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Peer-reviewedCC BY-NC-NDJournal of the American Heart Association

Combined Prognostic Value of Cardiac Magnetic Resonance–Derived Myocardial Extracellular Volume and the Fibrosis‐4 Index in Patients With Heart Failure With Preserved Ejection Fraction

  • Chen‐Yu Huang1,2,3,4
  • Yen‐Liang Lin5
  • Ting‐Tse Lin4,6
  • Cho‐Kai Wu4,6
  • Yi‐Chih Wang4,6
  • Lian‐Yu Lin4,6
6 affiliations
  1. 1National Taiwan University
  2. 2National Tsing Hua University
  3. 3Cathay General Hospital
  4. 4National Taiwan University College of Medicine and Hospital
  5. 5National Taiwan University Hospital Hsinchu branch
  6. 6College of Medicine, National Taiwan University
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Abstract

Background Heart failure with preserved ejection fraction is increasingly recognized as a multisystem metabolic–inflammatory syndrome. We investigated the comparative and complementary prognostic value of cardiac magnetic resonance–derived extracellular volume fraction (ECV) and the Fibrosis‐4 index for predicting adverse cardiovascular outcomes in patients with heart failure with preserved ejection fraction. Methods Between 2017 and 2019, 250 patients with heart failure with preserved ejection fraction underwent assessment of myocardial ECV by cardiac magnetic resonance and hepatic fibrosis using the Fibrosis‐4 index. The primary outcome was a composite of cardiovascular death or heart failure hospitalization. Multivariable Cox regression and discrimination analyses were performed to evaluate prognostic performance. Results During a median follow‐up of 1190 days, 75 patients (30.0%) experienced the primary outcome. Both ECV (hazard ratio [HR], 1.13 [95% CI, 1.08–1.17]; P <0.001) and the Fibrosis‐4 index (HR, 1.12 [95% CI, 1.02–1.22]; P =0.015) independently predicted the primary outcome. Patients with concomitantly elevated ECV and Fibrosis‐4 index had a markedly increased risk of adverse events compared with those with low values of both markers. ECV‐based models demonstrated superior discrimination compared with Fibrosis‐4–based models (concordance index, 0.732 versus 0.663; P =0.011). Addition of ECV to the Fibrosis‐4 model significantly improved discrimination, whereas addition of the Fibrosis‐4 index to the ECV model improved reclassification (continuous net reclassification improvement and integrated discrimination improvement) but not discrimination. Conclusions Both myocardial ECV and the Fibrosis‐4 index independently predict adverse cardiovascular outcomes in heart failure with preserved ejection fraction. Although ECV provides greater prognostic discrimination, combined assessment of ECV and the Fibrosis‐4 index identifies a subgroup at particularly high risk and may provide complementary information for risk stratification.

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Cite

BibTeXRIS
BibTeX
@article{huang2026combined,
  title = {{Combined Prognostic Value of Cardiac Magnetic Resonance–Derived Myocardial Extracellular Volume and the Fibrosis‐4 Index in Patients With Heart Failure With Preserved Ejection Fraction}},
  author = {Chen‐Yu Huang and Yen‐Liang Lin and Ting‐Tse Lin and Cho‐Kai Wu and Yi‐Chih Wang and Lian‐Yu Lin},
  journal = {Journal of the American Heart Association},
  year = {2026},
  month = oct,
  doi = {10.1161/jaha.126.053485},
  url = {https://www.ahajournals.org/doi/10.1161/JAHA.126.053485},
  note = {CC BY-NC-ND},
}
RIS
TY  - JOUR
TI  - Combined Prognostic Value of Cardiac Magnetic Resonance–Derived Myocardial Extracellular Volume and the Fibrosis‐4 Index in Patients With Heart Failure With Preserved Ejection Fraction
AU  - Chen‐Yu Huang
AU  - Yen‐Liang Lin
AU  - Ting‐Tse Lin
AU  - Cho‐Kai Wu
AU  - Yi‐Chih Wang
AU  - Lian‐Yu Lin
PY  - 2026
DA  - 2026/10/23
JO  - Journal of the American Heart Association
DO  - 10.1161/jaha.126.053485
UR  - https://www.ahajournals.org/doi/10.1161/JAHA.126.053485
AB  - Background Heart failure with preserved ejection fraction is increasingly recognized as a multisystem metabolic–inflammatory syndrome. We investigated the comparative and complementary prognostic value of cardiac magnetic resonance–derived extracellular volume fraction (ECV) and the Fibrosis‐4 index for predicting adverse cardiovascular outcomes in patients with heart failure with preserved ejection fraction. Methods Between 2017 and 2019, 250 patients with heart failure with preserved ejection fraction underwent assessment of myocardial ECV by cardiac magnetic resonance and hepatic fibrosis using the Fibrosis‐4 index. The primary outcome was a composite of cardiovascular death or heart failure hospitalization. Multivariable Cox regression and discrimination analyses were performed to evaluate prognostic performance. Results During a median follow‐up of 1190 days, 75 patients (30.0%) experienced the primary outcome. Both ECV (hazard ratio [HR], 1.13 [95% CI, 1.08–1.17]; P <0.001) and the Fibrosis‐4 index (HR, 1.12 [95% CI, 1.02–1.22]; P =0.015) independently predicted the primary outcome. Patients with concomitantly elevated ECV and Fibrosis‐4 index had a markedly increased risk of adverse events compared with those with low values of both markers. ECV‐based models demonstrated superior discrimination compared with Fibrosis‐4–based models (concordance index, 0.732 versus 0.663; P =0.011). Addition of ECV to the Fibrosis‐4 model significantly improved discrimination, whereas addition of the Fibrosis‐4 index to the ECV model improved reclassification (continuous net reclassification improvement and integrated discrimination improvement) but not discrimination. Conclusions Both myocardial ECV and the Fibrosis‐4 index independently predict adverse cardiovascular outcomes in heart failure with preserved ejection fraction. Although ECV provides greater prognostic discrimination, combined assessment of ECV and the Fibrosis‐4 index identifies a subgroup at particularly high risk and may provide complementary information for risk stratification.
SN  - 2047-9980
ER  -