Key result
123I-mIBG H/M ratio ≥1.60 is linked to ~60% fewer cardiac events in heart failure.
Why the study?
Single-center studies linked reduced myocardial 123I-mIBG uptake to poorer HF prognosis, but this had not been validated in large multicenter trials.
Does iodine-123 meta-iodobenzylguanidine imaging predict the composite of NYHA progression, arrhythmic events, or cardiac death in patients with NYHA class II/III heart failure and LVEF <=35%?
Cohort (n=961)
Yes
Does iodine-123 meta-iodobenzylguanidine imaging predict the composite of NYHA progression, arrhythmic events, or cardiac death in patients with NYHA class II/III heart failure and LVEF <=35%?
Iodine-123 meta-iodobenzylguanidine imaging provides independent prognostic value for predicting cardiac events in patients with symptomatic heart failure.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Increased cardiac sympathetic activity is a prominent feature of heart failure and is associated with progressive deterioration and remodeling of the myocardium, inexorable decline in left ventricular function, and worsening symptoms. Our results suggest that in appropriately selected patients with heart failure, the 123I-mIBG imaging procedure can alert clinicians to the potential need for considering additional treatments.”
“The ADMIRE-HF trial achieved its primary efficacy objective, which was to demonstrate a significantly different prognosis between patients with baseline images showing heart:mediastinum ratio of ≤1.6 or 1.6 in this NYHA Class II and III population with moderate to severe reduced ejection fraction. In addition, the prognostic value of 123I-mIBG imaging was demonstrated for all three categories of outcome events: HF progression, arrhythmic events and cardiac death.”
“Using imaging tests are consistent with current trends toward gaining improved and earlier understanding of heart disease at a molecular level and may enable preventive management strategies. This testing method is not new, however ADMIRE-HF is the first large-scale multicenter prospective validation of the potential prognostic power and provides data that clinicians may be able to use to improve current practice.”
I-123 mIBG H/M may stratify cardiac event risk in HF; hypothesis-generating and requires prospective validation before clinical use.
OBJECTIVES The ADMIRE-HF (AdreView Myocardial Imaging for Risk Evaluation in Heart Failure) study prospectively evaluated iodine-123 meta-iodobenzylguanidine ((123)I-mIBG) imaging for identifying symptomatic heart failure (HF) patients most likely to experience cardiac events. BACKGROUND Single-center studies have demonstrated the poorer prognosis of HF patients with reduced (123)I-mIBG myocardial uptake, but these observations have not been validated in large multicenter trials. METHODS A total of 961 subjects with New York Heart Association (NYHA) functional class II/III HF and left ventricular ejection fraction (LVEF) < or =35% were studied. Subjects underwent (123)I-mIBG myocardial imaging (sympathetic neuronal integrity quantified as the heart/mediastinum uptake ratio [H/M] on 4-h delayed planar images) and myocardial perfusion imaging and were then followed up for up to 2 years. Time to first occurrence of NYHA functional class progression, potentially life-threatening arrhythmic event, or cardiac death was compared with H/M (either in relation to estimated lower limit of normal [1.60] or as a continuous variable) using Cox proportional hazards regression. Multivariable analyses using clinical, laboratory, and imaging data were also performed. RESULTS A total of 237 subjects (25%) experienced events (median follow-up 17 months). The hazard ratio for H/M > or =1.60 was 0.40 (p < 0.001); the hazard ratio for continuous H/M was 0.22 (p < 0.001). Two-year event rate was 15% for H/M > or =1.60 and 37% for H/M <1.60; hazard ratios for individual event categories were as follows: HF progression, 0.49 (p = 0.002); arrhythmic events, 0.37 (p = 0.02); and cardiac death, 0.14 (p = 0.006). Significant contributors to the multivariable model were H/M, LVEF, B-type natriuretic peptide, and NYHA functional class. (123)I-mIBG imaging also provided additional discrimination in analyses of interactions between B-type natriuretic peptide, LVEF, and H/M. CONCLUSIONS ADMIRE-HF provides prospective validation of the independent prognostic value of (123)I-mIBG scintigraphy in assessment of patients with HF. (Meta-Iodobenzylguanidine Scintigraphy Imaging in Patients With Heart Failure and Control Subjects Without Cardiovascular Disease, NCT00126425; Meta-Iodobenzylguanidine [123I-mIBG] Scintigraphy Imaging in Patients With Heart Failure and Control Subjects Without Cardiovascular Disease, NCT00126438).
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Jacobson et al. (2010) conducted a cohort in Heart Failure (n=961). Iodine-123 meta-iodobenzylguanidine ((123)I-mIBG) imaging (H/M ratio >=1.60) vs. H/M ratio <1.60 was evaluated on Time to first occurrence of NYHA functional class progression, potentially life-threatening arrhythmic event, or cardiac death (HR 0.40, p=<0.001). An (123)I-mIBG heart/mediastinum uptake ratio ≥1.60 was associated with a lower 2-year rate of cardiac events compared to a ratio <1.60 in heart failure patients (15% vs 37%; HR 0.40, P<0.001).
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