title: The Combined Incremental Prognostic Value of LVEF, Late Gadolinium Enhancement, and Global Circumferential Strain Assessed by CMR.
abstract: OBJECTIVE
  This study aimed to assess the incremental prognostic value of global circumferential strain (GCS), as measured using cardiac magnetic resonance (CMR) tagging, in addition to baseline clinical characteristics, left ventricular ejection fraction (LVEF), and late gadolinium enhancement (LGE), in the prediction of major adverse cardiovascular events (MACE) in an unselected cohort of patients.
  
  
  BACKGROUND
  LVEF is a powerful predictor of mortality and is used for guiding treatment decisions. It is, however, subject to limitations. The value of GCS measured by CMR tagging in patients with suspected cardiac disease has not been fully explored despite its being considered as the gold standard noninvasive method of assessment of LV deformation.
  
  
  METHODS
  We prospectively evaluated data from 539 consecutive patients referred for CMR who underwent a CMR protocol that included cine imaging, tagging, and LGE. The primary endpoint was the prevalence of MACE, defined as a composite of all-cause mortality, heart failure-related hospitalization, and aborted sudden cardiac death.
  
  
  RESULTS
  MACE occurred in 62 of 539 patients (11.5%) over a mean follow-up period of 2.2 years. History of ischemic heart disease (IHD) and beta-blocker use were both significant clinical predictors of adverse outcomes. All 3 CMR parameters were significant multivariate predictors of the primary outcome when added to significant clinical predictors (LVEF, hazard ratio [HR]: 0.96 [95% confidence interval [CI]: 0.94 to 0.99; p = 0.005]; presence of LGE, HR: 2.07 [95% CI: 1.03 to 4.14; p = 0.04]; GCS, HR: 1.11 [95% CI: 1.02 to 1.21; p = 0.041]). Global chi-square increased significantly with the addition of both LGE and GCS. Both the presence of LGE and reduced GCS had independent prognostic value in the overall cohort. Patients with LVEF ≥35% but LGE present and reduced GCS had a poor outcome similar to that in those with LVEF <35%.
  
  
  CONCLUSIONS
  We found, in a large-scale cohort of patients, that GCS, in addition to clinical variables, LVEF, and LGE, had incremental independent prognostic value. This measure could provide further risk stratification, especially in patients with mild LV impairment.
authors.affiliation: British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom. Electronic address: ifyrmordi@doctors.org.uk.
authors.forename: Ify
authors.initials: I
authors.lastname: Mordi
authors.affiliation: Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio.
authors.forename: Hiram
authors.initials: H
authors.lastname: Bezerra
authors.affiliation: British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom.
authors.forename: David
authors.initials: D
authors.lastname: Carrick
authors.affiliation: British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom.
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Tzemos
mesh_terms: D000328:Adult; D001696:Biomechanical Phenomena; D016009:Chi-Square Distribution; D003287:Contrast Media; D016757:Death, Sudden, Cardiac / Q000453:epidemiology / Q000517:prevention & control; D018450:Disease Progression; D005260:Female; D019786:Gadolinium DTPA; D006331:Heart Diseases / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology; D006801:Humans; D053208:Kaplan-Meier Estimate; D019028:Magnetic Resonance Imaging, Cine; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009200:Myocardial Contraction; D011237:Predictive Value of Tests; D015995:Prevalence; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D013318:Stroke Volume; D013997:Time Factors; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology; D016277:Ventricular Function, Left
chemical_list: D003287:Contrast Media; D019786:Gadolinium DTPA
keywords: cardiac magnetic resonance; late gadolinium enhancement; strain; tagging