Cardiac-MRI Predicts Clinical Worsening and Mortality in Pulmonary Arterial Hypertension

Abstract

Objectives This meta-analysis evaluates assessment of pulmonary arterial hypertension (PAH), with a focus on clinical worsening and mortality. Background Cardiac magnetic resonance (CMR) has prognostic value in the assessment of patients with PAH. However, there are limited data on the prediction of clinical worsening, an important composite endpoint used in PAH therapy trials. Methods The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Web of Science databases were searched in May 2020. All CMR studies assessing clinical worsening and the prognosis of patients with PAH were included. Pooled hazard ratios of univariate regression analyses for CMR measurements, for prediction of clinical worsening and mortality, were calculated. Results Twenty-two studies with 1,938 participants were included in the meta-analysis. There were 18 clinical worsening events and 8 deaths per 100 patient-years. The pooled hazard ratios show that every 1% decrease in right ventricular (RV) ejection fraction is associated with a 4.9% increase in the risk of clinical worsening over 22 months of follow-up and a 2.2% increase in the risk of death over 54 months. For every 1 ml/m 2 increase in RV end-systolic volume index or RV end-diastolic volume index, the risk of clinical worsening increases by 1.3% and 0.7%, respectively, and the risk of mortality increases by 0.9% and 1%. Every 1 ml/m 2 decrease in left ventricular end-systolic volume index or left ventricular end-diastolic volume index increased the risk of death by 2.1% and 2.3%. Left ventricular parameters were not associated with clinical worsening. Conclusions This review confirms CMR as a powerful prognostic marker in PAH in a large cohort of patients. In addition to confirming previous observations that RV function and RV and left ventricular volumes predict mortality, RV function and volumes also predict clinical worsening. This study provides a strong rationale for considering CMR as a clinically relevant endpoint for trials of PAH therapies.

Repeatability and sensitivity to change of non-invasive end points in PAH: the RESPIRE study

“…This may reflect the ceiling effect of the 6MWT and the effect of comorbidities (including chronic kidney disease) that may influence 6MWT distance and NT-proBNP levels. MRI metrics predict clinical worsening 7 and mortality [2][3][4] fulfilling many of the criteria of a surrogate end point. 9 Given that pulmonary haemodynamics are commonly used in early phase PAH studies, 1 a direct comparison of MRI metrics and pulmonary haemodynamics, to detect longitudinal change following PAH therapy, is now required if MRI imaging is to be considered a primary end-point for PAH therapy trials.…”

“…[2][3][4] Despite new therapies and improvements in survival, 5 PAH remains a life-shortening condition. MRI is the gold standard for RV assessment, 6 has prognostic value 2 and predicts clinical worsening 7 in PAH. A trial end point that is highly repeatable, is sensitive to treatment and predicts outcomes would be highly desirable.…”

Right Ventricular Adaptation Assessed Using Cardiac Magnetic Resonance Predicts Survival in Pulmonary Arterial Hypertension

“…Assessments of disease severity and prognosis are essential in the selection of treatment options and the timing of lung transplantation ( 1 ). Right ventricular (RV) volume and mass parameters measured using cardiac magnetic resonance have been suggested to be prognostic in PAH ( 1 , 2 , 3 ).…”

Automated calculation of the right ventricle to left ventricle ratio on CT for the risk stratification of patients with acute pulmonary embolism

“…4 Flowchart illustrating the risk stratification as per each patient's CTPA report and the potential impact of the automated analysis leading to new risk stratification groups emphysema, left heart disease and other causes of pulmonary hypertension. RV volume is an important prognostic indicator in patients with non-PE related pulmonary hypertension [25]; however, the prognostic value of the RV:LV ratio in all patients without acute PE must be delineated before its use in routine clinical practice can be recommended. There is also a larger implication in terms of cost if all CTPA studies are analysed and so a cost-efficacy analysis is also an essential issue.…”