Myocardial Iodine-123 Meta-Iodobenzylguanidine Imaging and Cardiac Events in Heart Failure. Results of the Prospective ADMIRE-HF (AdreView Myocardial Imaging for Risk Evaluation in Heart Failure) Study

Objectives: The ADMIRE-HF (AdreView Myocardial Imaging for Risk Evaluation in Heart Failure) study prospectively evaluated iodine-123 meta-iodobenzylguanidine (¹²³I-mIBG) imaging for identifying symptomatic heart failure (HF) patients most likely to experience cardiac events. Background: Single-center studies have demonstrated the poorer prognosis of HF patients with reduced ¹²³I-mIBG myocardial uptake, but these observations have not been validated in large multicenter trials. Methods: A total of 961 subjects with New York Heart Association (NYHA) functional class II/III HF and left ventricular ejection fraction (LVEF) ≤35% were studied. Subjects underwent ¹²³I-mIBG myocardial imaging (sympathetic neuronal integrity quantified as the heart/mediastinum uptake ratio [H/M] on 4-h delayed planar images) and myocardial perfusion imaging and were then followed up for up to 2 years. Time to first occurrence of NYHA functional class progression, potentially life-threatening arrhythmic event, or cardiac death was compared with H/M (either in relation to estimated lower limit of normal [1.60] or as a continuous variable) using Cox proportional hazards regression. Multivariable analyses using clinical, laboratory, and imaging data were also performed. Results: A total of 237 subjects (25%) experienced events (median follow-up 17 months). The hazard ratio for H/M ≥1.60 was 0.40 (p < 0.001); the hazard ratio for continuous H/M was 0.22 (p < 0.001). Two-year event rate was 15% for H/M ≥1.60 and 37% for H/M <1.60; hazard ratios for individual event categories were as follows: HF progression, 0.49 (p = 0.002); arrhythmic events, 0.37 (p = 0.02); and cardiac death, 0.14 (p = 0.006). Significant contributors to the multivariable model were H/M, LVEF, B-type natriuretic peptide, and NYHA functional class. ¹²³I-mIBG imaging also provided additional discrimination in analyses of interactions between B-type natriuretic peptide, LVEF, and H/M. Conclusions: ADMIRE-HF provides prospective validation of the independent prognostic value of ¹²³I-mIBG scintigraphy in assessment of patients with HF. (Meta-Iodobenzylguanidine Scintigraphy Imaging in Patients With Heart Failure and Control Subjects Without Cardiovascular Disease, NCT00126425; Meta-Iodobenzylguanidine [123I-mIBG] Scintigraphy Imaging in Patients With Heart Failure and Control Subjects Without Cardiovascular Disease, NCT00126438).