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European Journal of Heart Failure 2001 3(3):323-330; doi:10.1016/S1388-9842(00)00150-1
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© 2001 European Society of Cardiology

Frequency, prognosis and predictors of improvement of systolic left ventricular function in patients with ‘classical’ clinical diagnosis of idiopathic dilated cardiomyopathy

Mariantonietta Cicoira, Luisa Zanolla*, Loredana Latina, Andrea Rossi, Giorgio Golia, Giovanna Brighetti and Piero Zardini

Divisione Clinicizzata di Cardiologia, Università degli Studi di Verona Verona, Italy

* Corresponding author. Divisione Clinicizzata di Cardiologia Ospedale Civile Maggiore, Piazzale Stefani 1, 37126 Verona, Italy. Tel.: +39-045-807-2040; fax: +39-045-914-727 E-mail address: znllsu{at}borgoroma.univr.it (L. Zanolla).


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 Acknowledgments
 References
 
In patients with dilated cardiomyopathy (DCM) of different aetiologies, a variable frequency of improvement in the left ventricular (LV) systolic function has been reported, while in patients with a ‘classic’ idiopathic DCM, the frequency of improvement is still under debate, and clinical and haemodynamic predictors of recovery of the LV function are needed. The aim of the present study was to determine the frequency of improvement in the LV systolic function in idiopathic DCM and to identify predictors of reversibility of the impaired LV contractility. A sample of 98 consecutive patients with idiopathic DCM was retrospectively evaluated. Echocardiographic and Doppler measurements were directly taken from the routine echo-report. LV systolic function was assessed semiquantitatively using a score index (SFSI). According to the improvement in the LV systolic function, the patients were divided into group 1 patients with improvement, and group 2 patients without improvement. During a follow-up of at least 12 months, 19 patients (19%) showed an improvement, with a significant increase in the mean SFSI; all these group 1 patients survived without heart transplant; in group 2, 18 patients (23%) died and 3 (4%) received a heart transplant. Patients in group 1 had a significantly shorter duration of symptoms (P = 0.0045), a younger age (P = 0.006), a shorter DtE (P = 0.04), a lower SFSI (P < 0.01), a worse NYHA class (P < 0.001) and more frequently had a history of hypertension (P < 0.0001). The same variables were significant predictors of improvement at the univariate analysis. At the multivariate logistic regression analysis, a shorter duration of symptoms (P = 0.02), a history of hypertension (P = 0.003), and a worse NYHA class (P = 0.01) were independent predictors of improvement. A relatively large percentage of patients with an idiopathic DCM will have a marked improvement in the LV systolic function. This is more likely to happen in the presence of a short duration of symptoms and a history of hypertension. After an improvement, the prognosis is excellent.

Key Words: Idiopathic cardiomyopathy • Spontaneous improvement • Left ventricular function

Received July 20, 2000; Revised October 20, 2000; Accepted November 30, 2000


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 Acknowledgments
 References
 
Heart failure due to dilated cardiomyopathy (DCM) is a frequent syndrome with an overall dismal prognosis, but many authors have reported a variable prevalence of patients with a marked improvement in the left ventricular (LV) systolic function; these patients have an excellent outcome [1]. As heart transplantation is greatly limited through a shortage of organ donors, an accurate characterisation of predictors of recovery is needed for a better selection of heart recipients.

A relevant frequency of improvement in patients with recent onset DCM has been reported [1–3], but these studies included patients with acute myocarditis and other possible causes of DCM, such as antecedent viral syndromes, peripartum cardiomyopathies, or heavy alcohol use. In these conditions, the mechanisms underlying heart disease might differ from those of idiopathic DCM; moreover, the likelihood of reversibility of LV dysfunction is apparently higher in secondary forms of DCM. Based on these considerations, in our opinion, it is essential to distinguish between ‘classic’ idiopathic DCM and other cardiomyopathies in which it is possible to address an associated condition as the cause of heart disease.

Unfortunately, only a few reports were focused on ‘classic’ idiopathic DCM, and were unable to draw any conclusion because of the low number of patients studied and the short follow-up period. Therefore, the frequency of improvement in LV function in idiopathic DCM is far from being clearly established. Furthermore, in this group of patients, no clear clinical and echocardiographic predictors of reversibility of the LV dysfunction have been identified.

In the present study, we aimed to determine the frequency and outcome of improvement in LV dysfunction in a large population of patients with idiopathic DCM, and to assess whether there are any simple clinical parameters associated with improvement in LV systolic function and clinical conditions.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 5. Conclusions
 Acknowledgments
 References
 
2.1. Study population
We retrospectively evaluated 98 consecutive patients with primary DCM seen at the outpatient heart failure clinic of our Institution, between January 1993 and December 1998. The diagnosis of heart failure due to DCM was made in the presence of symptoms of exertional dyspnoea or fatigue, and evidence of a severely impaired LV systolic function and LV dilation, as assessed by echocardiography. The diagnosis of idiopathic DCM was made in the absence of significant coronary artery disease or inducible ischaemia, of primary restrictive, hypertrophic, valvular, chemotherapy-induced cardiomyopathy, recent viral syndromes, heavy alcohol use or peripartum cardiomyopathies. Eight patients with a recent episode of supraventricular tachycardia or paroxysmal atrial fibrillation were also excluded from the study, because of the well-known relation of these arrhythmias to transient LV systolic dysfunction [4–7]. Patients in whom a history of hypertension or diabetes was documented in the medical records were included in the study, because in an individual patient, it is often unclear whether these risk factors cause or are unrelated to the development of cardiomyopathy [3].

The medical records of patients identified as having idiopathic DCM were reviewed to confirm the clinical features, the duration of symptoms, the absence of excluding criteria, the drug treatment and the dose at the time of beginning the follow-up. Patients had subsequent follow-up visits at intervals of 1 week to 3 months, according to the severity of heart failure.

2.2. Echocardiography
Echocardiographic parameters to assess the severity of LV systolic and diastolic dysfunction were directly taken from the routine echo-reports. Complete M-mode, two-dimensional and colour Doppler echocardiograms were performed in every patient in the left lateral position. Toshiba SSH 140 units with 2.5- and 3.75-MHz transducers were used. LV end-diastolic and end-systolic diameters (LVEDD and LVESD), wall thickness and left atrial diameter (LAD) were measured by M-mode echocardiography from the parasternal long-axis view, as recommended by the American Society of Echocardiography [8]. LV systolic dysfunction was semiquantitatively assessed using a systolic function score index (SFSI), grading from severely reduced (grade 1), moderately to severely reduced (grade 2), moderately reduced (grade 3), mildly to moderately reduced (grade 4), mildly reduced (grade 5), borderline (grade 6) and normal (grade 7). An inclusion criterion for the study was a SFSI≤3. The reproducibility between observers of the evaluation of the SFSI was assessed by duplicate reading of 46 examinations by two experienced echocardiographers (G.G. and A.R.).

Mitral flow velocities were recorded using an apical four-chamber view; a 0.5–1.0 com pulsed-wave Doppler sample volume was placed between the tips of the mitral leaflets, where the maximal flow velocity was recorded. E and A wave velocities (Emax and Amax) and their ratio (E/A) were measured. Deceleration time of the E wave (DtE) was measured as the interval (in ms) from the peak early mitral filling to an extrapolation of the deceleration to 0 m/s.

2.3. Outcome
The clinical end-points considered were cardiac transplantation and death. All patients were followed for at least 12 months, or until cardiac transplantation or death. The date of the last follow-up corresponded to the date of the last visit performed in our centre. Patients who survived without cardiac transplantation were considered to have an improvement (group 1) if they had an increase in the SFSI≥3 grades, reaching a final SFSI≥4; the remaining patients were considered without improvement (group 2).

2.4. Statistical analysis
Results are expressed as mean value±standard deviation (S.D.). Variables with a non-normal distribution are expressed as a median value and interquartile range. Differences between the average values of the two groups were compared using the Student's t-test for unpaired data, or non-parametric Wilcoxon rank–sum test. Differences within the group, from baseline to follow-up parameters, were compared using a t-test for paired data. The reproducibility between observers of the evaluation of the SFSI was assessed by Cohen's kappa statistic. A P value lower than 0.05 was considered as being statistically significant.

To assess the relative influence of clinical and echocardiographic parameters on the probability of improvement in the LV systolic function, an univariate logistic regression analysis was performed. Several models of multivariate regression analysis were performed, by combining significant univariate predictors. Survival curves of the two groups were calculated based on the method described by Kaplan and Meier [9] and compared by using the log-rank test.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 5. Conclusions
 Acknowledgments
 References
 
Baseline clinical and echocardiographic characteristics of the study patients, divided into the two groups according to our definition of improvement, are summarised in Table 1. Criteria for improvement were met in 19 patients (19%). The median follow-up period was 37 months for the whole population, 38.9 months for group 1 and 36.3 months for group 2 patients.


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  		Table 1 Baseline characteristics of 98 patients with idiopathic DCMa

 
3.1. Clinical characteristics
The median New York Heart Association (NYHA) functional class at the beginning of the follow-up was significantly higher in group 1 patients compared with group 2 (3.0 vs. 2.0, P=0.0003). Patients in group 1 were younger than those in group 2 (53.1±8.9 vs. 60±9.7, P=0.006). Patients with an improvement in the LV function during follow-up also had a shorter duration of symptoms (2.4±2.6 vs. 19.9±26.1 months, P=0.0045) and more frequently had a history of hypertension (P<0.0001). Of the patients in group 2, 10 (13%) were in chronic atrial fibrillation; every patient in group 1 was in sinus rhythm. There was no statistically significant difference in the frequency of improvement between women and men and between diabetic vs. non-diabetic patients. The frequency of use and dosage of β-blockers, ACE inhibitors, digoxin and diuretics was comparable in the two groups of patients. The proportion of patients who did not have a coronary angiography in the two groups was 45% in group 1 and 68% in group 2.

3.2. Echocardiography
Baseline echocardiographic parameters of patient population divided into the two groups are summarised in Table 1. Mean LVEDD, LVESD and LAD did not differ between the two groups at the beginning of the follow-up; baseline SFSI was significantly lower in group 1 compared to group 2 (1.3±0.6 vs. 1.9±0.7, P<0.01). Mean SFSI at the end of the follow-up of group 1 patients was 6.16±0.96 (P<0.0001 vs. baseline), while in group 2 patients there was a worsening to 1.7±0.42 (P<0.05 vs. baseline). LAD in group 1 showed a significant reduction at the end of the follow-up (38.5±5.22 vs. 46.5±4.39, P<0.0001), while the follow-up LAD in group 2 did not significantly change from baseline (45.3±8.5 vs. 44.9±7.25, NS). Among the mitral-flow Doppler parameters, only DtE was significantly shorter in group 1 compared to group 2 (182.7±44.14 vs. 240.48±95.5, P=0.04), while Emax, Amax and the E/A ratio did not reach a statistically significant difference. The rate of agreement between observers in the duplicate assessment of the SFSI was statistically significant ({kappa}=0.74, P<0.001).

3.3. Predictors of improvement
On univariate analysis (Table 2), improvement in LV systolic function was associated with a shorter duration of symptoms before evaluation (P<0.0001; OR: 0.16, 95% CI: 0.05–0.48), a history of hypertension (P<0.0001; OR: 6.75, 95% CI: 2.2–19.9), a worse NYHA class (P<0.0001; OR: 3.16, 95% CI: 1.71–5.82), a younger age (P=0.01; OR: 0.93, 95% CI: 0.88–0.98), a lower baseline SFSI (P=0.008; OR: 0.3, 95% CI: 0.13–0.73), and a shorter DtE (P=0.05; OR: 0.98, 95% CI: 0.97–1.00). LV dimensions, wall thickness and LAD on M-mode, Emax, Amax and E/A ratio did not predict improvement in the LV function.


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  		Table 2 Predictors of improvement of left ventricular function (univariate analysis)

 
The results of multivariate analysis models are listed in Table 3. A shorter duration of symptoms (P=0.02, OR: 0.1, 95% CI: 0.14–0.75), a history of hypertension (P=0.003; OR: 27.8, 95% CI: 2.88–219.37) and NYHA class (P=0.01; OR: 6.2, 95% CI: 1.55–25.08) were independent predictors of improvement. Age and baseline SFSI reached only borderline significance. Hypertension had a high sensitivity (94.7%) [10] but a poor specificity (44.3%) in predicting an improvement in the LV function; a symptom duration <6 months had a 73.7% sensitivity and a 79.7% specificity. The positive predictive values were low, both for hypertension (46.7%) and for symptom duration <6 months (29%), but the negative predictive values were high, both for hypertension (92.6%) and for symptom duration <6 months (97.2%).


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  		Table 3 Predictors of improvement of left ventricular function (multivariate analyses)

 
3.4. Outcome
During the follow-up, 18 patients in group 2 (23%) died and 3 (4%) underwent heart transplantation. All patients with improvement survived without heart transplantation at the end of the follow-up. Fig. 1 describes the Kaplan–Meier survival curves of the two groups of patients that were significantly different (P=0.02) at the log-rank test.


Figure 1
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  		Fig. 1 Kaplan–Meier survival curves of group 1 vs. group 2 patients (group 1=improvement; group 2=without improvement); the survival probability was significantly different (P=0.02) at the log-rank test.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
5. Conclusions
 Acknowledgments
 References
 
In the present study, we describe the frequency of a spontaneous improvement in the LV systolic function in patients with ‘classic’ idiopathic DCM in a large, consecutive, unselected population. We were able to identify some simple predictors of improvement among clinical parameters routinely assessed in everyday clinical practice.

In our population, 19% of patients had a relevant improvement in the LV systolic function. A history of hypertension and a recent onset of the symptoms were the strongest predictors of a reversibility of the LV systolic dysfunction. The prognosis was excellent in the group of patients who showed improvement, with 100% survival at the end of the follow-up without heart transplantation.

4.1. Frequency of improvement in idiopathic DCM: comparison with previous studies
It has been reported that a spontaneous improvement in the LV function can be observed in up to 27–50% [1–3] of patients with DCM, but very often these studies also included patients with DCM of known aetiology, such as peripartum cardiomyopathy, alcohol abuse, or even ischaemic heart disease, or had very small sample size [11–14]. It is well known that the mechanisms underlying heart disease in those conditions are different from the idiopathic DCM; similarly, the likelihood of improvement seems to be quite high in secondary forms of DCM. In fact, it has been reported that in peripartum cardiomyopathy, the prevalence of spontaneous improvement can be up to 52% [15–17]. Alcohol abuse has also been recognised as a risk factor for the development of DCM [17], and an improvement in the LV function has been frequently observed in patients who reduce alcohol intake or abstain [18–20]; the disease progression has been reported to be significantly worse in patients with idiopathic DCM compared to heart failure due to excessive alcohol intake [21]. Another recognised cause of transient LV dysfunction is supraventricular arrhythmia [4–7]; this phenomenon is associated with a complete normalisation of the LV contractility after restoring the sinus rhythm.

In an attempt to describe the frequency of improvement in the LV function in DCM, it is essential to distinguish between the above-mentioned conditions and other forms of DCM, in which an apparent cause cannot be recognised. Therefore, in the present study, we excluded all the conditions known to cause DCM.

4.2. Clinical predictors of reversibility of LV dysfunction
In our study, we identified simple and non-invasive predictors of improvement, among those routinely used in everyday clinical practice. A short duration of symptoms, a history of hypertension, and a poor functional status (as expressed by NYHA functional class) were independent predictors of improvement in our population. At the univariate analysis, a young age and a short DtE also predicted an improvement.

The contractile reserve has been suggested as a predictor of improvement [13], but this hypothesis has only been tested on a small group of patients with a recent onset of the disease. Moreover, although the average EF during dobutamine infusion was higher in patients with subsequent recovery, the individual values widely overlapped, thus limiting the prognostic value in the single patient.

Similarly, the myocardial glucose utilisation rate, as assessed by PET, was used to predict improvement in the LV function in a small number of patients with DCM [22]. Despite the high sensitivity and specificity of this technique, it is unfortunately not widely available and therefore it cannot be proposed as a routine investigation in order to stratify patients. In a previous study [1], symptom duration, higher serum sodium, lower pulmonary capillary wedge and right atrial pressures were independent predictors of improvement, but this study also included only patients with recent-onset DCM.

Figulla et al. [12] reported the usefulness of the pathological examination in predicting improvement in the LV function in patients with DCM, but the myocardial biopsy is an invasive and risky procedure and the tissue specimens are too small to predict an improvement in the function of the entire LV. On the other hand, there is also evidence that an endomyocardial biopsy is of limited prognostic value in the routine evaluation of DCM [23]; therefore, other clinical and non-invasive haemodynamic parameters should be considered when assessing patient risk and management strategies.

In our study, a history of hypertension and a recent onset of symptoms appear to be an important key in predicting which patients might improve. Patients with a symptom duration <6 months and a history of hypertension have a high probability of improving; on the contrary, the likelihood of improvement is very low in patients with a symptom duration >6 months or without a history of hypertension, with a negative predictive value of 97.2 and 92.6%, respectively.

4.3. Role of echocardiography in predicting improvement
Among the echocardiographic parameters, we found that at the univariate analysis, a short DtE was a predictor of improvement in the LV function. This observation is apparently in contrast with reports of previous studies, which clearly evidenced that a short DtE is associated with a poor prognosis in patients with DCM [24–26]. A possible explanation for this contrasting observation can be found if we look at the history of the patients who improved in our study: the increased operative LV stiffness might represent the shift of the pressure–volume relation on a steeper portion of the curve due to recent LV dilation, more than an increased muscular stiffness due to histological changes which can only be induced over time. The clinical implications of this finding are relevant, because despite the well known association of a short DtE with a bad prognosis, in a subgroup of patients, a short DtE might simply reflect the shorter duration of the disease, and these patients are the ones who are more likely to improve and have a more favourable outcome.

In a recently published paper, Pinamonti and colleagues [27] reported that among patients with a DCM, severe diastolic abnormalities and a poor functional status, a subgroup had subsequent improvement in LV systolic function. This observation is consistent with our data. In their study, the patients who improved had a higher frequency of associated hypertension compared to the patients who did not improve; the two groups had otherwise similar characteristics concerning other clinical, echocardiographic and haemodynamic invasive data, but the duration of the disease had not been considered. We might therefore hypothesise that the clinical and echocardiographic presentation of a recent-onset DCM, which is likely to improve, may seem like a severe, end-stage heart failure, and the only difference between the two situations is the duration of the disease and the presence of hypertension.

4.4. Study limitations
This study has the typical limitations of a retrospective study, so the number of variables it could accurately screen for predictive value was necessarily limited. Nevertheless, we were able to identify a few clinical parameters as significant predictors of improvement in the LV systolic function.

We cannot rule out the possibility of a late deterioration of the LV systolic function in patients with improvement, although we were unable to observe this event. In fact, none of the 19 patients who showed improvement had a subsequent worsening of the clinical conditions and the LV function at echocardiography, after a long period of follow-up. We cannot draw any conclusion concerning the influence of different drug therapy on the improvement, considering the relatively small number of patients in each group, although the frequency and dose of ACE inhibitors and beta-blockers were similar in the two groups. A prospective study in a larger, selected population is needed to rule out the influence of different treatments on the likelihood of improvement.


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
Acknowledgments
 References
 
A relatively large number of patients with idiopathic DCM may show a significant improvement in the LV systolic function shortly after the onset of symptoms and the prognosis is excellent after recovery of the LV function. The improvement is very unlikely to occur in patients with a symptom duration >6 months and without a history of hypertension; it can thus be suggested that a heart transplantation could be considered earlier in these patients.

According to previous reports, the frequency of improvement seems to be higher in patients with DCM secondary to other diseases, compared to those with ‘classic’ idiopathic DCM; therefore, an attempt to recognise a possible etiological factor should always be made in every single patient with a clinical picture of heart failure and DCM, in order to avoid fatal mistakes in selecting patients for cardiac transplantation.


   Acknowledgments
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 Acknowledgments
References
 
The Authors wish to thank Ms Barbara Lyon for reviewing the manuscript.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 Acknowledgments
 References
 

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