title: Infarct tissue heterogeneity by contrast-enhanced magnetic resonance imaging is a novel predictor of mortality in patients with chronic coronary artery disease and left ventricular dysfunction.
abstract: BACKGROUND
  Strategies for prevention of sudden cardiac death focus on severe left ventricular (LV) dysfunction, although most sudden cardiac death postmyocardial infarction occurs in patients with mild/moderate LV dysfunction. We tested the hypothesis that infarct heterogeneity by cardiac magnetic resonance is associated with mortality beyond LV ejection fraction (LVEF) in patients with coronary artery disease and LV dysfunction. In addition, we examined the association between infarct heterogeneity and mortality in those with LVEF >35%.
  
  
  RESULTS
  We studied 301 patients with coronary artery disease and LV dysfunction referred for cardiac magnetic resonance. We quantified total infarct mass, infarct core mass, and peri-infarct zone (PIZ) normalized for total infarct mass (%PIZ) using signal-intensity criteria of >2 SDs, >3 SDs, and 2- to -3 SDs above remote myocardium, respectively. Mean LVEF was 41 ± 14%. After 3.9 years median follow-up, 66 (22%) patients died (13 sudden cardiac death; 33 with LVEF >35%). In patients with LVEF >35%, below-median %PIZ carried an annual death rate of 2.8% versus 12% in patients with above-median %PIZ (P<0.001). In a multivariable model, %PIZ maintained strong association with mortality adjusted to patient age, LVEF, right ventricular ejection fraction, prolonged QT interval, and total infarct size and resulted in improve risk reclassification 0.492 (95% confidence interval, 0.183-0.817).
  
  
  CONCLUSIONS
  Cardiac magnetic resonance infarct heterogeneity has a strong association with mortality independent of LVEF in patients with coronary artery disease and LV dysfunction, particularly in patients with mild or moderate LV dysfunction. Further studies incorporating cardiac magnetic resonance in clinical decision making for defibrillator therapy are warranted.
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: Eri
authors.initials: E
authors.lastname: Watanabe
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: Siddique A
authors.initials: SA
authors.lastname: Abbasi
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: Bobak
authors.initials: B
authors.lastname: Heydari
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: Otavio R
authors.initials: OR
authors.lastname: Coelho-Filho
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: Ravi
authors.initials: R
authors.lastname: Shah
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: Tomas G
authors.initials: TG
authors.lastname: Neilan
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: Venkatesh L
authors.initials: VL
authors.lastname: Murthy
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: François-Pierre
authors.initials: FP
authors.lastname: Mongeon
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: Chirag
authors.initials: C
authors.lastname: Barbhaiya
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: Michael
authors.initials: M
authors.lastname: Jerosch-Herold
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: Ron
authors.initials: R
authors.lastname: Blankstein
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: Hiroto
authors.initials: H
authors.lastname: Hatabu
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: Robert J
authors.initials: RJ
authors.lastname: van der Geest
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: William G
authors.initials: WG
authors.lastname: Stevenson
authors.affiliation: Section of Noninvasive Cardiovascular Imaging (E.W., S.A.A., B.H., O.R.C.-F., R.S., T.G.N., V.L.M., F.-P.M., R.B., R.Y.K.), Cardiovascular Division, Department of Medicine (C.B., R.B., W.G.S., R.Y.K.), and Department of Radiology (M.J.-H., H.H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands (R.J.v.d.G.).
authors.forename: Raymond Y
authors.initials: RY
authors.lastname: Kwong
mesh_terms: D000368:Aged; D002908:Chronic Disease; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology; D016757:Death, Sudden, Cardiac / Q000209:etiology*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D019028:Magnetic Resonance Imaging, Cine; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D009206:Myocardium / Q000473:pathology*; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D013318:Stroke Volume; D013997:Time Factors; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D016277:Ventricular Function, Left
keywords: cardiac magnetic resonance imaging; cardiac mortality; coronary artery disease