左心室射血分数≤35%的扩张型心肌病的预后与风险分层：心脏磁共振成像对改善预后的见解
Prognosis and Risk Stratification in Dilated Cardiomyopathy With LVEF≤35%: Cardiac MRI Insights for Better Outcomes.
作者信息
Zhou Di, Zhu Leyi, Li Shuang, Wu Weichun, Zhuang Baiyan, Xu Jing, Yang Wenjing, He Jian, Wang Yining, Zhang Yuhui, Liu Guanshu, Sun Xiaoxin, Zhang Qiang, Teng Zhongzhao, Sirajuddin Arlene, Arai Andrew E, Zhao Shihua, Lu Minjie
机构信息
Department of Magnetic Resonance Imaging (D.Z., L.Z., S.L., B.Z., J.X., W.Y., J.H., Y.W., S.Z., M.L.), Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Department of Echocardiography (W.W.), Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
出版信息
Circ Cardiovasc Imaging. 2025 Mar;18(3):e017246. doi: 10.1161/CIRCIMAGING.124.017246. Epub 2025 Mar 18.
BACKGROUND
Current guidelines recommend implantable cardioverter defibrillators for the primary prevention of sudden cardiac death (SCD) in patients with dilated cardiomyopathy with left ventricular ejection fraction (LVEF)≤35%. However, its effectiveness is hindered by the inability to reliably discriminate between the risk of SCD and competing death of heart failure deterioration, thereby limiting its clinical utility. We aimed to refine the SCD risk stratification model based on cardiac magnetic resonance imaging for patients with dilated cardiomyopathy with LVEF≤35%.
METHODS
A total of 1272 patients with dilated cardiomyopathy with LVEF≤35% who underwent cardiac magnetic resonance imaging were consecutively enrolled in this study. The primary end point is a composite of SCD or aborted SCD and the second end point is a composite of heart failure death and heart transplantation.
RESULTS
Over a median follow-up of 86.3 months, 101 patients reached the primary end point. In the adjusted analysis, age (hazard ratio [HR], 1.02 [95% CI, 1.01-1.04]; =0.006) years, a family history of SCD (HR, 2.00 [95% CI, 1.01-3.98]; =0.05), NT-proBNP (N-terminal pro-B-type natriuretic peptide) (HR, 2.02 [95% CI, 1.18-3.44]; =0.01), LVEF (per 5% HR, 0.79 [95% CI, 0.66-0.95]; =0.01), and late gadolinium enhancement≥7.5% (HR, 4.11[95% CI, 2.72-6.21]; <0.001) were associated with SCD or aborted SCD. Left atrial volume index≥68.3 mL/m was an independent predictor of the secondary end point (adjusted HR, 1.65 [95% CI, 1.13-2.40]; =0.009). Compared with late gadolinium enhancement<7.5%, patients with late gadolinium enhancement≥7.5% and LVEF≤20% had a 7.12-fold higher risk of experiencing SCD events in competing Cox analysis (annual event rate, 4.8%).
CONCLUSIONS
Patients with dilated cardiomyopathy with late gadolinium enhancement≥7.5% were at heightened risk of SCD events, which can be used for risk assessment. Risk stratifications for SCD, combining clinical and cardiac magnetic resonance imaging may potentially guide decision-making for implantable cardioverter defibrillator therapy.
背景
当前指南推荐对左心室射血分数（LVEF）≤35%的扩张型心肌病患者植入心脏复律除颤器以进行心脏性猝死（SCD）的一级预防。然而，由于无法可靠地区分SCD风险与因心力衰竭恶化导致的竞争性死亡风险，其有效性受到阻碍，从而限制了其临床应用。我们旨在基于心脏磁共振成像完善LVEF≤35%的扩张型心肌病患者的SCD风险分层模型。
方法
本研究连续纳入了1272例LVEF≤35%且接受了心脏磁共振成像检查的扩张型心肌病患者。主要终点为SCD或SCD未遂的复合终点，次要终点为心力衰竭死亡和心脏移植的复合终点。
结果
在中位随访86.3个月期间，101例患者达到主要终点。在多因素分析中，年龄（风险比[HR]，1.02[95%CI，1.01 - 1.04]；P = 0.006）岁、SCD家族史（HR，2.00[95%CI，1.01 - 3.98]；P = 0.05）、N末端B型利钠肽原（NT - proBNP）（HR，2.02[95%CI，1.18 - 3.44]；P = 0.01）、LVEF（每降低5%，HR，0.79[95%CI，0.66 - 0.95]；P = 0.01）以及钆延迟强化≥7.5%（HR，4.11[95%CI，2.72 - 6.21]；P < 0.001）与SCD或SCD未遂相关。左心房容积指数≥68.3 mL/m²是次要终点的独立预测因素（校正HR，1.65[95%CI，1.13 - 2.40]；P = 0.009）。在竞争性Cox分析中，与钆延迟强化<7.5%相比，钆延迟强化≥7.5%且LVEF≤20%的患者发生SCD事件的风险高7.12倍（年事件发生率，4.8%）。
结论
钆延迟强化≥7.5%的扩张型心肌病患者发生SCD事件的风险增加，可用于风险评估。结合临床和心脏磁共振成像的SCD风险分层可能潜在地指导植入式心脏复律除颤器治疗的决策。
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