Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2021 May;14(5):931-942.
doi: 10.1016/j.jcmg.2020.08.013. Epub 2020 Sep 30.

Cardiac-MRI Predicts Clinical Worsening and Mortality in Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis

Samer Alabed  1 , Yousef Shahin  2 , Pankaj Garg  3 , Faisal Alandejani  3 , Christopher S Johns  2 , Robert A Lewis  4 , Robin Condliffe  5 , James M Wild  6 , David G Kiely  7 , Andrew J Swift  8
Affiliations
Meta-Analysis

Cardiac-MRI Predicts Clinical Worsening and Mortality in Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis

Samer Alabed et al. JACC Cardiovasc Imaging. 2021 May.

Erratum in

  • Correction.
    [No authors listed] [No authors listed] JACC Cardiovasc Imaging. 2021 Apr;14(4):884. doi: 10.1016/j.jcmg.2021.02.001. JACC Cardiovasc Imaging. 2021. PMID: 33832670 Free PMC article. No abstract available.

Abstract

Objectives: This meta-analysis evaluates assessment of pulmonary arterial hypertension (PAH), with a focus on clinical worsening and mortality.

Background: Cardiac magnetic resonance (CMR) has prognostic value in the assessment of patients with PAH. However, there are limited data on the prediction of clinical worsening, an important composite endpoint used in PAH therapy trials.

Methods: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Web of Science databases were searched in May 2020. All CMR studies assessing clinical worsening and the prognosis of patients with PAH were included. Pooled hazard ratios of univariate regression analyses for CMR measurements, for prediction of clinical worsening and mortality, were calculated.

Results: Twenty-two studies with 1,938 participants were included in the meta-analysis. There were 18 clinical worsening events and 8 deaths per 100 patient-years. The pooled hazard ratios show that every 1% decrease in right ventricular (RV) ejection fraction is associated with a 4.9% increase in the risk of clinical worsening over 22 months of follow-up and a 2.1% increase in the risk of death over 54 months. For every 1 ml/m2 increase in RV end-systolic volume index or RV end-diastolic volume index, the risk of clinical worsening increases by 1.3% and 1%, respectively, and the risk of mortality increases by 0.9% and 0.6%. Every 1 ml/m2 decrease in left ventricular stroke volume index or left ventricular end-diastolic volume index increased the risk of death by 2.5% and 1.8%. Left ventricular parameters were not associated with clinical worsening.

Conclusions: This review confirms CMR as a powerful prognostic marker in PAH in a large cohort of patients. In addition to confirming previous observations that RV function and RV and left ventricular volumes predict mortality, RV function and volumes also predict clinical worsening. This study provides a strong rationale for considering CMR as a clinically relevant endpoint for trials of PAH therapies.

Keywords: CMR; PAH; cardiac MRI; meta-analysis; mortality; prognosis; pulmonary arterial hypertension; systematic review.

PubMed Disclaimer

Conflict of interest statement

Funding Support and Author Disclosures The study was supported by the Wellcome Trust grants 215799/Z/19/Z and 205188/Z/16/Z. The funder did not have any role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, and approval of the paper. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Pooled Baseline CMR Characteristics The included studies had homogeneous mean baseline cardiac magnetic resonance (CMR) measurements as shown by the overlapping confidence intervals, with relatively more heterogeneity in right ventricular mass and volumes. The overall pooled mean CMR measurements show moderately impaired right ventricular function and volumes at baseline and indicate a relatively advanced disease. LVEDVI = left ventricular end-diastolic volume index; LVEF = left ventricular ejection fraction; LVESVI = left ventricular end-systolic volume index; LVMI = left ventricular mass index; RVEDVI = right ventricular end-diastolic volume index; RVEF = right ventricular ejection fraction; RVMI = right ventricular mass index; RVESVI = right ventricular end-systolic volume index.
Figure 2
Figure 2
Meta-Analyses of RV and LV Function and Mass The meta-analyses of right ventricular (RV) and left ventricular (LV) function and mass showed that RVEF and RVMI are significant prognostic markers. RVEF could predict clinical worsening separate from mortality, whereas RVMI is a nonspecific prognostic marker. Unpublished data are indicated by (+). CI = confidence interval; other abbreviations as in Figure 1.
Figure 3
Figure 3
Meta-Analyses of RV And LV Volume Measurements RV and LV volumes are significant prognostic markers. A decrease in RV volumes can predict mortality and clinical worsening, whereas an increase in LV volumes indicates an increased risk for death only. Unpublished data are indicated by (+). LVSVI = left ventricular stroke volume index; RVSVI = right ventricular stroke volume index; other abbreviations as in Figures 1 and 2.
Central Illustration
Central Illustration
Cardiac Magnetic Resonance Imaging for Prediction of Clinical Worsening and Mortality in Pulmonary Arterial Hypertension Pooled results for mortality and clinical worsening are presented in the forest plots and described in the table underneath for various factors. The literature search details and demographic characteristics of the meta-analysis cohort are shown on the left. LVEDVI = left ventricular end-diastolic volume index; LVESVI = left ventricular end-systolic volume index; LVSVI = left ventricular stroke volume index; RVEDVI = right ventricular end-diastolic volume index; RVEF = right ventricular ejection fraction; RVESVI = right ventricular end-systolic volume index.
See this image and copyright information in PMC

Comment in

References

    1. Kiely D.G., Levin D., Hassoun P. EXPRESS: Statement on imaging and pulmonary hypertension from the Pulmonary Vascular Research Institute (PVRI) Pulm Circ. 2019;9 2045894019841990. - PMC - PubMed
    1. Kiely D.G., Elliot C.A., Sabroe I., Condliffe R. Pulmonary hypertension: diagnosis and management. BMJ. 2013;346:f2028. - PubMed
    1. Galiè N., Humbert M., Vachiery J.L. 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2015;46:903–975. - PubMed
    1. Wijeratne D.T., Lajkosz K., Brogly S.B. Increasing incidence and prevalence of World Health Organization Groups 1 to 4 pulmonary hypertension: a population-based cohort study in Ontario, Canada. Circ Cardiovasc Qual Outcomes. 2018;11 - PMC - PubMed
    1. McGoon M.D., Benza R.L., Escribano-Subias P. Pulmonary arterial hypertension: epidemiology and registries. J Am Coll Cardiol. 2013;62(Suppl 25):D51–D59. - PubMed

Publication types

MeSH terms