Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis (P.B., N.T., K.I., Y.G., S.C., P.S.S.A., A.R., A.J., A.H.M., I.N., D.F., P.V., T.E., H.A., A.K., C.S.).
Circulation. 2024 Mar 12;149(11):807-821. doi: 10.1161/CIRCULATIONAHA.123.067032. Epub 2023 Nov 6.
Randomized trials in obstructive coronary artery disease (CAD) have largely shown no prognostic benefit from coronary revascularization. Although there are several potential reasons for the lack of benefit, an underexplored possible reason is the presence of coincidental nonischemic cardiomyopathy (NICM). We investigated the prevalence and prognostic significance of NICM in patients with CAD (CAD-NICM).
We conducted a registry study of consecutive patients with obstructive CAD on coronary angiography who underwent contrast-enhanced cardiovascular magnetic resonance imaging for the assessment of ventricular function and scar at 4 hospitals from 2004 to 2020. We identified the presence and cause of cardiomyopathy using cardiovascular magnetic resonance imaging and coronary angiography data, blinded to clinical outcomes. The primary outcome was a composite of all-cause death or heart failure hospitalization, and secondary outcomes were all-cause death, heart failure hospitalization, and cardiovascular death.
Among 3023 patients (median age, 66 years; 76% men), 18.2% had no cardiomyopathy, 64.8% had ischemic cardiomyopathy (CAD+ICM), 9.3% had CAD+NICM, and 7.7% had dual cardiomyopathy (CAD+dualCM), defined as both ICM and NICM. Thus, 16.9% had CAD+NICM or dualCM. During a median follow-up of 4.8 years (interquartile range, 2.9, 7.6), 1116 patients experienced the primary outcome. In Cox multivariable analysis, CAD+NICM or dualCM was independently associated with a higher risk of the primary outcome compared with CAD+ICM (adjusted hazard ratio, 1.23 [95% CI, 1.06-1.43]; =0.007) after adjustment for potential confounders. The risks of the secondary outcomes of all-cause death and heart failure hospitalization were also higher with CAD+NICM or dualCM (hazard ratio, 1.21 [95% CI, 1.02-1.43]; =0.032; and hazard ratio, 1.37 [95% CI, 1.11-1.69]; =0.003, respectively), whereas the risk of cardiovascular death did not differ from that of CAD+ICM (hazard ratio, 1.15 [95% CI, 0.89-1.48]; =0.28).
In patients with CAD referred for clinical cardiovascular magnetic resonance imaging, NICM or dualCM was identified in 1 of every 6 patients and was associated with worse long-term outcomes compared with ICM. In patients with obstructive CAD, coincidental NICM or dualCM may contribute to the lack of prognostic benefit from coronary revascularization.
在阻塞性冠状动脉疾病（CAD）的随机试验中，冠状动脉血运重建并未显示出明显的预后获益。尽管存在多种潜在的原因，但一个尚未充分探讨的可能原因是同时存在非缺血性心肌病（NICM）。我们研究了 CAD 患者中 NICM 的患病率和预后意义（CAD-NICM）。
我们对 2004 年至 2020 年在四家医院进行的阻塞性 CAD 冠状动脉造影患者进行了一项连续患者的注册研究，这些患者接受了对比增强心血管磁共振成像检查以评估心室功能和疤痕。我们使用心血管磁共振成像和冠状动脉造影数据确定了心肌病的存在和原因，结果是盲目的临床结局。主要结局是全因死亡或心力衰竭住院的复合结局，次要结局是全因死亡、心力衰竭住院和心血管死亡。
在 3023 名患者中（中位年龄 66 岁；76%为男性），18.2%没有心肌病，64.8%有缺血性心肌病（CAD+ICM），9.3%有 CAD+NICM，7.7%有双心肌病（CAD+双 CM），定义为 ICM 和 NICM 均存在。因此，16.9%有 CAD+NICM 或双 CM。在中位随访 4.8 年（四分位距，2.9，7.6）期间，1116 名患者发生了主要结局。在 Cox 多变量分析中，与 CAD+ICM 相比，CAD+NICM 或双 CM 与更高的主要结局风险相关（调整后的危险比，1.23 [95%CI，1.06-1.43]；=0.007），校正了潜在混杂因素。CAD+NICM 或双 CM 与全因死亡和心力衰竭住院的次要结局风险较高也相关（危险比，1.21 [95%CI，1.02-1.43]；=0.032；危险比，1.37 [95%CI，1.11-1.69]；=0.003），而心血管死亡风险与 CAD+ICM 无差异（危险比，1.15 [95%CI，0.89-1.48]；=0.28）。
在接受临床心血管磁共振成像检查的 CAD 患者中，每 6 名患者中就有 1 名被诊断为 NICM 或双 CM，与 ICM 相比，预后较差。在阻塞性 CAD 患者中，偶然发生的 NICM 或双 CM 可能导致冠状动脉血运重建的预后获益不足。
