Delayed enhancement in CMR: the "gold standard" for prognosis?

A couple of years ago many people debated whether CMR was the gold standard for viabiliby. Then came the gold standard for detection of infarcts. Are we into a new era as DLE stands for the gold standard of prognosis? In very wide and different scenarios DLE always seems to add prognostic information. This article by Dr. Cheong et al adds another point on the graph:

http://circ.ahajournals.org/cgi/content/abstract/120/21/2069?etoc


Prognostic Significance of Delayed-Enhancement Magnetic Resonance Imaging
Survival of 857 Patients With and Without Left Ventricular Dysfunction
Benjamin Y.C. Cheong, MD; Raja Muthupillai, PhD; James M. Wilson, MD; Angela Sung; Steffen Huber, MD; Samir Amin, BA; MacArthur A. Elayda, MD, PhD; Vei-Vei Lee, MS; Scott D. Flamm, MD

From the Departments of Radiology (B.Y.C.C., R.M., S.H., A.S., S.D.F.), Cardiology (B.Y.C.C., J.M.W., S.D.F.), and Biostatistics and Epidemiology (M.A.E., V.V.L.), the Texas Heart Institute at St. Luke’s Episcopal Hospital, and the Departments of Medicine (B.Y.C.C., S.A.) and Radiology (B.Y.C.C., R.M., S.D.F.), Baylor College of Medicine, Houston, Tex. Dr Flamm is currently at the Cleveland Clinic Foundation, Cleveland, Ohio.

Correspondence to B.Y.C. Cheong, MD, Department of Diagnostic and Interventional Radiology, St. Luke’s Episcopal Hospital and the Texas Heart Institute, 6720 Bertner Ave, MC 2–270, Houston, TX 77030. E-mail bcheong@sleh.com

Received January 20, 2009; accepted September 11, 2009.

Background— Left ventricular ejection fraction is a powerful independent predictor of survival in cardiac patients, especially those with coronary artery disease. Delayed-enhancement magnetic resonance imaging (DE-MRI) can accurately identify irreversible myocardial injury with high spatial and contrast resolution. To date, relatively limited data are available on the prognostic value of DE-MRI, so we sought to determine whether DE-MRI findings independently predict survival.

Methods and Results— The medical records of 857 consecutive patients who had complete cine and DE-MRI evaluation at a tertiary care center were reviewed regardless of whether the patients had coronary artery disease. The presence and extent of myocardial scar were evaluated qualitatively by a single experienced observer. The primary, composite end point was all-cause mortality or cardiac transplantation. Survival data were obtained from the Social Security Death Index. The median follow-up was 4.4 years; 252 patients (29%) reached one of the end points. Independent predictors of mortality or transplantation included congestive heart failure, ejection fraction, and age (P<0.0001 for each), as well as scar index (hazard ratio, 1.26; 95% confidence interval, 1.02 to 1.55; P=0.033). Similarly, in subsets of patients with or without coronary artery disease, scar index also independently predicted mortality or transplantation (hazard ratio, 1.33; 95% confidence interval, 1.05 to 1.68; P=0.018; and hazard ratio, 5.65; 95% confidence interval, 1.74 to 18.3; P=0.004, respectively). Cox regression analysis showed worse outcome in patients with any DE in addition to depressed left ventricular ejection fraction (<50%).

Conclusion— The degree of DE detected by DE-MRI appears to strongly predict all-cause mortality or cardiac transplantation after adjustment for traditional, well-known prognosticators.