Prognostic Value of Cardiac Magnetic Resonance Tissue Characterization in Risk Stratifying Patients With Suspected Myocarditis

Abstract

Background: Diagnosing myocarditis is challenged by nonspecific clinical signs and symptoms and low accuracy of endomyocardial biopsy. Cardiac magnetic resonance imaging (CMR) provides both cardiac anatomy and tissue characterization in this setting, but the prognostic value of this method as a primary assessment tool in patients with suspected myocarditis remains limited.

Objectives: This study sought to determine cardiac event-free survival of a consecutive cohort with suspected myocarditis with regard to CMR findings.

Methods: Six hundred seventy patients with suspected myocarditis underwent CMR including late gadolinium enhancement (LGE) parameters between 2002 and 2015 and were included and followed. We performed multivariable model for major adverse cardiovascular events (MACE) and determined the continuous net reclassification improvement by LGE markers.

Results: At a median follow-up of 4.7 years (interquartile range [IQR]: 2.3 to 7.3 years), 98 patients experienced a MACE. Two hundred ninety-four (44%) patients showed LGE presence, which was associated with a more than doubling risk of MACE (hazard ratio [HR]: 2.22; 95% confidence interval [CI]: 1.47 to 3.35; p < 0.001). Annualized MACE rates were 4.8% and 2.1% corresponding to LGE presence and absence, respectively (p < 0.001). In the multivariable model, LGE presence maintained significant association with MACE (HR: 1.72; 95% CI: 1.08 to 2.76; p = 0.023). The computed continuous net reclassification improvement was 0.39 (95% CI: 0.10 to 0.67) when LGE presence was added to the multivariable model for MACE. Regarding location and pattern, septal and midwall LGE showed strongest associations with MACE (HR: 2.55; 95% CI: 1.77 to 3.83 and HR: 2.39; 95% CI: 1.54 to 3.69, respectively; both p < 0.001). A patchy distribution portended to a near 3-fold increased hazard to MACE (HR: 2.93; 95% CI: 1.79 to 4.80; p < 0.001). LGE extent (per 10% increase) corresponded to a 79% increase in risk of MACE (HR: 1.79; 95% CI: 1.25 to 2.57; p = 0.002). A normal CMR study corresponded to low annual MACE and death rates of 0.8% and 0.3%, respectively.

Conclusions: CMR tissue characterization provides effective risk stratification in patients with suspected myocarditis.

Keywords: CMR; cardiovascular magnetic resonance imaging; extracellular volume; myocarditis; outcome.