Key result
Visually assessed myocardial fibrosis in CAD is linked to ~10-fold higher SCD risk.
Why the study?
The gray zone of myocardial fibrosis on CMR may provide a substrate for ventricular arrhythmias, but its ability to predict sudden cardiac death and ventricular arrhythmias in CAD patients across a wide range of LVEFs was undetermined.
Does myocardial fibrosis visual assessment and gray zone fibrosis quantification predict sudden cardiac death and ventricular arrhythmias better than LVEF in patients with coronary artery disease?
Cohort (n=979)
Does myocardial fibrosis visual assessment and gray zone fibrosis quantification predict sudden cardiac death and ventricular arrhythmias better than LVEF in patients with coronary artery disease?
Myocardial fibrosis visual assessment and gray zone fibrosis quantification by CMR are stronger predictors of sudden cardiac death and ventricular arrhythmias than LVEF <35% in CAD patients, suggesting a potential shift in criteria for ICD patient selection.
BACKGROUND The "gray zone" of myocardial fibrosis (GZF) on cardiovascular magnetic resonance may be a substrate for ventricular arrhythmias (VAs). OBJECTIVES The purpose of this study was to determine whether GZF predicts sudden cardiac death (SCD) and VAs (ventricular fibrillation or sustained ventricular tachycardia) in patients with coronary artery disease (CAD) and a wide range of left ventricular ejection fractions (LVEFs). METHODS In this retrospective study of CAD patients, the presence of myocardial fibrosis on visual assessment (MFVA) and GZF mass in patients with MFVA were assessed in relation to SCD and the composite, arrhythmic endpoint of SCD or VAs. RESULTS Among 979 patients (mean age [± SD]: 65.8 ± 12.3 years), 29 (2.96%) experienced SCD and 80 (8.17%) met the arrhythmic endpoint over median 5.82 years (interquartile range: 4.1 to 7.3 years). In the whole cohort, MFVA was strongly associated with SCD (hazard ratio: 10.1; 95% confidence interval [CI]: 1.42 to 1,278.9) and the arrhythmic endpoint (hazard ratio: 28.0; 95% CI: 4.07 to 3,525.4). In competing risks analyses, associations between LVEF <35% and SCD (subdistribution hazard ratio [sHR]: 2.99; 95% CI: 1.42 to 6.31) and the arrhythmic endpoint (sHR: 4.71; 95% CI: 2.97 to 7.47) were weaker. In competing risk analyses of the MFVA subcohort (n = 832), GZF using the 3SD method (GZF3SD) >5.0 g was strongly associated with SCD (sHR: 10.8; 95% CI: 3.74 to 30.9) and the arrhythmic endpoint (sHR: 7.40; 95% CI: 4.29 to 12.8). Associations between LVEF <35% and SCD (sHR: 2.62; 95% CI: 1.24 to 5.52) and the arrhythmic endpoint (sHR: 4.14; 95% CI: 2.61 to 6.57) were weaker. CONCLUSIONS In CAD patients, MFVA plus quantified GZF3SD mass was more strongly associated with SCD and VAs than LVEF. In selecting patients for implantable cardioverter-defibrillators, assessment of MFVA followed by quantification of GZF3SD mass may be preferable to LVEF.
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Zegard et al. (2021) conducted a cohort in Coronary artery disease (n=979). Myocardial fibrosis on visual assessment (MFVA) vs. Absence of myocardial fibrosis was evaluated on Sudden cardiac death (SCD) (HR 10.1, 95% CI 1.42-1278.9). In patients with coronary artery disease, myocardial fibrosis on visual assessment was strongly associated with sudden cardiac death (HR 10.1; 95% CI 1.42-1278.9).
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