Thread by @cshenoy3

@jameschilee @purviparwani @krychtiukmd @DrRyanPDaly @venkmurthy @journalofCMR @MarcDweck @AmitRPatelMD @onco_cardiology @ash71us @SHummelMD @SCMRorg 1/11 Why CMR for newly diagnosed HF? First, CMR is the gold standard for LVEF assessment and LVEF is used to diagnose cardiomyopathy, to decide medications and other treatments such as ICD and CRT. Sometimes, we don’t find a cardiomyopathy on CMR that was diagnosed on echo.

@jameschilee @purviparwani @krychtiukmd @DrRyanPDaly @venkmurthy @journalofCMR @MarcDweck @AmitRPatelMD @onco_cardiology @ash71us @SHummelMD @SCMRorg 2/11 Second, CMR tells us about the etiology of the cardiomyopathy. This is critical because the etiology is closely linked to prognosis and management. The prognostic relevance was nicely shown by @dukehfdoc in a landmark NEJM paper 18 years ago - goo.gl/xQP6JT

@jameschilee @purviparwani @krychtiukmd @DrRyanPDaly @venkmurthy @journalofCMR @MarcDweck @AmitRPatelMD @onco_cardiology @ash71us @SHummelMD @SCMRorg @DukeHFDoc 3/11 A 2016 AHA Scientific Statement also stresses the importance of the etiology of cardiomyopathy - goo.gl/cyoH2E
Treatments can be uniquely different for the various types of NICM – immunosuppression for sarcoidosis, eosinophilic and giant cell myocarditis...

@jameschilee @purviparwani @krychtiukmd @DrRyanPDaly @venkmurthy @journalofCMR @MarcDweck @AmitRPatelMD @onco_cardiology @ash71us @SHummelMD @SCMRorg @DukeHFDoc 4/11 ...family screening for arrhythmogenic and familial cardiomyopathies, exercise restriction for arrhythmogenic cardiomyopathies, phlebotomy or chelation therapy for iron-overload cardiomyopathies, enzyme replacement therapy for lysosomal storage disorders, etc.

@jameschilee @purviparwani @krychtiukmd @DrRyanPDaly @venkmurthy @journalofCMR @MarcDweck @AmitRPatelMD @onco_cardiology @ash71us @SHummelMD @SCMRorg @DukeHFDoc 5/11 So have we not been doing a good job at diagnosing the etiology? 5 studies of patients that underwent heart transplants, where pre-transplant clinical diagnoses were compared to post-transplant pathology diagnoses (gold standard) showed 8-21% errors, mostly with NICMs.

@jameschilee @purviparwani @krychtiukmd @DrRyanPDaly @venkmurthy @journalofCMR @MarcDweck @AmitRPatelMD @onco_cardiology @ash71us @SHummelMD @SCMRorg @DukeHFDoc 6/11 What about coronary angiography, stress echo, SPECT, etc.? One of these is often used in newly diagnosed HF. These are all reasonably good (but inferior to CMR) in diagnosing ICM from NICM, but are poor to diagnose the specific etiology of a NICM.

@jameschilee @purviparwani @krychtiukmd @DrRyanPDaly @venkmurthy @journalofCMR @MarcDweck @AmitRPatelMD @onco_cardiology @ash71us @SHummelMD @SCMRorg @DukeHFDoc 7/11 Why is CMR superior to coronary angiography for ICM vs. NICM? Because the presence of obstructive CAD in a patient with cardiomyopathy does not always signify ICM and the CAD may simply be incidental. goo.gl/7jYwEr

@jameschilee @purviparwani @krychtiukmd @DrRyanPDaly @venkmurthy @journalofCMR @MarcDweck @AmitRPatelMD @onco_cardiology @ash71us @SHummelMD @SCMRorg @DukeHFDoc 8/11 Conversely, the absence of obstructive CAD does not always rule out ICM; in a systematic review of MINOCA, 24% had LGE in an ischemic pattern, possibly due to spontaneous healing of thrombotic occlusion from atherosclerosis or thromboembolic disorders, or coronary vasospasm.

@jameschilee @purviparwani @krychtiukmd @DrRyanPDaly @venkmurthy @journalofCMR @MarcDweck @AmitRPatelMD @onco_cardiology @ash71us @SHummelMD @SCMRorg @DukeHFDoc 9/11 Third, CMR tells us about the prognosis of the patient with newly diagnosed cardiomyopathy. Above and beyond LVEF, the presence of LGE is universally bad for every cardiomyopathy studied – both in terms of the odds of adverse outcomes and the odds of functional recovery.

@jameschilee @purviparwani @krychtiukmd @DrRyanPDaly @venkmurthy @journalofCMR @MarcDweck @AmitRPatelMD @onco_cardiology @ash71us @SHummelMD @SCMRorg @DukeHFDoc 10/11 LGE extent is also prognostic – more the LGE, worse the outcomes and lower the odds of functional recovery. LGE is prognostic even when a specific etiology is not found, i.e., in idiopathic dilated cardiomyopathy, as shown by Assomull et al., Gulati et al., and @bphlondon

@jameschilee @purviparwani @krychtiukmd @DrRyanPDaly @venkmurthy @journalofCMR @MarcDweck @AmitRPatelMD @onco_cardiology @ash71us @SHummelMD @SCMRorg @DukeHFDoc @BPHlondon 11/11 Summary – NICM is not a complete diagnosis. The specific etiology of cardiomyopathy matters. CMR can make a difference.