title: Effectiveness of late gadolinium enhancement to improve outcomes prediction in patients referred for cardiovascular magnetic resonance after echocardiography.
abstract: BACKGROUND
  Echocardiography (echo) is a first line test to assess cardiac structure and function. It is not known if cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE) ordered during routine clinical practice in selected patients can add additional prognostic information after routine echo. We assessed whether CMR improves outcomes prediction after contemporaneous echo, which may have implications for efforts to optimize processes of care, assess effectiveness, and allocate limited health care resources.
  
  
  RESULTS
  We prospectively enrolled 1044 consecutive patients referred for CMR. There were 38 deaths and 3 cardiac transplants over a median follow-up of 1.0 years (IQR 0.4-1.5). We first reproduced previous survival curve strata (presence of LGE and ejection fraction (EF) < 50%) for transplant free survival, to support generalizability of any findings. Then, in a subset (n = 444) with contemporaneous echo (median 3 days apart, IQR 1-9), EF by echo (assessed visually) or CMR were modestly correlated (R(2) = 0.66, p < 0.001), and 30 deaths and 3 transplants occurred over a median follow-up of 0.83 years (IQR 0.29-1.40). CMR EF predicted mortality better than echo EF in univariable Cox models (Integrated Discrimination Improvement (IDI) 0.018, 95% CI 0.008-0.034; Net Reclassification Improvement (NRI) 0.51, 95% CI 0.11-0.85). Finally, LGE further improved prediction beyond EF as determined by hazard ratios, NRI, and IDI in all Cox models predicting mortality or transplant free survival, adjusting for age, gender, wall motion, and EF.
  
  
  CONCLUSIONS
  Among those referred for CMR after echocardiography, CMR with LGE further improves risk stratification of individuals at risk for death or death/cardiac transplant.
authors: Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors: Timothy C
authors: TC
authors: Wong
authors: Kayla
authors: K
authors: Piehler
authors: Kathy S
authors: KS
authors: Puntil
authors: Diego
authors: D
authors: Moguillansky
authors: Christopher G
authors: CG
authors: Meier
authors: Joan M
authors: JM
authors: Lacomis
authors: Peter
authors: P
authors: Kellman
authors: Stephen C
authors: SC
authors: Cook
authors: David S
authors: DS
authors: Schwartzman
authors: Marc A
authors: MA
authors: Simon
authors: Suresh R
authors: SR
authors: Mulukutla
authors: Erik B
authors: EB
authors: Schelbert
mesh_terms: D000328:Adult; D000368:Aged; D016009:Chi-Square Distribution; D003287:Contrast Media; D018572:Disease-Free Survival; D004452:Echocardiography; D005260:Female; D005682:Gadolinium; D006331:Heart Diseases / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000401:mortality / Q000473:pathology / Q000503:physiopathology / Q000628:therapy; D016027:Heart Transplantation; D006571:Heterocyclic Compounds; D006801:Humans; D053208:Kaplan-Meier Estimate; D016014:Linear Models; D019028:Magnetic Resonance Imaging, Cine; D008297:Male; D008875:Middle Aged; D009206:Myocardium / Q000473:pathology; D009942:Organometallic Compounds; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D013318:Stroke Volume; D013997:Time Factors; D016277:Ventricular Function, Left
chemical_list: D003287:Contrast Media; D006571:Heterocyclic Compounds; D009942:Organometallic Compounds; C062402:gadoteridol; D005682:Gadolinium