Background:

Acute heart failure (AHF) is a syndrome defined by symptoms of systemic congestion and decreased cardiac output, with high morbidity and mortality. Despite similar clinical presentation, the underlying structural and/or functional cause is heterogeneous, but desirable to optimize therapeutic strategies. Cardiac magnetic resonance imaging (CMR) as a reference technique for non-invasive myocardial tissue characterization offers such an opportunity. The aim of this study was to assess the ability of CMR to find a more accurate and individualized diagnosis of the actual cause of AHF.

Methods:

From a prospective cohort study of patients admitted with AHF to a tertiary care hospital, those with available CMR were identified. In these patients, the most likely cause of AHF was first determined by an interdisciplinary team including emergency physicians, cardiologists, and other specialities in the emergency department (ED) based on the clinical presentation, laboratory parameters, ECG and echocardiography. Subsequently, these patients were examined by means of CMR before discharge using conventional cine, T2-weighted and late gadolinium enhancement images, as well as T1 and T2 mapping techniques on a 1.5 T or 3 T scanner, and a CMR-based diagnosis was established blinded to the initial diagnosis. Then, diagnoses were compared. 

Results:

Overall, N=27 patients with AHF were analyzed (30% female, mean age 73 ± 12 years, mean NYHA stage 3.5 ± 0.5, mean ejection fraction 35 ± 13%). Initial diagnosis in the ED was as follows:  ischemic cardiomyopathy in 8 patients, arrhythmia induced cardiomyopathy in 9 patients, hypertensive, dilated, and unspecified cardiomyopathy in 3 patients each and myocarditis in one patient. CMR-based diagnosis matched the initial diagnosis only in 9/27 (33%) patients. Moreover, in several cases CMR identified rare causes of AHF such as amyloidosis or myocarditis (Figure 1).

Conclusion:

Early CMR during the hospital admission of patients with AHF can help to identify the correct diagnosis of the cause of AHF and thus optimize treatment. Based on these hypothesis-generating findings, CMR should be considered part of the initial work-up of selected patients presenting with AHF.

Figure 1: Sankey Plot illustrating the change of diagnosis after CMR: Initial diagnosis in den ED matched CMR-based diagnosis only in 33% of the cases. Moreover, rare causes of AHF such as amyloidosis or myocarditis could be identified by means of CMR.