Further Refining Risk in Hypertrophic Cardiomyopathy With Late Gadolinium Enhancement by CMR
Key result
Late gadolinium enhancement of ≥15% of left ventricular mass was associated with a 3-fold increase in the composite endpoint of sudden cardiac death and appropriate ICD discharge in patients with obstructive hypertrophic cardiomyopathy.
Why the study?
Does the extent of late gadolinium enhancement (LGE) on CMR predict the risk of sudden cardiac death and appropriate ICD discharge in patients with hypertrophic cardiomyopathy?
Population
1,423 patients with hypertrophic cardiomyopathy deemed to be low to intermediate risk, including 965 with…
Comparison
Late gadolinium enhancement ≥15% of left… vs LGE <15% of LV mass or no LGE, and no myectomy.
Design
Editorial
Authors
Discussion
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Implication
The extent of late gadolinium enhancement (≥15% of LV mass) on CMR is a significant predictor of sudden cardiac death risk in hypertrophic cardiomyopathy, while myectomy appears to mitigate this risk.
Key Points
- To assess how the presence and extent of late gadolinium enhancement on cardiac magnetic resonance refine sudden cardiac death risk stratification in patients with hypertrophic cardiomyopathy.
- Evaluated 1,423 low-to-intermediate risk hypertrophic cardiomyopathy patients recruited over an 8-year period, including 965 patients (68%) with obstructive disease of whom 71% underwent myectomy.
- Measured late gadolinium enhancement (LGE) extent as a percentage of total left ventricular mass using cardiac magnetic resonance imaging.
- Tracked a primary composite endpoint defined as sudden cardiac death (SCD) and appropriate implantable cardioverter-defibrillator (ICD) discharge.
- Extensive late gadolinium enhancement of ≥15% of left ventricular mass was associated with a 3-fold increase in the primary composite endpoint in obstructive disease, whereas surgical myectomy was associated with a greater than 50% decrease in risk.
- In patients who underwent surgical myectomy, the threshold of late gadolinium enhancement associated with heightened risk increased to 25% of left ventricular mass.
- Incorporating both late gadolinium enhancement extent and surgical myectomy status into U.S. guideline risk markers and the European HCM Risk-SCD Calculator improved overall risk discrimination.
Structured PICO
Does the extent of late gadolinium enhancement (LGE) on CMR predict the risk of sudden cardiac death and appropriate ICD discharge in patients with hypertrophic cardiomyopathy?
P
Population
1,423 low to intermediate risk patients with hypertrophic cardiomyopathy evaluated for the prognostic value of late gadolinium enhancement.
E
Exposure
Late gadolinium enhancement (LGE) ≥15% of left ventricular (LV) mass on cardiac magnetic resonance (CMR), and myectomy.
C
Comparator
LGE <15% of LV mass or no LGE, and no myectomy.
O
Outcome
Composite of sudden cardiac death (SCD) and appropriate ICD discharge.composite
Main Result
Effect estimate: 3-fold increase
The extent of late gadolinium enhancement (≥15% of LV mass) on CMR is a significant predictor of sudden cardiac death risk in hypertrophic cardiomyopathy, while myectomy appears to mitigate this risk.
Limitations
- Single-center cohort, may not be representative of the HCM patient community at large
- Replacement fibrosis may not be the only type of fibrosis that affects risk
- Single-center cohort with referral bias for myectomy, which may not be representative of the HCM patient community at large.
- Replacement fibrosis (measured by LGE) may not be the only type of fibrosis affecting risk, as interstitial fibrosis is prevalent and may also influence risk.
Cite This Study
Kramer et al. (2018) conducted an editorial in Hypertrophic cardiomyopathy (HCM) (n=1,423). Late gadolinium enhancement (LGE) ≥15% of LV mass vs. LGE <15% of LV mass was evaluated on Composite of sudden cardiac death (SCD) and appropriate ICD discharge (3-fold increase). Late gadolinium enhancement of ≥15% of left ventricular mass was associated with a 3-fold increase in the composite endpoint of sudden cardiac death and appropriate ICD discharge in patients with obstructive hypertrophic cardiomyopathy.