Association Between Midwall Late Gadolinium Enhancement and Sudden Cardiac Death in Patients With Dilated Cardiomyopathy and Mild and Moderate Left Ventricular Systolic Dysfunction

Brian P Halliday, Ankur Gulati, Aamir Ali, Kaushik Guha, Simon Newsome, Monika Arzanauskaite, Vassilios S Vassiliou, Amrit Lota, Cemil Izgi, Upasana Tayal, Zohya Khalique, Colin Stirrat, Dominique Auger, Nilesh Pareek, Tevfik F Ismail, Stuart D Rosen, Ali Vazir, Francisco Alpendurada, John Gregson, Michael P Frenneaux, Martin R Cowie, John G F Cleland, Stuart A Cook, Dudley J Pennell, Sanjay K Prasad, Brian P Halliday, Ankur Gulati, Aamir Ali, Kaushik Guha, Simon Newsome, Monika Arzanauskaite, Vassilios S Vassiliou, Amrit Lota, Cemil Izgi, Upasana Tayal, Zohya Khalique, Colin Stirrat, Dominique Auger, Nilesh Pareek, Tevfik F Ismail, Stuart D Rosen, Ali Vazir, Francisco Alpendurada, John Gregson, Michael P Frenneaux, Martin R Cowie, John G F Cleland, Stuart A Cook, Dudley J Pennell, Sanjay K Prasad

Abstract

Background: Current guidelines only recommend the use of an implantable cardioverter defibrillator in patients with dilated cardiomyopathy for the primary prevention of sudden cardiac death (SCD) in those with a left ventricular ejection fraction (LVEF) <35%. However, registries of out-of-hospital cardiac arrests demonstrate that 70% to 80% of such patients have an LVEF >35%. Patients with an LVEF >35% also have low competing risks of death from nonsudden causes. Therefore, those at high risk of SCD may gain longevity from successful implantable cardioverter defibrillator therapy. We investigated whether late gadolinium enhancement (LGE) cardiovascular magnetic resonance identified patients with dilated cardiomyopathy without severe LV systolic dysfunction at high risk of SCD.

Methods: We prospectively investigated the association between midwall LGE and the prespecified primary composite outcome of SCD or aborted SCD among consecutive referrals with dilated cardiomyopathy and an LVEF ≥40% to our center between January 2000 and December 2011 who did not have a preexisting indication for implantable cardioverter defibrillator implantation.

Results: Of 399 patients (145 women, median age 50 years, median LVEF 50%, 25.3% with LGE) followed for a median of 4.6 years, 18 of 101 (17.8%) patients with LGE reached the prespecified end point, compared with 7 of 298 (2.3%) without (hazard ratio [HR], 9.2; 95% confidence interval [CI], 3.9-21.8; P<0.0001). Nine patients (8.9%) with LGE compared with 6 (2.0%) without (HR, 4.9; 95% CI, 1.8-13.5; P=0.002) died suddenly, whereas 10 patients (9.9%) with LGE compared with 1 patient (0.3%) without (HR, 34.8; 95% CI, 4.6-266.6; P<0.001) had aborted SCD. After adjustment, LGE predicted the composite end point (HR, 9.3; 95% CI, 3.9-22.3; P<0.0001), SCD (HR, 4.8; 95% CI, 1.7-13.8; P=0.003), and aborted SCD (HR, 35.9; 95% CI, 4.8-271.4; P<0.001). Estimated HRs for the primary end point for patients with an LGE extent of 0% to 2.5%, 2.5% to 5%, and >5% compared with those without LGE were 10.6 (95% CI, 3.9-29.4), 4.9 (95% CI, 1.3-18.9), and 11.8 (95% CI, 4.3-32.3), respectively.

Conclusions: Midwall LGE identifies a group of patients with dilated cardiomyopathy and an LVEF ≥40% at increased risk of SCD and low risk of nonsudden death who may benefit from implantable cardioverter defibrillator implantation.

Clinical trial registration: URL: https://ichgcp.net/clinical-trials-registry/NCT00930735" title="See in ClinicalTrials.gov">NCT00930735.

Keywords: cardiovascular MRI; dilated cardiomyopathy; implantable cardioverter-defibrillator; late gadolinium enhancement; sudden cardiac death.

© 2017 The Authors.

Figures

Figure 1.
Figure 1.
Identification of the study population. Flow chart detailing the identification, inclusion, and exclusion of patients. CAD indicates coronary artery disease; CMR, cardiovascular magnetic resonance; LGE, late gadolinium enhancement; LVEDV, left ventricular end-diastolic volume; and LVEF, left ventricular ejection fraction.
Figure 2.
Figure 2.
Primary end point survival analysis. Kaplan-Meier curve of the time to first event for the primary end point by presence (red line) or absence (blue line) of midwall late gadolinium enhancement (LGE).
Figure 3.
Figure 3.
Five-year risk estimates of the primary end point. Five-year risk estimates for primary end point based on LVEF alone (green line) and midwall LGE status in addition to LVEF (red line, presence of LGE; blue line, absence of LGE). LGE indicates late gadolinium enhancement; and LVEF, left ventricular ejection fraction.

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