Diagnostic and prognostic utility of cardiovascular magnetic resonance imaging in heart failure with preserved ejection fraction - implications for clinical trials

Abstract

Background: Heart failure with preserved ejection fraction (HFpEF) is a poorly characterized condition. We aimed to phenotype patients with HFpEF using multiparametric stress cardiovascular magnetic resonance imaging (CMR) and to assess the relationship to clinical outcomes.

Methods: One hundred and fifty four patients (51% male, mean age 72 ± 10 years) with a diagnosis of HFpEF underwent transthoracic echocardiography and CMR during a single study visit. The CMR protocol comprised cine, stress/rest perfusion and late gadolinium enhancement imaging on a 3T scanner. Follow-up outcome data (death and heart failure hospitalization) were captured after a minimum of 6 months.

Results: CMR detected previously undiagnosed pathology in 42 patients (27%), who had similar baseline characteristics to those without a new diagnosis. These diagnoses consisted of: coronary artery disease (n = 20, including 14 with 'silent' infarction), microvascular dysfunction (n = 11), probable or definite hypertrophic cardiomyopathy (n = 10) and constrictive pericarditis (n = 5). Four patients had dual pathology. During follow-up (median 623 days), patients with a new CMR diagnosis were at higher risk of adverse outcome for the composite endpoint (log rank test: p = 0.047). In multivariate Cox proportional hazards analysis, a new CMR diagnosis was the strongest independent predictor of adverse outcome (hazard ratio: 1.92; 95% CI: 1.07 to 3.45; p = 0.03).

Conclusions: CMR diagnosed new significant pathology in 27% of patients with HFpEF. These patients were at increased risk of death and heart failure hospitalization.

Trial registration: ClinicalTrials.gov Identifier: NCT03050593 . Retrospectively registered; Date of registration: February 06, 2017.

Keywords: Cardiovascular magnetic resonance imaging; Diagnostic; Heart failure; Heart failure with preserved ejection fraction; Prognostic; Transthoracic echocardiography.

Conflict of interest statement

Ethics approval and consent to participate

All study participants provided written informed consent. The study was approved by the National Research Ethics Service Committee East Midlands – Nottingham 1 on July 24, 2012 (Reference: 12/EM/0222). Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests .

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Figures

Fig. 1

Study overview. *Of the 20 patients with newly diagnosed coronary artery disease (CAD), 4 patients had concomitant hypertrophic cardiomyopathy (HCM)

Fig. 2

Examples of typical findings in the ‘new diagnoses’ group. CMR images of: a sub-endocardial, inferolateral myocardial infarction of 25–50% transmurality on LGE; b inferoseptal and inferior perfusion defect consistent with right coronary artery territory ischaemia; c global, concentric perfusion defect consistent with microvascular dysfunction; d horizontal long axis cine demonstrating asymmetrical septal hypertrophy in HCM; E) constrictive pericarditis with circumferential pericardial hyperenhancement on LGE; white arrows point towards pathology; LGE = late gadolinium enhancement imaging

Fig. 3

Characteristics of newly diagnosed myocardial infarction according to coronary arterial distribution and transmurality. LAD = left anterior descending artery; RCA = right coronary artery; LCX = left circumflex artery; % transmurality of MI is illustrated as 1–25, 26–50, 51–75, 76–100; RWMA = regional wall motion abnormality

Fig. 4

Kaplan Meier analysis for the composite endpoint of death and/or hospitalization with heart failure. Nil