Myocardial remodelling and left ventricular recovery after guideline-directed medical therapy in non-ischaemic dilated cardiomyopathy
Authors: Tomoaia R , Kaselampao L M , Javed W , Lwin M , Soo C , Anderton T , Kamani C , Thompson P , Wahab A , Brown B , Plein S , Swoboda P 
Published: January 2025

Abstract

Aims
We aimed to identify the proportion of patients with presumed dilated cardiomyopathy (DCM) who undergo left ventricular (LV) reverse remodelling on initiation of guideline-directed medical therapy (GDMT). Our secondary aim was to identify if any clinical or echocardiographic parameters of presentation were predictive of reverse remodelling.

Methods
We prospectively recruited patients diagnosed by echocardiography with DCM as defined by the current criteria, who were referred for early CMR examination. Patients with an established diagnosis of coronary artery disease and known structural or congenital heart disease were excluded. LV reverse remodelling was defined as LV cavity dilatation on intial echocardiography with subsequent normalisation of LVEDVi measured by cardiovascular magnetic resonance (CMR) .

Results
A total of 395 patients were recruited including 166 (42%) who fulfilled the definition of LV reverse remodelling. DCM patients who did not achieve reverse remodelling exhibited larger LV (LVEDVi 111.8 ±31.7 vs 81 ± 16.5 mL/BSA, p&lt;0.0001), worse LVEF (26.7 ± 9.24 vs 30.7 ±9.8%, p&lt;0.0001), greater left atrium dilatation (LAVi 49.7 ± 16.5 vs 43 ± 9.7 mL/BSA, p=0.0008), higher incidence of mitral regurgitation (MR) of greater severity, more congestion requiring diuretic therapy and a higher probability of pulmonary hypertension as determined by echocardiography. These individuals also presented higher prevalence of ischaemic LGE (24.1 vs 15.7%, p= 0.04), LBBB (39.6 vs 18%, p=0.0003), and greater QRS duration (124.2 ±30.7 vs 105.7 ± 23.5 ms, p&lt;0.0001), but a lower incidence of AF(26.6 vs 47%, p=0.0005).
The multivariable regression analysis adjusted for NYHA class, number of days between echocardiography and CMR, and diuretic use showed that LVEDVi (OR 1.08, 95% CI 1.05 to 1.12, p &lt;0.0001), LVEF (OR 0.97, 95%CI 0.94 to 0.99, p=0.01), more than mild mitral regurgitation (MR, OR 2.08, 95% CI 1.32 to 3.27, p = 0.0017 ), more than mild tricuspid regurgitation (TR, OR 1.99, 95% CI 1.07 to 3.69, p = 0.03), LBBB (OR 3.26 , 95% CI 1.64 to 6.45, p = 0.0007) and QRS duration (OR 1.03 , 95% CI 1.01 to 1.04, p &lt; 0.0001) remained independent predictors of failure of LV reverse remodelling in patients with DCM. Conversely, the presence of AF was associated with a higher probability of LV reverse remodelling (OR 0.45, 95% CI 0.28 to 0.71, p = 0.0007). Ischaemic LGE was also independently associated with LV reverse remodelling (OR 1.82, 95%CI 1.03 to 3.21, p=0.04).

Conclusion
Contemporary GDMT leads to reverse remodelling in a significant proportion of patients presenting with DCM. Predictors of failure to reverse remodel included larger LV cavity, lower LVEF, greater severity of MR and TR, wider QRS complex, and lower incidence of AF. Incidental ischaemic LGE was also associated with LV reverse remodelling. This has potential therapeutic significance as multimodality imaging is a powerful predictor of cardiovascular outcome in heart failure.
Univariable logistic regression Multivariable logistic regression