CMR 在 DCM 中的风险分层和预后价值；EF 和 LGE 之外的参数映射和 GLS- 值？,European Heart Journal - Cardiovascular Imaging

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CMR 在 DCM 中的风险分层和预后价值；EF 和 LGE 之外的参数映射和 GLS- 值？
European Heart Journal - Cardiovascular Imaging ( IF 6.7 ) Pub Date : 2021-02-09 , DOI: 10.1093/ehjci/jeaa356.315
P Brown ₁ , A Dimarco ₂ , J Bradley ₁ , G Nucifora ₁ , C Miller ₁ , M Schmitt ₁

Affiliation

资金致谢资金来源类型：私人公司。主要资金来源：Pamela Brown 博士得到 Alliance Medical 的资助。背景; 扩张型心肌病 (DCM) 中的心律失常风险分层和装置植入带来了重大挑战，正如 DANISH 试验所证明的，似乎已经达到了临床疗效的渐近线。现在有大量证据表明，纳入患者的 LGE 状态可能会增强 DCM 患者的风险分层和设备选择。此外，有人建议基于 CMR 的参数映射和应变分析可以进一步推进风险分层。对 2015 年 3 月至 2018 年 12 月期间接受临床指征 CMR 扫描并前瞻性纳入 UHSM-CMR 研究 (NCT02326324) 的 703 名 DCM 患者进行了分析。多变量 Cox 比例风险模型和约登指数驱动的 C 统计量用于评估 GLS、T1 和 ECV 映射对心血管死亡、心脏移植、LVAD 插入或心力衰竭住院联合终点的附加预后价值，在纳入 NHYA 类的模型中， EF 和 LGE 状态。此外。评估了 GLS、T1 和 ECV 在预测显着心律失常事件 (SAV)（室性心律失常 (VA)、心脏骤停复苏 (rCA) 或心源性猝死 (SCD)）方面的价值。结果; 患者（平均年龄 59 岁，66% 男性，60% ≥NYHA II，平均 EF 42%，平均 GLS -12%，平均 ECV 27%）接受良好的药物治疗（β 受体阻滞剂 74%%，ACE 79%，MRA 38 %，Entresto 5%，CRT 23%）。平均随访时间为 21 个月；合并终点发生在 34 名患者（5%）中。单变量分析 NYHA 等级 (HR 2.44 (1. 67-3.57), p < 0.001), ECV (HR 1.14 (1.05-1.22), p < 0.001), GLS% (HR 1.14 (1.07-1.21) p < 0.001,) T1 (HR 1.06 (1.005-1.1), p = 0.03), RVEF (HR 0.95 (0.93-0.98), p < 0.001), LVEF (HR 0.92 (0.9-0.95), p < 0.001) 都与结果显着相关。在多变量分析中，只有 EF 和 NYHA 等级与结果相关。SAV 作为疾病的首发表现或在 27 名患者 (4%) 的随访期间发生。在单变量分析中，LGE、ECV、GLS、EF 和 NYHA 等级均与 SAV 相关。然而，在多变量分析中，只有 EF、LGE 和 ECV（HR 1.11 (1.01-1.22)，p = 0.03）而不是 GLS 在已经包含 EF、NYHA 和 LGE 的模型中保持独立预测。结论经过优化处理的 DCM 人群的事件发生率非常低。基于 CMR 的 LGE 和 ECV 评估纤维化状态/负担的评估有可能增强 ICD 治疗的患者选择。虽然 GLS 越来越被认为是早期疾病检测的敏感成像生物标志物，但在已经包含 EF、NYHA 类和 LGE 状态的模型中，它没有提供附加价值，可能是因为它与 EF 具有高共线性。

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Risk stratification and prognostic value of CMR in DCM; parametric mapping and GLS- value beyond EF and LGE?

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Dr Pamela Brown was suppoerted by funding from Alliance Medical. Background; Arrhythmia risk stratification and device implantation in dilated cardiomyopathy (DCM) poses significant challenges and as demonstrated by the DANISH trial appears to have reached the asymptote of clinical efficacy. A body of evidence now demonstrates that risk stratification of and device selection for DCM patients may be enhanced by inclusion of patients" LGE-status. Furthermore, it has been suggested that CMR based parametric mapping and strain analysis may further advance risk stratification. Methods; 703 patients with DCM undergoing clinically indicated CMR scans and prospectively enrolled into the UHSM-CMR study (NCT02326324) between 03/2015-12/2018 were analysed. Multivariable Cox proportional hazard models and Youden index driven C-statistics were used to assess additive prognostic value of GLS, T1 and ECV mapping on the combined endpoint of cardiovascular death, cardiac transplantation, LVAD insertion or hospitalisation for heart failure in models incorporating NHYA class, EF and LGE status. Additionally. the value of GLS, T1, and ECV on predicting significant arrhythmic events (SAV) (ventricular arrhythmia (VA), resuscitated cardiac arrest (rCA) or sudden cardiac death (SCD)) was assessed. Results; Patients (mean age 59, 66% male, 60% ≥NYHA II, mean EF 42%, mean GLS -12%, mean ECV 27%) were on good medical therapy (beta blocker 74%%, ACE 79%, MRA 38%, Entresto 5%, CRT 23%). Mean follow-up was 21 months; the combined endpoint occurred in 34 patients (5%). On univariate analysis NYHA class (HR 2.44 (1.67-3.57), p < 0.001), ECV (HR 1.14 (1.05-1.22), p < 0.001), GLS% (HR 1.14 (1.07-1.21) p < 0.001,) T1 (HR 1.06 (1.005-1.1), p = 0.03), RVEF (HR 0.95 (0.93-0.98), p < 0.001), LVEF (HR 0.92 (0.9-0.95), p < 0.001) were all significantly associated with outcome. On multivariate analysis only EF and NYHA class was associated with outcome. SAV occurred as the first manifestation of disease or during follow up in 27 patients (4%). At univariate analysis LGE, ECV, GLS, EF and NYHA class were all associated with SAV. However, on multivariable analysis only EF, LGE and ECV (HR 1.11 (1.01-1.22), p = 0.03) but not GLS remained independently predictive in a model already incorporating EF, NYHA and LGE. Conclusion Optimally treated DCM populations have very low event rates. CMR based assessment of fibrosis status/burden with both LGE and ECV assessment has the potential to enhance patient selection for ICD therapy. Whilst GLS is increasingly recognised as a sensitive imaging biomarker of early disease detection it provides no additive value, likely because of it’s high co-linearity with EF, in models already containing EF, NYHA class and LGE status.

更新日期：2021-02-09

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