Author + information
- Received May 10, 2017
- Revision received August 22, 2017
- Accepted August 23, 2017
- Published online October 9, 2017.
- Christoph Gräni, MDa,
- Christian Eichhorn, BSca,
- Loïc Bière, MD, PhDa,
- Venkatesh L. Murthy, MD, PhDb,
- Vikram Agarwal, MDc,
- Kyoichi Kaneko, MD, PhDa,
- Sarah Cuddy, MDa,
- Ayaz Aghayev, MDc,
- Michael Steigner, MDc,
- Ron Blankstein, MDa,c,
- Michael Jerosch-Herold, PhDc and
- Raymond Y. Kwong, MD, MPHa,∗ ()
- aNoninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- bDivision of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
- cNoninvasive Cardiovascular Imaging Section, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- ↵∗Address for correspondence:
Dr. Raymond Y. Kwong, Cardiovascular Division, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115.
Background Diagnosing myocarditis is challenged by nonspecific clinical signs and symptoms and low accuracy of endomyocardial biopsy. Cardiac magnetic resonance imaging (CMR) provides both cardiac anatomy and tissue characterization in this setting, but the prognostic value of this method as a primary assessment tool in patients with suspected myocarditis remains limited.
Objectives This study sought to determine cardiac event-free survival of a consecutive cohort with suspected myocarditis with regard to CMR findings.
Methods Six hundred seventy patients with suspected myocarditis underwent CMR including late gadolinium enhancement (LGE) parameters between 2002 and 2015 and were included and followed. We performed multivariable model for major adverse cardiovascular events (MACE) and determined the continuous net reclassification improvement by LGE markers.
Results At a median follow-up of 4.7 years (interquartile range [IQR]: 2.3 to 7.3 years), 98 patients experienced a MACE. Two hundred ninety-four (44%) patients showed LGE presence, which was associated with a more than doubling risk of MACE (hazard ratio [HR]: 2.22; 95% confidence interval [CI]: 1.47 to 3.35; p < 0.001). Annualized MACE rates were 4.8% and 2.1% corresponding to LGE presence and absence, respectively (p < 0.001). In the multivariable model, LGE presence maintained significant association with MACE (HR: 1.72; 95% CI: 1.08 to 2.76; p = 0.023). The computed continuous net reclassification improvement was 0.39 (95% CI: 0.10 to 0.67) when LGE presence was added to the multivariable model for MACE. Regarding location and pattern, septal and midwall LGE showed strongest associations with MACE (HR: 2.55; 95% CI: 1.77 to 3.83 and HR: 2.39; 95% CI: 1.54 to 3.69, respectively; both p < 0.001). A patchy distribution portended to a near 3-fold increased hazard to MACE (HR: 2.93; 95% CI: 1.79 to 4.80; p < 0.001). LGE extent (per 10% increase) corresponded to a 79% increase in risk of MACE (HR: 1.79; 95% CI: 1.25 to 2.57; p = 0.002). A normal CMR study corresponded to low annual MACE and death rates of 0.8% and 0.3%, respectively.
Conclusions CMR tissue characterization provides effective risk stratification in patients with suspected myocarditis.
Dr. Gräni receives funding support from the Novartis Foundation for Medical-Biological Research, Bangerter-Rhyner Foundation, Swiss Sports Medicine Society, and Kreislauf Kardiologie Foundation. Dr. Murthy owns stock in General Electric; receives speaking fees from Bracco Diagnostics; and received research funding from INVIA Medical Imaging Solutions and 1R01HL136685 from NHLBI. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 10, 2017.
- Revision received August 22, 2017.
- Accepted August 23, 2017.
- 2017 American College of Cardiology Foundation