Late gadolinium-enhanced cardiovascular magnetic resonance identifies patients with standardized definition of ischemic cardiomyopathy: A single centre experience

doi:10.1016/j.ijcard.2006.03.040

International Journal of Cardiology

Volume 116, Issue 2, 20 March 2007, Pages 167-173

https://doi.org/10.1016/j.ijcard.2006.03.040 Get rights and content

Abstract

Background

Definition of ischemic cardiomyopathy (IC) is not always obvious, which is why new criteria based on prognosis and the extent of the coronary artery disease (CAD) have been proposed. In the present study, we assess the capability of late gadolinium-enhanced cardiovascular magnetic resonance (CMR) for predicting IC as determined by standardized criteria previously reported.

Methods and results

123 patients with heart failure (HF) and left ventricular (LV) systolic dysfunction, underwent both late gadolinium-enhanced CMR and coronary angiography 37 / 123 (30%) of patients were assigned to the IC group and 86 / 123 (70%) to the non-IC group. Subendocardial late gadolinium enhancement (LGE) was found in 35 / 37 (94%) of patients in the IC group, whereas only 12 / 86 (14%) had this distribution in the non-IC group (p < 0.001). There was a significant positive correlation between the extent of subendocardial LGE and that of the CAD as determined by the CAD Prognostic Index (r = 0.78, p < 0.01), the number of coronary stenoses ≥ 50% (r = 0.76, p < 0.01) and the number of coronary stenoses of any percentage (r = 0.70, p < 0.01).

Conclusion

In patients with HF and LV systolic dysfunction presence of subendocardial LGE makes an excellent indicator of underlying significant CAD, and the extent of the LGE correlates with the severity of the disease. It is therefore appealing as a method for diagnosing IC.

Introduction

Because of the high rate of coronary disease in patients suffering from heart failure (HF) and left ventricular (LV) systolic dysfunction, the etiological analysis is based on excluding underlying coronary artery disease (CAD) [1], [2], [3]. Heart failure associated with idiopathic dilated cardiomyopathy may be clinically indistinguishable from that caused by ischemic cardiomyopathy (IC). The angina symptoms and risk factors generally associated with CAD are not sufficient as exclusion criteria nor are they invariable. Furthermore the frequent association with complete left bundle branch block in the ECG makes diagnosis even more difficult, since it impedes the detection of Q waves suggestive of a previous myocardial infarction [4].

The final diagnosis of IC depends on documenting obstructive CAD by means of coronary angiography, but even with the observational information about the coronary anatomy, the determination of IC is not always simple or obvious, which is why new criteria based on prognosis and the extent of the disease have been proposed [5], [6]. Although coronary angiography carries little risk of complications, those complications can be serious [7], and a noninvasive diagnostic approximation may therefore be preferable, especially in patients who present without any chest pain.

It has been shown recently that using late gadolinium-enhanced cardiovascular magnetic resonance (CMR) to detect areas of necrotic tissue in the myocardium of patients with HF makes it possible to identify those with underlying CAD [8], even in patients without a history of myocardial infarction or clinical findings suggestive of CAD [9].

In the present study, we adopt the hypothesis that areas of subendocardial myocardial necrosis are highly prevalent in patients suffering from HF with LV systolic dysfunction due to CAD. We assess the capability of late gadolinium enhancement (LGE) for predicting IC as determined by standardized criteria previously reported [6].

Section snippets

Patient population

We prospectively selected the patients from our cardiology department either at hospital admission or during scheduled visits to our HF clinic. The selection criteria were the following: 1. clinical evidence of HF; 2. LV systolic dysfunction documented by echocardiograms as LV ejection fraction < 50%. The exclusion criteria were: 1. acute myocardial infarction and/or unstable angina in the previous three months; 2. secondary causes of HF, including significant primary valve disease and

Results

Based on clinical histories and the results from coronary angiography, 37 / 123 (30%) of patients were assigned to the IC group and 86 / 123 (70%) to the nonischemic cardiomyopathy group. The baseline characteristics of the patients in both groups are shown in Table 1. The patients in the IC group were older and had more risk factors. There were no significant differences in gender, nor in the LV ejection fraction, New York Heart Association functional class, progress of the disease over time, and

Discussion

The present study demonstrates that the presence of subendocardial LGE found by CMR in patients with HF and LV systolic dysfunction is an excellent indicator for predicting IC as determined by standardized criteria previously reported [6]. If subendocardial LGE is absent, then IC is very improbable. In our study, subendocardial LGE was not observed in only two patients who were classified in the IC group (negative predictive value 97%, IC 95% 93–100), and they both presented with obstructive

Acknowledgements

This research was funded in part by Grant FIS PI042591 from the Instituto de Salud Carlos III.

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Multicentre medicoeconomic evaluation of cardiac magnetic resonance imaging for predicting coronary artery disease in left ventricular dysfunction: The CAMAREC study design
2023, Archives of Cardiovascular Diseases
Cardiac magnetic resonance imaging may provide a non-invasive alternative to coronary angiography for differentiating between ischaemic and non-ischaemic cardiomyopathy in cases of unexplained reduced left ventricular ejection fraction.
The CAMAREC study aims to evaluate the diagnostic accuracy of cardiac magnetic resonance imaging in predicting significant coronary artery disease in patients with reduced left ventricular ejection fraction, using coronary angiography as the gold standard for comparison.
CAMAREC is a prospective cohort study of 406 patients in 10 centres with newly diagnosed, unexplained left ventricular ejection fraction ≤ 45%. Cardiac magnetic resonance imaging and coronary angiography will be conducted within a 2-week interval, starting with cardiac magnetic resonance imaging; independent committees will review the results blindly. Primary outcome is sensitivity of detecting ischaemic scar on cardiac magnetic resonance imaging for predicting significant coronary artery disease on coronary angiography according to Felker's criteria. Secondary outcomes include specificity and positive and negative predictive values (with 95% confidence intervals) of cardiac magnetic resonance imaging for predicting significant coronary artery disease in patients with reduced left ventricular ejection fraction, kappa concordance coefficient between cardiac magnetic resonance imaging and coronary angiography for diagnosing the affected myocardial territory, and the impact of cardiac magnetic resonance imaging on revascularization decisions. Two ancillary studies will evaluate the incremental cost-effectiveness of using cardiac magnetic resonance imaging first versus coronary angiography first, and the sensitivity of pre- and postcontrast T1-mapping for predicting significant coronary artery disease in patients with reduced left ventricular ejection fraction.
Our study protocol is designed to rigorously evaluate cardiac magnetic resonance imaging as a non-invasive alternative to coronary angiography in patients with unexplained reduced left ventricular ejection fraction. The results will have significant implications for patient management, and may support growing evidence for the clinical utility of cardiac magnetic resonance imaging.
Diagnostic Accuracy of CMR With Late Gadolinium Enhancement for Ischemic Cardiomyopathy: A Systematic Review and Meta-Analysis
2023, JACC: Cardiovascular Imaging
Accuracy of cardiac magnetic resonance imaging to rule out significant coronary artery disease in patients with systolic heart failure of unknown aetiology: Single-centre experience and comprehensive meta-analysis
2018, Archives of Cardiovascular Diseases
Citation Excerpt :
The presence of a single mild and/or distal coronary artery stenosis probably cannot solely explain the severity and extent of the left ventricular dysfunction in some cases [21]. Indeed, as suggested by Soriano et al. [10], who previously reported a correlation between the extent of st-LGE and a standardized definition of ischaemic cardiomyopathy (history of myocardial infarction and/or coronary revascularization; or stenosis ≥ 75% in the left main coronary artery and/or in the anterior descending coronary artery before the first diagonal branch; or two or more stenoses ≥ 75% in epicardial coronary arteries) [19], it could be speculated that this was a fortuitous association in some cases. However, beyond the therapeutic and prognostic implications of the presence of a “real” ischaemic cardiomyopathy, we believe that the presence of any CAD may also carry relevant individual information for patients with systolic HF (medical treatment, follow-up, prognostic evaluation, etc.).
Coronary artery disease (CAD) is the leading cause of systolic heart failure (HF). Cardiac magnetic resonance imaging (CMR) is a non-invasive technique that detects a myocardial infarction scar as subendocardial or transmural late gadolinium enhancement (st-LGE).
We sought to evaluate whether a lack of st-LGE could rule out CAD in new-onset systolic HF of unknown aetiology.
We included 232 consecutive patients with new-onset HF and left ventricular ejection fraction ≤ 35% who underwent both coronary angiography and CMR to assess HF aetiology. CAD was defined as the presence of coronary artery stenosis ≥ 50% on a coronary angiogram. We assessed sensitivity, specificity, and positive and negative likelihood ratios (PLR and NLR) of the presence of st-LGE to detect underlying CAD. A complementary meta-analysis of 11 studies (including ours) was also performed.
In our study, 49 (21.1%) patients had CAD. The sensitivity and specificity of the presence of st-LGE to detect CAD were 69 and 92%, respectively. PLR and NLR were 8.47 and 0.33, respectively. In the meta-analysis, 1227 patients were included, and the prevalence of CAD ranged from 19.2 to 68.3%. Sensitivity, specificity, PLR and NLR were 87% (95% confidence interval [CI] 0.80–0.92), 93% (95% CI 0.89–0.96), 12.91 (95% CI 7.70–21.64) and 0.14 (95% CI 0.09–0.22), respectively. Altogether, 55 patients presented CAD with no st-LGE; inversely, 75 patients presented st-LGE with no CAD.
With a CMR specificity of 93%, the absence of st-LGE rules out significant underlying CAD in patients with systolic HF of unknown aetiology in most cases.
La coronaropathie est la principale cause d’insuffisance cardiaque (IC) systolique. L’imagerie par résonance magnétique cardiaque (IRM-C) est une technique non invasive qui permet de détecter les cicatrices d’infarctus du myocarde sous la forme d’un rehaussement tardif sous-endocardique ou transmural après injection de gadolinium (st-RT).
L’objectif de cette étude est d’évaluer si l’absence de st-RT peut exclure la coronaropathie chez les patients présentant une IC systolique d’étiologie inconnue.
Au total, 232 patients consécutifs présentant une IC avec une fraction d’éjection ventriculaire gauche ≤ 35 % et qui ont eu à la fois une angiographie coronaire et une IRM-C ont été inclus. La coronaropathie était définie par la présence d’une sténose coronaire ≥ 50 % en angiographie. La sensibilité, la spécificité, les rapports de vraisemblance positifs et négatifs (RVP et RVN) de la présence d’un st-RT à l’IRM-C pour détecter la coronaropathie ont été évalué. Une méta-analyse complémentaire de 11 études (dont la nôtre) a également été réalisée.
Dans notre étude, 49 (21,1 %) patients avaient une coronaropathie. La sensibilité et la spécificité de la présence de st-RT pour détecter cette dernière étaient de 69 et 92 %, respectivement. Les RVP et RVN étaient respectivement de 8,47 et 0,33. La méta-analyse a inclus 1227 patients. La prévalence de la coronaropathie variait de 19,2 à 68,3 %. La sensibilité, la spécificité, le RVP et le RVN étaient respectivement de 87 % (IC95 % 0,80–0,92), 93 % (IC95 % 0,89–0,96), 12,91 (IC95 % 7,70–21,64) et 0,14 (IC95 % 0,09–0,22). Au total, 55 patients ne présentaient pas de st-RT mais une coronaropathie ; inversement 75 patients présentaient une st-LGE sans coronaropathie.
Avec une spécificité de l’IRM cardiaque de 93 %, l’absence de st-RT exclut une coronaropathie chez les patients présentant une IC systolique d’étiologie inconnue dans la plupart des cas.
The abscense of an ischemic pattern on cardiac magnetic resonance in patients with dilated cardiomyopathy of unknown origin suggests nonischemic etiology even with the presence of significan coronary artery disease
2016, Revista Clinica Espanola
Diagnostic Accuracy of Cardiac Magnetic Resonance Imaging in the Evaluation of Newly Diagnosed Heart Failure with Reduced Left Ventricular Ejection Fraction
2015, American Journal of Cardiology
Citation Excerpt :
The lack of underlying severe CAD in more than half of new HFrEF cases highlights the need to investigate noninvasive alternatives to coronary angiography in this setting. Most previous studies evaluating the diagnostic utility of CMR in HFrEF had several notable differences from the present study, including (1) data primarily from European sites, (2) inclusion of patients with longstanding HFrEF, (3) exclusion of patients with any signs or symptoms of CAD, and (4) evaluation of LGE alone.7,9–11 Given that the United States has among the highest rates of obesity and diabetes mellitus in the developed nations, the prevalence of these co-morbidities is higher than reports from outside the United States.7,9–13
The aim of this study was to determine the diagnostic value of cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE), cine imaging, and resting first-pass perfusion (FPP) in the evaluation for ischemic (IC) versus nonischemic (NIC) cardiomyopathy in new-onset heart failure with reduced (≤40%) left ventricular ejection fraction (HFrEF). A retrospective chart review analysis identified 83 patients from January 2009 to June 2012 referred for CMR imaging evaluation for new-onset HFrEF with coronary angiography performed within 6 months of CMR. The diagnosis of IC was established using Felker criteria on coronary angiography. CMR sequences were evaluated for the presence of patterns suggestive of severe underlying coronary artery disease as the cause of HFrEF (subendocardial and/or transmural LGE, regional wall motion abnormality on cine, regional hypoperfusion defect on resting FPP). Discriminative power was assessed using receiver operator characteristics curve analysis. Coronary angiography identified 36 patients (43%) with IC. Presence of subendocardial and/or transmural LGE alone demonstrated good discriminative power (C-statistic 0.85, 95% confidence interval 0.76 to 0.94) for the diagnosis of IC. The presence of an ischemic pattern on both LGE and cine sequences resulted in a specificity of 87% for the diagnosis of IC, whereas the absence of an ischemic pattern on both LGE and cine sequences resulted in a specificity of 94% for the diagnosis of NIC. Addition of resting FPP on a subset of patients did not improve diagnostic values. In conclusion, CMR has potential value in the diagnostic evaluation of IC versus NIC.
Clinical significance of papillary muscle late enhancement detected via cardiac magnetic resonance imaging in patients with single old myocardial infarction
2011, International Journal of Cardiology
Citation Excerpt :
Thus, the function and location of PMs determine mitral valve function, and their accurate evaluation is very important in understanding the pathoetiology of mitral valve disease. Cardiac magnetic resonance imaging (MRI) using gadolinium-based contrast agents has been validated for accurate evaluation of the morphology and function of the LV [2] and mitral valve [3], and of injured myocardial tissue in patients not only with myocardial infarction (MI) [4] but also with non-infarct-related diseases [5,6]. Recently, it was reported that late enhancement (LE) of PMs was detected by contrast-enhanced MRI in patients with several types of heart disease [7–13].
Contrast-enhanced cardiac magnetic resonance imaging (MRI) can depict papillary muscle (PM) necrosis or fibrosis by late enhancement (LE) of PM, but its clinical significance in old myocardial infarction (OMI) has been little understood.
Myocardial LE and PM-LE were detected with contrast imaging in 60 patients with OMI caused by a single culprit coronary artery lesion. Left ventricular (LV) morphology and function, mitral valve geometry, and severity of mitral regurgitation were also evaluated by cine imaging. Sphericity index was calculated for the assessment of LV remodeling.
PM-LE was detected in 32 of 60 (53.3%) OMI patients. Unilateral PM-LE was detected in 22 patients and bilateral PM-LE in 10 patients. Patients with bilateral PM-LE demonstrated more severe LV remodeling and functional mitral regurgitation than those with unilateral or no PM-LE (sphericity index; bilateral PM-LE, 1.60 ± 0.15, unilateral PM-LE, 1.71 ± 0.29, no PM-LE, 1.85 ± 0.27, p ≤ 0.05) (mitral regurgitation; bilateral PM-LE, 1.10 ± 0.57, unilateral PM-LE, 0.41 ± 0.73, no PM-LE, 0.54 ± 0.84, p ≤ 0.05). In cases of unilateral PM-LE, posteromedial PM-LE resulting from right coronary artery-related OMI was accompanied by less severe mitral regurgitation, while anterolateral PM-LE resulting from left coronary artery-related OMI was not associated with severity of mitral regurgitation.
More than half of patients with OMI showed unilateral or bilateral PM-LE, and bilateral PM-LE was closely related to more severe LV remodeling and functional mitral regurgitation.

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Late gadolinium-enhanced cardiovascular magnetic resonance identifies patients with standardized definition of ischemic cardiomyopathy: A single centre experience

Abstract

Background

Methods and results

Conclusion

Introduction

Section snippets

Patient population

Results

Discussion

Acknowledgements

Int J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology

Eur Heart J

Guidelines for the diagnosis and treatment of chronic heart failure. Task Force for the Diagnosis and Treatment of Chronic Heart Failure, European Society of Cardiology

Eur Heart J

Differentiation of heart failure related to dilated cardiomyopathy and coronary artery disease using gadolinium-enhanced cardiovascular magnetic resonance

Circulation