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Comparison of Cardiovascular Magnetic Resonance and Single-Photon Emission Computed Tomography in Women With Suspected Coronary Artery Disease From the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease (CE-MARC) Trial
Study Questions:
How does gender impact the diagnostic accuracy of cardiac magnetic resonance (CMR) imaging and single-photon emission computed tomography (SPECT) to identify coronary artery disease (CAD)?
Methods:
This study evaluated 235 women and 393 men with suspected angina and at least one cardiovascular risk factor who underwent CMR, SPECT, and invasive coronary angiography (ICA), and compared the diagnostic performance of CMR and SPECT stratified by gender, as compared to ICA as a reference standard. A positive CMR was defined as abnormal adenosine stress/rest perfusion, any regional wall motion abnormalities, an obstructive stenosis by angiography, or an infarct using late gadolinium enhancement. A positive SPECT included evidence of a perfusion defect, regional wall motion abnormalities, or other ancillary findings.
Results:
With CMR, there were no differences between women and men in regards to sensitivity (88.7% vs. 85.6%; p = 0.57) or specificity (83.5% vs. 82.8%; p = 0.86). Using SPECT, there was reduced sensitivity in women versus men (50.9% vs. 70.8%; p = 0.007), but no difference in specificity (84.1% vs. 81.3%; p = 0.48). CMR resulted in higher sensitivity than SPECT in both genders (p < 0.001 for each), with no difference between CMR and SPECT in regards to specificity in women (p = 0.77) or men (p = 1.0). The relative sensitivity of SPECT and CMR to detect single-vessel CAD was 48.6% and 85.7% in females and 65.6% and 77.1% in males. The sensitivity of SPECT and CMR to identify multivessel CAD was 55.6% and 94.4% in females and 75.8% and 93.9% in males, respectively. In an analysis limited to detection of perfusion abnormalities, the area under the receiver-operating characteristic curves was higher with CMR as compared to SPECT for both men (0.89 vs. 0.74, p < 0.001) and women (0.90 vs. 0.67, p < 0.001); there was no difference in the area under the curves by gender with CMR (p = 1.0), although a significant difference was observed with SPECT (p < 0.001).
Conclusions:
The sensitivity of CMR is higher than SPECT for both genders, with no difference in specificity. The diagnostic performance of CMR is similar between genders, while SPECT is associated with reduced sensitivity in women.
Perspective:
This single-center study finds that CMR results in higher sensitivity in both men and women as compared to SPECT, and observes that women are particularly susceptible to reduced sensitivity when imaged with SPECT, with no differences observed between genders using CMR. It must be noted that this study utilized SPECT without attenuation correction, which is now recommended in societal guidelines. Attenuation correction has been demonstrated to improve the diagnostic accuracy of SPECT largely by improving specificity, and whether the use of this technology would have significantly altered these results is unknown. Nevertheless, these results suggest that CMR may be a reasonable option in both genders (but particularly women) with suspected angina, especially at sites without available attenuation correction for SPECT. The lack of widespread availability and expertise in stress CMR remain potential barriers, as well as challenges in performing exercise stress CMR, which has advantages over pharmacologic stress testing. Future multicenter studies that incorporate newer technologies and examine the cost-effectiveness of CMR versus SPECT may be useful.
Keywords: Coronary Artery Disease, Tomography, Emission-Computed, Single-Photon, Risk Factors, Constriction, Pathologic, Magnetic Resonance Spectroscopy, Magnetic Resonance Imaging, Exercise Test
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