title: Association of fibrosis with mortality and sudden cardiac death in patients with nonischemic dilated cardiomyopathy.
abstract: OBJECTIVE
  Risk stratification of patients with nonischemic dilated cardiomyopathy is primarily based on left ventricular ejection fraction (LVEF). Superior prognostic factors may improve patient selection for implantable cardioverter-defibrillators (ICDs) and other management decisions.
  
  
  OBJECTIVE
  To determine whether myocardial fibrosis (detected by late gadolinium enhancement cardiovascular magnetic resonance [LGE-CMR] imaging) is an independent and incremental predictor of mortality and sudden cardiac death (SCD) in dilated cardiomyopathy.
  
  
  METHODS
  Prospective, longitudinal study of 472 patients with dilated cardiomyopathy referred to a UK center for CMR imaging between November 2000 and December 2008 after presence and extent of midwall replacement fibrosis were determined. Patients were followed up through December 2011.
  
  
  METHODS
  Primary end point was all-cause mortality. Secondary end points included cardiovascular mortality or cardiac transplantation; an arrhythmic composite of SCD or aborted SCD (appropriate ICD shock, nonfatal ventricular fibrillation, or sustained ventricular tachycardia); and a composite of HF death, HF hospitalization, or cardiac transplantation.
  
  
  RESULTS
  Among the 142 patients with midwall fibrosis, there were 38 deaths (26.8%) vs 35 deaths (10.6%) among the 330 patients without fibrosis (hazard ratio [HR], 2.96 [95% CI, 1.87-4.69]; absolute risk difference, 16.2% [95% CI, 8.2%-24.2%]; P < .001) during a median follow-up of 5.3 years (2557 patient-years of follow-up). The arrhythmic composite was reached by 42 patients with fibrosis (29.6%) and 23 patients without fibrosis (7.0%) (HR, 5.24 [95% CI, 3.15-8.72]; absolute risk difference, 22.6% [95% CI, 14.6%-30.6%]; P < .001). After adjustment for LVEF and other conventional prognostic factors, both the presence of fibrosis (HR, 2.43 [95% CI, 1.50-3.92]; P < .001) and the extent (HR, 1.11 [95% CI, 1.06-1.16]; P < .001) were independently and incrementally associated with all-cause mortality. Fibrosis was also independently associated with cardiovascular mortality or cardiac transplantation (by fibrosis presence: HR, 3.22 [95% CI, 1.95-5.31], P < .001; and by fibrosis extent: HR, 1.15 [95% CI, 1.10-1.20], P < .001), SCD or aborted SCD (by fibrosis presence: HR, 4.61 [95% CI, 2.75-7.74], P < .001; and by fibrosis extent: HR, 1.10 [95% CI, 1.05-1.16], P < .001), and the HF composite (by fibrosis presence: HR, 1.62 [95% CI, 1.00-2.61], P = .049; and by fibrosis extent: HR, 1.08 [95% CI, 1.04-1.13], P < .001). Addition of fibrosis to LVEF significantly improved risk reclassification for all-cause mortality and the SCD composite (net reclassification improvement: 0.26 [95% CI, 0.11-0.41]; P = .001 and 0.29 [95% CI, 0.11-0.48]; P = .002, respectively).
  
  
  CONCLUSIONS
  Assessment of midwall fibrosis with LGE-CMR imaging provided independent prognostic information beyond LVEF in patients with nonischemic dilated cardiomyopathy. The role of LGE-CMR in the risk stratification of dilated cardiomyopathy requires further investigation.
authors: Royal Brompton Hospital, London, England.
authors: Ankur
authors: A
authors: Gulati
authors: Andrew
authors: A
authors: Jabbour
authors: Tevfik F
authors: TF
authors: Ismail
authors: Kaushik
authors: K
authors: Guha
authors: Jahanzaib
authors: J
authors: Khwaja
authors: Sadaf
authors: S
authors: Raza
authors: Kishen
authors: K
authors: Morarji
authors: Tristan D H
authors: TD
authors: Brown
authors: Nizar A
authors: NA
authors: Ismail
authors: Marc R
authors: MR
authors: Dweck
authors: Elisa
authors: E
authors: Di Pietro
authors: Michael
authors: M
authors: Roughton
authors: Ricardo
authors: R
authors: Wage
authors: Yousef
authors: Y
authors: Daryani
authors: Rory
authors: R
authors: O'Hanlon
authors: Mary N
authors: MN
authors: Sheppard
authors: Francisco
authors: F
authors: Alpendurada
authors: Alexander R
authors: AR
authors: Lyon
authors: Stuart A
authors: SA
authors: Cook
authors: Martin R
authors: MR
authors: Cowie
authors: Ravi G
authors: RG
authors: Assomull
authors: Dudley J
authors: DJ
authors: Pennell
authors: Sanjay K
authors: SK
authors: Prasad
mesh_terms: D000328:Adult; D000368:Aged; D002311:Cardiomyopathy, Dilated / Q000401:mortality* / Q000473:pathology*; D002423:Cause of Death; D016757:Death, Sudden, Cardiac / Q000453:epidemiology*; D017147:Defibrillators, Implantable; D005260:Female; D005355:Fibrosis; D005682:Gadolinium; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009206:Myocardium / Q000473:pathology*; D018579:Patient Selection; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D018570:Risk Assessment; D013318:Stroke Volume; D006113:United Kingdom / Q000453:epidemiology; D016277:Ventricular Function, Left
chemical_list: D005682:Gadolinium