Extracellular Volume by Computed Tomography Is Useful for Prediction of Prognosis in Dilated Cardiomyopathy Cases with Heart Failure with Reduced Ejection Fraction

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Dilated cardiomyopathy (DCM) with heart failure with reduced ejection fraction (HFrEF) (n=101). Intervention: Elevated left ventricular myocardial extracellular volume fraction (ECV ≥ 32.3%) on cardiac CT vs. Lower left ventricular myocardial extracellular volume fraction (ECV < 32.3%) on cardiac CT. Primary outcome: Major adverse cardiac events (MACE: composite of cardiovascular death, hospitalization due to heart failure, and fatal arrhythmic events) (HR 8.00, 95% CI 1.88-33.97, p=0.0048).

Q: What does this research mean for the field?

Elevated left ventricular myocardial extracellular volume fraction measured by cardiac computed tomography is a significant predictor of major adverse cardiac events in patients with dilated cardiomyopathy and heart failure with reduced ejection fraction. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Satomi Yashima; Hiroyuki Takaoka; Joji Ota; Moe Matsumoto; Yusei Nishikawa; Y. Noguchi; Shuhei Aoki; Kazuki Yoshida; Katsuya Suzuki; Makiko Kinoshita; Haruka Sasaki; Noriko Suzuki-Eguchi; Tomonori Kanaeda; Yoshio Kobayashi

doi:10.3390/jcdd11120399

December 11, 2024Journal of Cardiovascular Development and DiseaseOpen Access

Extracellular Volume by Computed Tomography Is Useful for Prediction of Prognosis in Dilated Cardiomyopathy Cases with Heart Failure with Reduced Ejection Fraction

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Why the study?

Cardiac CT is useful to screen coronary stenosis in DCM, and extracellular volume fraction (ECV) analysis has recently become eligible for CT, but its prognostic value in DCM with HFrEF needed evaluation.

Does extracellular volume fraction (ECV) measured by cardiac CT predict major adverse cardiac events (MACE) in patients with dilated cardiomyopathy and heart failure with reduced ejection fraction (HFrEF)?

Key Points

To evaluate whether extracellular volume fraction measured by cardiac computed tomography can predict clinical outcomes in patients with dilated cardiomyopathy and heart failure with reduced ejection fraction.
Analyzed 101 consecutive patients with dilated cardiomyopathy and heart failure with reduced ejection fraction (left ventricular ejection fraction < 40%) who underwent cardiac computed tomography.
Measured extracellular volume of the left ventricular myocardium and followed patients over an observation period of 40 ± 46 months.
Tracked major adverse cardiac events, defined as cardiovascular death, heart failure hospitalization, and fatal arrhythmic events.
Major adverse cardiac events occurred in 27 of 101 patients (27%), who demonstrated significantly higher left ventricular extracellular volume on computed tomography compared to patients without events (37.2 ± 6.7% vs. 32.2 ± 3.6%, p = 0.0008).
Receiver operating characteristic curve analysis identified an optimal extracellular volume cutoff of 32.3% to predict major adverse cardiac events (area under the curve = 0.75, p < 0.001, sensitivity 93%, specificity 49%).
Univariate Cox proportional hazards regression identified extracellular volume as a significant predictor of major adverse cardiac events (hazard ratio 8.00, 95% confidence interval 1.88–33.97, p = 0.0048).

Study Design

Type

Cohort (n=101)

Multicenter

Yes

Structured PICO

Does extracellular volume fraction (ECV) measured by cardiac CT predict major adverse cardiac events (MACE) in patients with dilated cardiomyopathy and heart failure with reduced ejection fraction (HFrEF)?

P

Population

101 consecutive patients with dilated cardiomyopathy and HFrEF (LVEF < 40%) without significant coronary artery disease who underwent cardiac CT at two Japanese centers, followed for a mean of 40 ± 46 months.

E

Exposure

Extracellular volume fraction (ECV) analysis of the left ventricular myocardium (LVM) measured by late-phase iodinated contrast-enhanced cardiac CT (specifically ECV > 32.3% or ≥ 32.3%)

C

Comparator

Lower extracellular volume fraction (ECV ≤ 32.3% or < 32.3%) of the left ventricular myocardium on cardiac CT

O

Outcome

Major adverse cardiac events (MACE), defined as a composite of cardiovascular death, hospitalization due to heart failure, and fatal arrhythmic events, over a mean follow-up period of 40 ± 46 months after CTcomposite

Main Result

Hazard Ratio: 8 (95% CI 1.88–33.97)

p-value: p=0.0048

Limitations

Retrospective bi-center design with a relatively small sample size (n=101)
Single-energy CT scan used for ECV analysis requiring subtraction of late-phase and non-contrast images, which may cause misregistration errors
Myocardial biopsy was not performed in all cases, so other non-ischemic cardiomyopathy etiologies cannot be completely ruled out
Selection bias because cardiac CT was only performed in patients suspected of having coronary artery disease
Inclusion of older cases (around 2010) limited the evaluation of newer heart failure medications such as angiotensin receptor/neprilysin inhibitors
Retrospective study conducted at two centers with a relatively small sample size
Single-energy scan was applied for ECV analysis requiring subtraction of late-phase and non-contrast images, which may introduce misregistration errors
Diagnosis was mainly based on echocardiography and cardiac CT findings without routine myocardial biopsy in all cases
Potential selection bias because cardiac CT was only performed in cases suspected of coronary artery disease
Included cases from around 2010 onward, making it difficult to evaluate the efficacy of newer heart failure drugs such as angiotensin receptor/neprilysin inhibitors

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Answers are grounded in this paper and cite their sources.

Implication

Adding a late-phase scan to routine coronary screening CT enables myocardial ECV quantification, which strongly predicts MACE in patients with DCM and HFrEF and offers an accessible alternative when cardiac MRI is unavailable or contraindicated.

Abstract

Objective: Cardiac computed tomography (CT) helps screen coronary artery stenosis in cases with dilated cardiomyopathy (DCM). Extracellular volume fraction (ECV) analysis has recently been eligible for CT. Method: We evaluated the impact of ECV on the CT to predict the prognosis in DCM patients with heart failure with reduced ejection fraction (HFrEF). Patients or Materials: We analyzed 101 consecutive DCM cases with HFrEF who underwent cardiac CT. All the patients had a lower left ventricular (LV) ejection fraction (LVEF) of less than 40%. We evaluated the effect of ECV to predict the patients’ prognosis. Cardiovascular death, hospitalization due to heart failure, and fatal arrhythmic events were included in the major adverse cardiac events (MACE). Results: MACE occurred in 27 cases (27%). The patients with MACE (27 cases) had an increased ECV on the LVM on the CT (37.2 ± 6.7 vs. 32.2 ± 3.6%, p = 0.0008) compared to the others (74 cases). Based on the receiver operating characteristics curve analysis, the best cutoff value of the ECV on the LVM to predict the MACE was 32.3%. The patients with ECV ≥ 32.3% had significantly higher MACE based on the Kaplan–Meier analysis. The ECV on the LVM was a significant marker to predict MACE based on the univariate Cox proportional hazard model (hazard ratio of 8.00, 95% confidence interval 1.88–33.97, p = 0.0048). Conclusions: ECV by CT is helpful to predict MACE in cases with DCM and HFrEF.

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Cite This Study

Yashima et al. (2024) conducted a cohort in Dilated cardiomyopathy (DCM) with heart failure with reduced ejection fraction (HFrEF) (n=101). Elevated left ventricular myocardial extracellular volume fraction (ECV ≥ 32.3%) on cardiac CT vs. Lower left ventricular myocardial extracellular volume fraction (ECV < 32.3%) on cardiac CT was evaluated on Major adverse cardiac events (MACE: composite of cardiovascular death, hospitalization due to heart failure, and fatal arrhythmic events) (HR 8.00, 95% CI 1.88-33.97, p=0.0048).

synapsesocial.com/papers/6a7c51cf77f6c035284009c3 https://doi.org/10.3390/jcdd11120399

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Extracellular Volume by Computed Tomography Is Useful for Prediction of Prognosis in Dilated Cardiomyopathy Cases with Heart Failure with Reduced Ejection Fraction

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Extracellular Volume by Computed Tomography Is Useful for Prediction of Prognosis in Dilated Cardiomyopathy Cases with Heart Failure with Reduced Ejection Fraction

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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