Myocardial Fibrosis as a Predictor of Sudden Death in Patients With Coronary Artery Disease

Abbasin Zegard; Osita Okafor; Joseph de Bono; Manish Kalla; Mauro Lencioni; Howard Marshall; Lucy Hudsmith; Tian Qiu; Richard Steeds; Berthold Stegemann; Francisco Leyva

doi:10.1016/j.jacc.2020.10.046

Myocardial Fibrosis as a Predictor of Sudden Death in Patients With Coronary Artery Disease

Abbasin Zegard, Osita Okafor, Joseph de Bono, Manish Kalla, Mauro Lencioni, Howard Marshall, Lucy Hudsmith, Tian Qiu, Richard Steeds, Berthold Stegemann, Francisco Leyva^*

^*Corresponding author for this work

Research output: Contribution to journal › Article › peer-review

Abstract

Background: The “gray zone” of myocardial fibrosis (GZF) on cardiovascular magnetic resonance may be a substrate for ventricular arrhythmias (VAs). Objectives: The purpose of this study was to determine whether GZF predicts sudden cardiac death (SCD) and VAs (ventricular fibrillation or sustained ventricular tachycardia) in patients with coronary artery disease (CAD) and a wide range of left ventricular ejection fractions (LVEFs). Methods: In this retrospective study of CAD patients, the presence of myocardial fibrosis on visual assessment (MF_VA) and GZF mass in patients with MF_VA were assessed in relation to SCD and the composite, arrhythmic endpoint of SCD or VAs. Results: Among 979 patients (mean age [± SD]: 65.8 ± 12.3 years), 29 (2.96%) experienced SCD and 80 (8.17%) met the arrhythmic endpoint over median 5.82 years (interquartile range: 4.1 to 7.3 years). In the whole cohort, MF_VA was strongly associated with SCD (hazard ratio: 10.1; 95% confidence interval [CI]: 1.42 to 1,278.9) and the arrhythmic endpoint (hazard ratio: 28.0; 95% CI: 4.07 to 3,525.4). In competing risks analyses, associations between LVEF <35% and SCD (subdistribution hazard ratio [sHR]: 2.99; 95% CI: 1.42 to 6.31) and the arrhythmic endpoint (sHR: 4.71; 95% CI: 2.97 to 7.47) were weaker. In competing risk analyses of the MF_VA subcohort (n = 832), GZF using the 3SD method (GZF_3SD) >5.0 g was strongly associated with SCD (sHR: 10.8; 95% CI: 3.74 to 30.9) and the arrhythmic endpoint (sHR: 7.40; 95% CI: 4.29 to 12.8). Associations between LVEF <35% and SCD (sHR: 2.62; 95% CI: 1.24 to 5.52) and the arrhythmic endpoint (sHR: 4.14; 95% CI: 2.61 to 6.57) were weaker. Conclusions: In CAD patients, MF_VA plus quantified GZF_3SD mass was more strongly associated with SCD and VAs than LVEF. In selecting patients for implantable cardioverter-defibrillators, assessment of MF_VA followed by quantification of GZF_3SD mass may be preferable to LVEF.

Original language	English
Pages (from-to)	29-41
Number of pages	13
Journal	Journal of the American College of Cardiology
Volume	77
Issue number	1
Early online date	4 Jan 2021
DOIs	https://doi.org/10.1016/j.jacc.2020.10.046
Publication status	Published - 5 Jan 2021

Bibliographical note

Funding Information:
Medtronic provided support for this study in the form of an unrestricted educational grant. Medtronic provided funding for Dr. Zegard’s salary as a research fellow and had no participation in the study. Dr. Leyva has served as a consultant for and has received research funding from Medtronic Inc., Boston Scientific, Abbott, Microport, and Biotronik. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Publisher Copyright:
© 2021 American College of Cardiology Foundation

Copyright:
Copyright 2020 Elsevier B.V., All rights reserved.

Keywords

cardiovascular magnetic resonance
gray zone mass
implantable cardioverter-defibrillator
peri-infarct mass
primary prevention
ventricular fibrillation
ventricular tachycardia

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10.1016/j.jacc.2020.10.046

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@article{1a164c25649642b7a1942986222f80e1,

title = "Myocardial Fibrosis as a Predictor of Sudden Death in Patients With Coronary Artery Disease",

abstract = "Background: The “gray zone” of myocardial fibrosis (GZF) on cardiovascular magnetic resonance may be a substrate for ventricular arrhythmias (VAs). Objectives: The purpose of this study was to determine whether GZF predicts sudden cardiac death (SCD) and VAs (ventricular fibrillation or sustained ventricular tachycardia) in patients with coronary artery disease (CAD) and a wide range of left ventricular ejection fractions (LVEFs). Methods: In this retrospective study of CAD patients, the presence of myocardial fibrosis on visual assessment (MFVA) and GZF mass in patients with MFVA were assessed in relation to SCD and the composite, arrhythmic endpoint of SCD or VAs. Results: Among 979 patients (mean age [± SD]: 65.8 ± 12.3 years), 29 (2.96%) experienced SCD and 80 (8.17%) met the arrhythmic endpoint over median 5.82 years (interquartile range: 4.1 to 7.3 years). In the whole cohort, MFVA was strongly associated with SCD (hazard ratio: 10.1; 95% confidence interval [CI]: 1.42 to 1,278.9) and the arrhythmic endpoint (hazard ratio: 28.0; 95% CI: 4.07 to 3,525.4). In competing risks analyses, associations between LVEF <35% and SCD (subdistribution hazard ratio [sHR]: 2.99; 95% CI: 1.42 to 6.31) and the arrhythmic endpoint (sHR: 4.71; 95% CI: 2.97 to 7.47) were weaker. In competing risk analyses of the MFVA subcohort (n = 832), GZF using the 3SD method (GZF3SD) >5.0 g was strongly associated with SCD (sHR: 10.8; 95% CI: 3.74 to 30.9) and the arrhythmic endpoint (sHR: 7.40; 95% CI: 4.29 to 12.8). Associations between LVEF <35% and SCD (sHR: 2.62; 95% CI: 1.24 to 5.52) and the arrhythmic endpoint (sHR: 4.14; 95% CI: 2.61 to 6.57) were weaker. Conclusions: In CAD patients, MFVA plus quantified GZF3SD mass was more strongly associated with SCD and VAs than LVEF. In selecting patients for implantable cardioverter-defibrillators, assessment of MFVA followed by quantification of GZF3SD mass may be preferable to LVEF.",

keywords = "cardiovascular magnetic resonance, gray zone mass, implantable cardioverter-defibrillator, peri-infarct mass, primary prevention, ventricular fibrillation, ventricular tachycardia",

author = "Abbasin Zegard and Osita Okafor and {de Bono}, Joseph and Manish Kalla and Mauro Lencioni and Howard Marshall and Lucy Hudsmith and Tian Qiu and Richard Steeds and Berthold Stegemann and Francisco Leyva",

note = "Funding Information: Medtronic provided support for this study in the form of an unrestricted educational grant. Medtronic provided funding for Dr. Zegard{\textquoteright}s salary as a research fellow and had no participation in the study. Dr. Leyva has served as a consultant for and has received research funding from Medtronic Inc., Boston Scientific, Abbott, Microport, and Biotronik. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Publisher Copyright: {\textcopyright} 2021 American College of Cardiology Foundation Copyright: Copyright 2020 Elsevier B.V., All rights reserved.",

year = "2021",

month = jan,

day = "5",

doi = "10.1016/j.jacc.2020.10.046",

language = "English",

volume = "77",

pages = "29--41",

journal = "Journal of the American College of Cardiology",

issn = "0735-1097",

publisher = "Elsevier",

number = "1",

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TY - JOUR

T1 - Myocardial Fibrosis as a Predictor of Sudden Death in Patients With Coronary Artery Disease

AU - Zegard, Abbasin

AU - Okafor, Osita

AU - de Bono, Joseph

AU - Kalla, Manish

AU - Lencioni, Mauro

AU - Marshall, Howard

AU - Hudsmith, Lucy

AU - Qiu, Tian

AU - Steeds, Richard

AU - Stegemann, Berthold

AU - Leyva, Francisco

N1 - Funding Information: Medtronic provided support for this study in the form of an unrestricted educational grant. Medtronic provided funding for Dr. Zegard’s salary as a research fellow and had no participation in the study. Dr. Leyva has served as a consultant for and has received research funding from Medtronic Inc., Boston Scientific, Abbott, Microport, and Biotronik. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Publisher Copyright: © 2021 American College of Cardiology Foundation Copyright: Copyright 2020 Elsevier B.V., All rights reserved.

PY - 2021/1/5

Y1 - 2021/1/5

N2 - Background: The “gray zone” of myocardial fibrosis (GZF) on cardiovascular magnetic resonance may be a substrate for ventricular arrhythmias (VAs). Objectives: The purpose of this study was to determine whether GZF predicts sudden cardiac death (SCD) and VAs (ventricular fibrillation or sustained ventricular tachycardia) in patients with coronary artery disease (CAD) and a wide range of left ventricular ejection fractions (LVEFs). Methods: In this retrospective study of CAD patients, the presence of myocardial fibrosis on visual assessment (MFVA) and GZF mass in patients with MFVA were assessed in relation to SCD and the composite, arrhythmic endpoint of SCD or VAs. Results: Among 979 patients (mean age [± SD]: 65.8 ± 12.3 years), 29 (2.96%) experienced SCD and 80 (8.17%) met the arrhythmic endpoint over median 5.82 years (interquartile range: 4.1 to 7.3 years). In the whole cohort, MFVA was strongly associated with SCD (hazard ratio: 10.1; 95% confidence interval [CI]: 1.42 to 1,278.9) and the arrhythmic endpoint (hazard ratio: 28.0; 95% CI: 4.07 to 3,525.4). In competing risks analyses, associations between LVEF <35% and SCD (subdistribution hazard ratio [sHR]: 2.99; 95% CI: 1.42 to 6.31) and the arrhythmic endpoint (sHR: 4.71; 95% CI: 2.97 to 7.47) were weaker. In competing risk analyses of the MFVA subcohort (n = 832), GZF using the 3SD method (GZF3SD) >5.0 g was strongly associated with SCD (sHR: 10.8; 95% CI: 3.74 to 30.9) and the arrhythmic endpoint (sHR: 7.40; 95% CI: 4.29 to 12.8). Associations between LVEF <35% and SCD (sHR: 2.62; 95% CI: 1.24 to 5.52) and the arrhythmic endpoint (sHR: 4.14; 95% CI: 2.61 to 6.57) were weaker. Conclusions: In CAD patients, MFVA plus quantified GZF3SD mass was more strongly associated with SCD and VAs than LVEF. In selecting patients for implantable cardioverter-defibrillators, assessment of MFVA followed by quantification of GZF3SD mass may be preferable to LVEF.

AB - Background: The “gray zone” of myocardial fibrosis (GZF) on cardiovascular magnetic resonance may be a substrate for ventricular arrhythmias (VAs). Objectives: The purpose of this study was to determine whether GZF predicts sudden cardiac death (SCD) and VAs (ventricular fibrillation or sustained ventricular tachycardia) in patients with coronary artery disease (CAD) and a wide range of left ventricular ejection fractions (LVEFs). Methods: In this retrospective study of CAD patients, the presence of myocardial fibrosis on visual assessment (MFVA) and GZF mass in patients with MFVA were assessed in relation to SCD and the composite, arrhythmic endpoint of SCD or VAs. Results: Among 979 patients (mean age [± SD]: 65.8 ± 12.3 years), 29 (2.96%) experienced SCD and 80 (8.17%) met the arrhythmic endpoint over median 5.82 years (interquartile range: 4.1 to 7.3 years). In the whole cohort, MFVA was strongly associated with SCD (hazard ratio: 10.1; 95% confidence interval [CI]: 1.42 to 1,278.9) and the arrhythmic endpoint (hazard ratio: 28.0; 95% CI: 4.07 to 3,525.4). In competing risks analyses, associations between LVEF <35% and SCD (subdistribution hazard ratio [sHR]: 2.99; 95% CI: 1.42 to 6.31) and the arrhythmic endpoint (sHR: 4.71; 95% CI: 2.97 to 7.47) were weaker. In competing risk analyses of the MFVA subcohort (n = 832), GZF using the 3SD method (GZF3SD) >5.0 g was strongly associated with SCD (sHR: 10.8; 95% CI: 3.74 to 30.9) and the arrhythmic endpoint (sHR: 7.40; 95% CI: 4.29 to 12.8). Associations between LVEF <35% and SCD (sHR: 2.62; 95% CI: 1.24 to 5.52) and the arrhythmic endpoint (sHR: 4.14; 95% CI: 2.61 to 6.57) were weaker. Conclusions: In CAD patients, MFVA plus quantified GZF3SD mass was more strongly associated with SCD and VAs than LVEF. In selecting patients for implantable cardioverter-defibrillators, assessment of MFVA followed by quantification of GZF3SD mass may be preferable to LVEF.

KW - cardiovascular magnetic resonance

KW - gray zone mass

KW - implantable cardioverter-defibrillator

KW - peri-infarct mass

KW - primary prevention

KW - ventricular fibrillation

KW - ventricular tachycardia

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JO - Journal of the American College of Cardiology

JF - Journal of the American College of Cardiology

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Myocardial Fibrosis as a Predictor of Sudden Death in Patients With Coronary Artery Disease

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Keywords

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