Prognostic role of cardiac magnetic resonance in ischemic and non-ischemic cardiomyopathy

Background Patients with ischemic and non-ischemic cardiomyopathy (ICM/NICM) and reduced left ventricular ejection fraction (LVEF) are at risk of adverse outcomes. Current risk stratification mainly relies on LVEF. Cardiac magnetic resonance (CMR) enables integrated functional, volumetric, and tissue assessment, improving prognostic accuracy. Purpose To assess the prognostic value of CMR-derived parameters for predicting major arrhythmic adverse cardiac events (MAACE) in NICM and all-cause mortality or heart failure hospitalization (ACM/HF) in ICM, and to develop multiparametric CMR-based risk scores. Methods Patients from the DERIVATE Registry with HF and LVEF<50% were included. Patients with arrhythmogenic or hypertrophic cardiomyopathy, amyloidosis, valvular, or congenital heart disease were excluded. Clinical, echocardiographic, and CMR data were centrally analyzed. CMR parameters included LV end-diastolic volume index (LVEDVi), LVEF, late gadolinium enhancement (LGE) extent, gray-zone mass, left atrial coupling index (LACI), and LV global strain parameters (GLS, GRS, GCS). The primary endpoint was MAACE in NICM and ACM/HF in ICM. Independent predictors were identified using Cox regression and used to derive disease-specific CMR risk scores. Prognostic performance was assessed by time-dependent ROC curves and Kaplan–Meier analysis. Results A total of 2158 patients (1297 NICM; 861 ICM) were analyzed, with a mean follow-up of 1220±810 days. In NICM, MAACE occurred in 8.4%. Independent predictors were LVEDVi, LGE extent, LACI, and GLS. The NICM-CMR Score demonstrated excellent discrimination (AUC 0.76), with 83% sensitivity and 99% negative predictive value. In ICM, ACM/HF occurred in 31.4%. Independent predictors included diabetes, NYHA class >II, lower CMR-LVEF, higher gray-zone mass, LACI, and impaired GLS. The ICM-CMR Score showed good prognostic performance (AUC 0.68–0.74), with a 2.4-fold higher event rate in high-risk patients. Conclusions Multiparametric CMR provides incremental prognostic value in both NICM and ICM. The proposed CMR-based risk scores offer practical tools for refined risk stratification and may support personalized clinical decision-making.