Prognostic Value of Angiography-Derived Microcirculatory Resistance and Vericiguat Therapy in Dilated Cardiomyopathy With Reduced Ejection Fraction

BACKGROUND: Coronary microvascular dysfunction (CMD) is associated with poor prognosis in patients with dilated cardiomyopathy with reduced ejection fraction (DCMrEF). However, its assessment remains challenging in routine clinical practice. This study aimed to explore the potential value of angiography-derived microcirculatory resistance (AMR) in predicting clinical outcomes in DCMrEF patients. METHODS: This multicentre retrospective study included DCMrEF patients (2019-2024) with a 5-year major adverse cardiovascular events (MACE) end point. AMR was calculated for all major arteries. Its prognostic value was assessed by means of Kaplan-Meier analysis and multivariate Cox regression. A subgroup analysis was conducted to evaluate the impact of vericiguat treatment on clinical outcomes according to patients' baseline AMR levels. RESULTS: A total of 531 eligible patients with DCMrEF were enrolled in the study, 204 of whom had end point events. The optimal AMR cutoffs were > 2.295 for the left anterior descending coronary artery (LAD); area under the receiver operating characteristic curve 0.776) and left circumflex artery (AUC 0.761), and > 2.5 for the right coronary artery (AUC 0.745), all with P < 0.001. Patients were then classified into the higher AMR group and the lower AMR group. Kaplan-Meier and multivariate Cox analyses confirmed that higher AMR was independently associated with increased MACE risk. LAD-AMR significantly improved risk reclassification over traditional factors (net reclassification improvement 0.015, integrated discrimination improvement 0.051, both P < 0.001). Subgroup analysis revealed vericiguat benefitted only patients with elevated AMR. CONCLUSIONS: AMR may be a powerful independent predictor of poor prognosis in DCMrEF patients, with LAD-AMR showing potential for greater predictive value. Vericiguat may represent a potential precision-targeted agent for the high risk of heart failure mediated by microcirculatory dysfunction.