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.

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