Both myocardial ECV and the Fibrosis-4 index independently predict adverse cardiovascular outcomes in HFpEF; although ECV provides greater prognostic discrimination, combined assessment identifies a subgroup at particularly high risk and may provide complementary information for risk stratification.
About 30% of patients with HFpEF experienced the composite primary outcome of cardiovascular death or heart failure hospitalization during follow-up.
Myocardial ECV measured by cardiac magnetic resonance independently predicted the primary outcome in multivariable Cox regression.
The Fibrosis-4 index, a marker of hepatic fibrosis, independently predicted the primary outcome in HFpEF.
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 showed superior discrimination compared with Fibrosis-4-based models.
Adding ECV to the Fibrosis-4 model significantly improved discrimination.
Adding the Fibrosis-4 index to the ECV model improved reclassification but not discrimination.
The authors conclude that combined ECV and Fibrosis-4 assessment may provide complementary information for risk stratification in HFpEF, even though ECV has greater discrimination.
This study followed 250 people with heart failure with preserved ejection fraction (HFpEF), a form of heart failure in which the heart pumps normally but is stiff, for a median of about 3.3 years. Researchers measured scarring in the heart muscle using cardiac MRI (extracellular volume, or ECV) and estimated liver scarring using a blood-test-based score called the Fibrosis-4 index. About 30% of patients died of cardiovascular causes or were hospitalized for heart failure. Both markers independently predicted these bad outcomes, even after accounting for other factors. Patients with high values of both had a markedly higher risk than those with low values of both. The heart MRI measure was better at distinguishing who would and would not have events than the liver score. Adding the liver score to the heart MRI measure did not significantly improve this discrimination, though it did improve how patients were reclassified into risk categories. This research suggests that HFpEF affects more than the heart and that liver fibrosis markers may add information about risk. The Fibrosis-4 index is cheap and uses routine blood tests, while ECV requires a specialized MRI. The study is observational and from a limited group of patients, so it shows association rather than proving that testing or treating these markers improves outcomes.
Huang C, Lin Y, Lin T, Wu C, Wang Y, Lin L. (2026). 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.. Journal of the American Heart Association. https://doi.org/10.1161/JAHA.126.053485