Sex-related differences of late gadolinium enhancement granularity in hypertrophic cardiomyopathy: a cardiovascular magnetic resonance study

Background Although prognosis in hypertrophic cardiomyopathy (HCM) differs between women and men, sex-related differences regarding cardiovascular magnetic resonance (CMR) features, especially late gadolinium enhancement (LGE), remains poorly studied. Purpose To assess the sex-related prognostic value of the “LGE granularity” concept to predict all-cause mortality in patients with HCM. Methods Between 2008 and 2024, all patients referred for HCM assessment using CMR were recruited in four French tertiary centres. The outcome was all-cause death using the French National Registry of Death. The concept of “LGE granularity” was defined as its extent (number of segment involved), location (septal or not), and pattern (midwall or subepicardial). Propensity-score matching was performed between men and women as well as Kaplan-Meier curves and multivariable Cox regression analyses. Results Among 3,074 patients with HCM (52±9 years, 43% women), 475 (15%) died during a median follow-up of 9 years [6-11], with 202 (15%) death in women and 273 (16%) death in men. Overall, 1,136 (37%) patients had LGE. After propensity-score matching (1,327 men vs 1,327 women), survival curves showed an increased risk of death for LGE extent >3 segments and LGE septal location for both men and women (Figure 1; all p<0.05). After adjustment for all traditional prognostic factors, the concept of LGE granularity demonstrated sex specific differential prognostic value. In women, a LGE extent greater than three segments was more strongly associated with all-cause mortality (HR: 5.86 [95% CI: 3.55-9.69]). In contrast, in men, septal LGE showed a stronger association with all-cause mortality (HR: 4.89 [95% CI: 2.92-8.19]). Moreover, midwall LGE was associated with all-cause mortality only in men whereas subepicardial and midwall LGE was associated with all-cause mortality only in women (Table 1; all p<0.05). Conclusion This study emphasizes differential prognostic value of CMR-LGE features between men and women in patients with HCM. Recognizing these sex-related differences is crucial in improving prognosis awareness and individualized therapeutic management.