Dual Cardiomyopathy in Patients With Coronary Artery Disease

We have dozens of randomized clinical trials that concluded there aren’t tangible prognostic benefits from coronary revascularization in some patients with single or multi-vessel coronary artery disease who are suffering from cardiomyopathy. Such lack of benefit may be explained by non-explored presence of co-incidental non-ischemic cardiomyopathy. Thus, the same patient may have both ischaemic and non-ischaemic aetiologies of cardiomyopathy simultaneously.

Dual cardiomyopathy, is not very uncommon, and it comprises more than one form of myocardial dysfunction causing complex diagnostic and therapeutic challenges

In a registry published in 2023 in Circulation, among more than 3000 patients with coronary artery disease who underwent contrast-enhanced cardiac MRI for the assessment of ventricular function and scarring, 7.7% had dual cardiomyopathy, with evidence of both ischemic and non-ischaemic cardiomyopathy at the same time, and strikingly 9.3% of the population showed only the pattern of non-ischameic cardiomyopathy with no evidence of the specific ischaemic injury.

So, Cardiac MRI may play a pivotal role in distinguishing  pure ischaemic cardiomyopathy from dual cardiomyopathy via the pattern of late gadolinium enhancement, perfusion and tissue characterization . Furthermore, stress TC99 imaging may be beneficial in this context by quantification of ischaemic burden and matching it with the anatomy.

Practical application 

Don’t rush to PCI in patients with cardiomyopathy  -who are not suffering from acute coronary syndrome or typical anginal pain – when the severity of lesions don’t explain the occurrence of cardiomyopathy. CMR or stress TC99 MPI scan (for ischaemic burden) may be beneficial in this situation to exclude dual cardiomyopathy and non-ischaemic cardiomyopathy, as these patients won’t tremendously benefit clinically from PCI.

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