by the combined presence or absence of mid-wall striae (MWS) fibrosis and LVEF ≤ 35%.
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