The alcohol-induced cardiomyopathy: A cardiovascular magnetic resonance characterization

Prognostic value of left ventricular strain determined using CMR-feature tracking in patients with alcoholic cardiomyopathy

OBJECTIVES

Previous studies have not sufficiently examined alcoholic cardiomyopathy (ACM). Therefore, this research aimed to evaluate the prognostic value of left ventricular strain parameters determined using CMR-feature tracking (CMR-FT) in patients with ACM.

METHODS

Patients with ACM who underwent CMR from September 2015 to October 2023 were enrolled in this single-center retrospective study. Major adverse cardiovascular events (MACE) included death, heart transplantation, implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy (CRT), and rehospitalization for worsening heart failure. Multiple linear regression was used to analyze the relationship of the degree of left ventricular strain impairment with daily alcohol intake and drinking duration. The risk factors for MACE were identified using multivariable Cox analysis.

RESULTS

A total of 64 patients with ACM were enrolled. During a median follow-up time of 30 months(IQR: 10.0-55.4), 24 (37.5 %) patients developed MACE, including heart transplantation (2 patients), ICD (4 patients), CRT (3 patients), and rehospitalization owing to heart failure (15 patients). Left ventricular ejection fraction, global circumferential strain, global radial strain and global longitudinal strain (GLS) were significantly worse in patients with MACE than those without MACE (p < 0.05). Regression analysis indicated that daily alcohol intake and drinking duration influence left ventricular strain. Multivariate Cox regression analysis revealed a significant association between GLS and MACE. Kaplan-Meier analysis suggested that patients with GLS <6.5 % showed more favorable clinical outcomes than those with GLS ≥6.5 % (p < 0.05).

CONCLUSION

GLS exhibits better independent prognostic value than conventional CMR features in patients with ACM.

Global, regional, and national burden of alcoholic cardiomyopathy from 1990 to 2021: an age-period-cohort analysis using the global burden of disease 2021 study

BACKGROUND

As a serious public health problem, alcoholic cardiomyopathy (ACM) has caused a heavy burden of disease.

METHODS

To summarize and deeply analyze the development trend of ACM at the global, regional, and national levels in the past 30 years, this study used the age-period-cohort model to analyze the age, period, and cohort effects of the prevalence, deaths, and disability-adjusted life years (DALYs) of ACM.

RESULTS

The results found that the overall time trend of ACM prevalence, deaths, and DALYs had been decreasing worldwide, but the opposite trend was observed in some countries and regions. The disease burden of male ACM patients was significantly higher than that of female patients. Moreover, the ASRs of prevalence, deaths, and DALYs for ACM were positively correlated with sociodemographic index levels. Finally, this study predicted that ACM prevalence will continue to decline over the next 10 years, while death rates and DALYs are expected to increase.

CONCLUSIONS

Overall, the results of this study provided an insightful, up-to-date global perspective on time trends in ACM-related disease burden, shedding light on the inadequacy of ACM prevention, control, and intervention programs at multiple levels.

Prognostic significance of myocardial fibrosis in men with alcoholic cardiomyopathy: insights from cardiac MRI

OBJECTIVES

Myocardial fibrosis significantly impacts prognosis in various cardiovascular diseases, yet its role in alcoholic cardiomyopathy (ACM) remains poorly understood. This study evaluates the prognostic value of myocardial fibrosis, as detected by cardiac magnetic resonance (CMR), in ACM patients.

METHODS

We conducted a retrospective analysis of consecutive ACM patients who underwent enhanced CMR from August 2015 to October 2023. Assessment of myocardial fibrosis was performed using late gadolinium enhancement (LGE), native T1, and extracellular volume (ECV) fraction. The primary outcome was a composite of cardiac-related mortality, heart transplantation, hospitalization for heart failure, life-threatening arrhythmias, and the need for implantable cardioverter-defibrillator or cardiac resynchronization therapy.

RESULTS

A total of 141 male patients were finally enrolled with 27.7% experiencing the primary outcome over a median follow-up of 30.6 months (IQR: 18.0-44.9). LGE was found in 55.3% of patients, with a median extent of 2.9%. Compared to DCM patients who didn't consume alcohol, ACM patients showed lower LGE, native T1, and ECV values. Multivariate analysis showed LGE (HR, 1.09 [1.04, 1.15]; p < 0.001), native T1 (per 10 ms increase, 1.06 [1.02, 1.10]; p = 0.003), and ECV (per 3% increase, 1.57 [1.22, 2.01]; p < 0.001) had significant prognostic associations with adverse outcomes. Including myocardial fibrosis parameters improved predictive accuracy beyond standard assessments. A nonlinear relationship was found between lifetime ethanol consumption and myocardial fibrosis, with a plateau at low exposures and a sharp increase at higher levels.

CONCLUSION

CMR-identified myocardial fibrosis has an association with major adverse cardiac events in ACM patients, underscoring its utility in risk stratification.

KEY POINTS

Question The prognostic role of myocardial fibrosis in alcoholic cardiomyopathy remains poorly understood. Findings Fibrosis detected by cardiac MRI has good incremental value for predictive models in assessing the risk of adverse cardiovascular events in patients with alcoholic cardiomyopathy. Clinical relevance Cardiac MRI may be a potential tool to identify high-risk alcoholic cardiomyopathy patients with cardiovascular adverse event, which is helpful for early clinical treatment, and improves patients prognosis.

Pathophysiology of dilated cardiomyopathy: from mechanisms to precision medicine

Dilated cardiomyopathy (DCM) is a complex disease with multiple causes and various pathogenic mechanisms. Despite improvements in the prognosis of patients with DCM in the past decade, this condition remains a leading cause of heart failure and premature death. Conventional treatment for DCM is based on the foundational therapies for heart failure with reduced ejection fraction. However, increasingly, attention is being directed towards individualized treatments and precision medicine. The ability to confirm genetic causality is gradually being complemented by an increased understanding of genotype-phenotype correlations. Non-genetic factors also influence the onset of DCM, and growing evidence links genetic background with concomitant non-genetic triggers or precipitating factors, increasing the extreme complexity of the pathophysiology of DCM. This Review covers the spectrum of pathophysiological mechanisms in DCM, from monogenic causes to the coexistence of genetic abnormalities and triggering environmental factors (the 'two-hit' hypothesis). The roles of common genetic variants in the general population and of gene modifiers in disease onset and progression are also discussed. Finally, areas for future research are highlighted, particularly novel therapies, such as small molecules, RNA and gene therapy, and measures for the prevention of arrhythmic death.

Biventricular Impairment and Ventricular Interdependence in Patients With Alcoholic Cardiomyopathy: Insights Through Cardiac Magnetic Resonance Imaging

BACKGROUND

Alcoholic cardiomyopathy (ACM) can lead to progressive cardiac dysfunction and heart failure, but little is known about biventricular impairment and ventricular interdependence (VI) in ACM patients.

PURPOSE

To use cardiac MRI to investigate biventricular impairment and VI in ACM patients.

STUDY TYPE

Retrospective.

POPULATION

Forty-one male patients with ACM and 45 sex- and age-matched controls.

FIELD STRENGTH/SEQUENCE

3.0 T/balanced steady-state free precession sequence, inversion recovery prepared echo-planar imaging sequence and phase-sensitive inversion recovery sequence.

ASSESSMENT

Biventricular structure, function, and global strain (encompassing peak strain [PS], peak systolic, and diastolic strain rate), PS of interventricular septal (IVS), microvascular perfusion (including upslope and time to maximum signal intensity [TTM]), late gadolinium enhancement (LGE), and baseline characteristics were compared between the controls and ACM patients.

STATISTICAL TESTS

Student's t-test, Mann-Whitney U test, Pearson's correlation, and multivariable linear regression models with a stepwise selection procedure. A two-tailed P value <0.05 was deemed as statistically significant.

RESULTS

Compared to control subjects, ACM patients showed significantly biventricular adverse remodeling, reduced left ventricle (LV) global upslope and prolonged global TTM, and the presence of LGE. ACM patients were characterized by a significant decline in all global strain within the LV, right ventricle (RV), and IVS compared with the controls. RV global PS was significantly associated with LV global PS and IVS PS in radial, circumferential, and longitudinal directions. Multivariable analyses demonstrated the longitudinal PS of IVS was significantly correlated with RV global radial PS (β = 0.614) and circumferential PS (β = 0.545). Additionally, RV global longitudinal PS (GLPS) was significantly associated with radial PS of IVS (β = -0.631) and LV GLPS (β = 1.096).

DATA CONCLUSION

ACM patients exhibited biventricular adverse structural alterations and impaired systolic and diastolic function. This cohort also showed reduced LV microvascular perfusion, the presence of LGE, and unfavorable VI.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 3.

Alcoholic cardiomyopathy: an update

Alcohol-induced cardiomyopathy (AC) is an acquired form of dilated cardiomyopathy (DCM) caused by prolonged and heavy alcohol intake in the absence of other causes. The amount of alcohol required to produce AC is generally considered as >80 g/day over 5 years, but there is still some controversy regarding this definition. This review on AC focuses on pathogenesis, which involves different mechanisms. Firstly, the direct toxic effect of ethanol promotes oxidative stress in the myocardium and activation of the renin-angiotensin system. Moreover, acetaldehyde, the best-studied metabolite of alcohol, can contribute to myocardial damage impairing actin-myosin interaction and producing mitochondrial dysfunction. Genetic factors are also involved in the pathogenesis of AC, with DCM-causing genetic variants in patients with AC, especially titin-truncating variants. These findings support a double-hit hypothesis in AC, combining genetics and environmental factors. The synergistic effect of alcohol with concomitant conditions such as hypertension or liver cirrhosis can be another contributing factor leading to AC. There are no specific cardiac signs and symptoms in AC as compared with other forms of DCM. However, natural history of AC differs from DCM and relies directly on alcohol withdrawal, as left ventricular ejection fraction recovery in abstainers is associated with an excellent prognosis. Thus, abstinence from alcohol is the most crucial step in treating AC, and specific therapies are available for this purpose. Otherwise, AC should be treated according to current guidelines of heart failure with reduced ejection fraction. Targeted therapies based on AC pathogenesis are currently being developed and could potentially improve AC treatment in the future.

Clinical and cardiac MRI characteristics: prognosis in patients with alcoholic cardiomyopathy

AIMS

Alcoholic cardiomyopathy (ACM) is recognized as a type of non-ischemic dilated cardiomyopathy (DCM). To date, the clinical prognosis of ACM remains a topic of debate in previous studies and there are limited studies on its cardiac MRI characteristics. The aim of this study was to summarize the clinical and MRI features of ACM patients and to identify the predictors of adverse prognosis based on clinical characteristics and MRI imaging findings.

MATERIALS AND METHODS

Adult patients who were clinically diagnosed with ACM and underwent enhanced CMR between September 2015 and August 2022 were retrospectively enrolled. The primary endpoints were major adverse cardiovascular events, including cardiac-related death, heart transplantation, hospitalization for heart failure and life-threatening ventricular arrhythmias (sustained ventricular tachycardia, ventricular fibrillation, or ICD shock). The risk factors associated with these primary end points were identified using multivariable Cox analysis.

RESULTS

A total of 62 ACM patients (50 ± 9 years, 62 men) were included. The majority of patients presented with symptoms of heart failure. Over a median follow-up period of 30.3 months (IQR 12.2-57.7 months), 24 patients reached the primary endpoints. For clinical variables, multivariable analysis showed that drinking duration (HR=1.05; 95%CI:1.01, 1.11; p=0.03) and persistent drinking (HR=3.71; 95%CI:1.46, 9.44; p=0.01) were associated with MACE. For CMR variables, late gadolinium enhancement (LGE) percent (HR = 1.09; 95% CI: 1.03, 1.14; p<0.001) stood out as an independent predictor for MACE.

CONCLUSIONS

In ACM patients, persistent drinking and cardiac MRI-defined myocardial scar were associated with adverse outcomes such as cardiac death, heart transplantation, hospitalization for heart failure or life-threatening ventricular arrhythmias.

Spectrum of Thoracic Imaging Findings in the Setting of Substance Abuse

ABSTRACT

Substance abuse continues to be prevalent nationwide and can lead to a myriad of chest pathologies. Imaging findings are vast and can include nodules, masses, ground-glass opacities, airspace disease, and cysts. Radiologists with awareness of these manifestations can assist in early identification of disease in situations where information is unable to be obtained from the patient. This review focuses on thoracic imaging findings associated with various forms of substance abuse, which are organized by portal of entry into the thorax: inhalation, ingestion, and injection.

Utilities and Limitations of Cardiac Magnetic Resonance Imaging in Dilated Cardiomyopathy

Dilated cardiomyopathy (DCM) is one of the most common types of non-ischemic cardiomyopathy. DCM is characterized by left ventricle (LV) dilatation and systolic dysfunction without coronary artery disease or abnormal loading conditions. DCM is not a single disease entity and has a complex historical background of revisions and updates to its definition because of its diverse etiology and clinical manifestations. In cases of LV dilatation and dysfunction, conditions with phenotypic overlap should be excluded before establishing a DCM diagnosis. The differential diagnoses of DCM include ischemic cardiomyopathy, valvular heart disease, burned-out hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, and non-compaction. Cardiac magnetic resonance (CMR) imaging is helpful for evaluating DCM because it provides precise measurements of cardiac size, function, mass, and tissue characterization. Comprehensive analyses using various sequences, including cine imaging, late gadolinium enhancement imaging, and T1 and T2 mapping, may help establish differential diagnoses, etiological work-up, disease stratification, prognostic determination, and follow-up procedures in patients with DCM phenotypes. This article aimed to review the utilities and limitations of CMR in the diagnosis and assessment of DCM.

Cardiac involvement in patients 1 year after recovery from moderate and severe COVID-19 infections

Background

Some patients suffered persistent cardiac symptoms after hospital discharge following COVID-19 infection, including chest tightness, chest pain, and palpitation. However, the cardiac involvement in these patients remains unknown. The purpose of this study was to investigate the effect of COVID-19 infection on the cardiovascular system after 1 year of recovery in patients hospitalized with persistent cardiac symptoms.

Materials and methods

In this prospective observational study, a total of 32 patients who had COVID-19 (11 diagnosed as severe COVID-19 and 21 as moderate) with persistent cardiac symptoms after hospital discharge were enrolled. Contrast-enhanced cardiovascular magnetic resonance (CMR) imaging was performed on all patients. Comparisons were made with age- and sex-matched healthy controls (n = 13), and age-, sex- and risk factor-matched controls (n = 21). Further analysis was made between the severe and moderate COVID-19 cohorts.

Results

The mean time interval between acute COVID-19 infection and CMR was 462 ± 18 days. Patients recovered from COVID-19 had reduced left ventricular ejection fraction (LVEF) (p = 0.003) and increased extracellular volumes (ECVs) (p = 0.023) compared with healthy controls. Focal late gadolinium enhancement (LGE) was found in 22 (68.8%) patients, mainly distributed linearly in the septal mid-wall or patchily in RV insertion point. The LGE extent in patients with severe COVID-19 was higher than that in patients with moderate COVID-19 (p = 0.009).

Conclusion

This 1-year follow-up study revealed that patients with persistent cardiac symptoms, after recovering from COVID-19, had decreased cardiac function and increased ECV compared with healthy controls. Patients with COVID-19 predominately had a LGE pattern of septal mid-wall or RV insertion point. Patients with severe COVID-19 had greater LGE extent than patients with moderate COVID-19.

Inhibition of ferroptosis reduces susceptibility to frequent excessive alcohol consumption-induced atrial fibrillation

Both long-term and short-term alcohol consumption can cause internal homeostasis imbalance, and they have been proved to be related to the initiation and development of atrial fibrillation (AF). Ferroptosis is an iron-dependent form of non-apoptotic oxidative death which also regulate the cell death homeostasis, but whether it involves in AF induced by alcohol consumption remains unclear. Here, we report a study on the effect of ferroptosis on susceptibility to AF at different alcohol consumption frequencies. We divided the mice into single or frequent excessive alcohol consumption group which given sterile drinking water or alcohol by gavage at different frequencies. Meanwhile, the experimental group was given an intraperitoneal injection of ferroptosis inhibitor (Fer-1) before alcohol drinking. It was found that once exposure to 5 g/kg/d frequent excessive alcohol consumption, compared with the single excessive alcohol consumption group, the mice serum non-heme iron concentration, accumulation of iron and oxidative stress reaction in atrial tissues were increased, while the body weight, heart weight and heart weight to tibia length (HW/TL) ratio were decreased. In addition, the inducibility rate of AF increased, while RR interval, effective refractory periods (ERPs) and 90 % action potential duration (APD90) shortened, as well as QTc interval prolonged. Furthermore, the protein and mRNA expression levels of GPx4, FTL, FTH1, Kv1.5, Kv2.1, Kv4.3, Cav1.2, Serca2α, p-PLB were down-regulated, while PTGS2 was up-regulated. Most of the changes can be partially or completely reversed by Fer-1. These results suggest that frequent excessive alcohol consumption activates ferroptosis and increases the inducibility rate of AF. Nevertheless, inhibition of ferroptosis can balance iron overload disorders and reduce the generation of reactive oxygen species (ROS), eventually decrease the susceptibility to AF. Our results highlight the importance of guidance and warnings for unhealthy alcohol-abuse lifestyle.