The Value of Myocardial Fibrosis Parameters Derived from Cardiac Magnetic Resonance Imaging in Risk Stratification for Patients with Hypertrophic Cardiomyopathy

Rationale and Objectives: The aim of the study was to determine whether myocardial fibrosis parameters of cardiac magnetic resonance imaging (MRI) has added value in the risk stratification of hypertrophic cardiomyopathy (HCM) patients. Materials and Methods: In this retrospective study, 108 patients with HCM (mean age +/- standard deviation, 55.5 +/- 13.4 years) were included from January 2019 to April 2022, and were followed up for 2 years to record sudden cardiac death (SCD) adverse events. All HCM patients underwent cardiac MRI and were divided into a training cohort (n = 81; mean age, 56.1 +/- 13.0 years) and a validation cohort (n = 27; mean age, 57.8 +/- 13.9 years). According to the presence of SCD risk factors defined by the 2020 AHA/ACC guidelines, HCM patients were classified into low-risk and high-risk groups. Cardiac MRI features, including late gadolinium enhancement (LGE), T1 mapping, and extracellular volume fraction (ECV), were assessed and compared between the two groups. Logistic regression analysis was used to select the optimal predictors of SCD from cardiac MRI features and HCM Risk-SCD score to construct prediction models. Receiver operating curve (ROC) analysis was used to assess the predictive performance of the constructed prediction model. Cox regression analysis was also used to determine the optimal predictors of SCD adverse events. Results: Multivariate logistic analysis showed that the global ECV was the single myocardial fibrosis parameter predictive of the risk of SCD (p < 0.001). The areas under the ROC curves (AUC) of global ECV were higher than those of LGE, global native T1, global postcontrast T1, and HCM Risk-SCD (AUC = 0.85 vs. 0.74, 0.77, 0.63, 0.78). An integrative risk stratification model combining global ECV (odds ratio, 1.36 [95% CI: 1.16-1.60]; p < 0.001) and HCM Risk-SCD score (odds ratio, 1.63 [95% CI: 1.08-2.47]; p < 0.001) achieved an AUC of 0.89 (95% CI: 0.81-0.96) in the training cohort, which was significantly higher than that of HCM Risk-SCD score alone (p = 0.03). The AUC of the integrative model was 0.93 (95% CI: 0.84-1.00) in the validation cohort. Multivariate Cox regression analysis also showed that the global ECV was an independent predictor of SCD adverse events (hazard ratio, 1.27 [95% CI: 1.10-1.47]). Conclusion: The ECV derived from cardiac MRI is comparable to the HCM Risk-SCD scale in predicting the SCD risk stratification in patients with HCM.