Read our accompanying editorial for our thoughts on the important paper –

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@paragbawaskar.bsky.social #CardioSky #MedSky #Sarcoidosis

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Finally, many thanks to @cshenoy.bsky.social for his mentorship, our outstanding team for their contributions, and the editors and reviewers at Circulation for all their efforts to make our paper better!

Read our paper here –https://www.ahajournals.org/doi/abs/10.1161/CIRCULATIONAHA.123.067032

And if you will be at #AHA23, come visit the poster session on Monday, Nov 13, 10:00-11.30 am, Zone 2.

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An important trial related to this topic was just funded in the UK – Peter Swoboda at the University of Leeds is the PI of an RCT to identify the best initial test for newly diagnosed HF… we look forward to the results of CROSS-HF in a few years.

And if NICM and dualCM do influence outcomes, the next trial should investigate whether the routine use of CMR to identify the cause of cardiomyopathy improves the selection of patients for coronary revascularization, and overall long-term outcomes.

We need to investigate whether NICM or dualCM in patients with CAD influences outcomes after coronary revascularization.

An ancillary study of the STICH3C trial by Mario Gaudino and Jonathan Weinsaft at Cornell will give us some answers in about 5 years.

So what? Patients with CAD+NICM or dualCM should be treated with a statin, aspirin, and guideline-directed HF therapy the same as those with CAD+ICM.

But do patients with CAD+ NICM or dualCM benefit from coronary revascularization in the same manner as those with CAD+ICM?

Prior studies have found better outcomes for NICM vs. ICM. What explains worse outcomes for NICM in our study?

We can only speculate, but it may be because patients in our study had 2-3 diseases – CAD+NICM… or CAD+ICM+NICM.

Prior studies compared NICM without CAD to ICM+CAD.

And we looked at their long-term outcomes.

Patients with CAD+NICM or dualCM had a greater risk of all-cause death or heart failure hospitalization, all-cause death, and heart failure hospitalization compared with CAD+ICM.

The risk of CV death was not different.

We found NICM or dualCM in 1 of every 6 patients with CAD.

CAD+NoCM - 18.2%
CAD+ICM - 64.8%
CAD+NICM - 9.3%
CAD+dualCM - 7.7%

The prevalence of CAD+NICM or dualCM was 16.9% or 1 in 6 patients with CAD.

We looked at their CMRs and coronary angiography data and classified them into one of:

1. No cardiomyopathy (CAD+NoCM) – normal LVEF and no LGE
2. Ischemic cardiomyopathy (CAD+ICM)
3. Non-ischemic cardiomyopathy (CAD+NICM)
4. Dual cardiomyopathy (CAD+dualCM) – both ICM and NICM

We did a large retrospective observational study of 3,023 patients with obstructive CAD who had CMR for any clinical indication at our health system.

So how often do patients with CAD have NICM or dual (both ICM and NICM) cardiomyopathy?

How do these patients do compared to patients with ICM?

We tried to answer these questions.

There has been interest in this topic of late because trials of coronary revascularization other than STICHES have not shown revascularization to be beneficial.

Currently, we determine the cause of cardiomyopathy based on coronary angiography findings… CAD=ICM; No CAD=NICM

However, pathology and small CMR studies have shown that

NICM can occur with “bystander” CAD
ICM can occur without CAD
Both ICM and NICM can occur together