The Role of CMRI in the Assessment and Prognosis of Stable CAD
A 63-year-old female patient presented to the outpatient cardiovascular clinic for evaluation of a 4-month history of exertional chest pain. She described the chest pain as a moderate-intensity, intermittent chest discomfort that occurs with exertion and resolves with rest or use of sublingual nitroglycerin. Her medical history was significant for hypertension and dyslipidemia. On examination, her blood pressure was 132/68 mmHg, and her heart rate was 65 bpm. Her lipid profile showed low-density lipoprotein of 84 mg/dL, high-density lipoprotein of 43 mg/dL, and triglyceride of 103 mg/dL. Her medication regimen included 81 mg of aspirin daily, nitroglycerin, and 20 mg of atorvastatin daily. Based on her symptoms, she underwent a coronary angiogram several weeks ago, which showed mild-to-moderate diffuse, nonobstructive coronary artery disease (CAD).
Due to the concern for microvascular dysfunction, an adenosine stress cardiac magnetic resonance imaging (CMRI) test was ordered. The CMRI showed that her left ventricular size and systolic function were normal with a left ventricular ejection fraction (LVEF) of 68%. There was mild tricuspid regurgitation, moderate aortic stenosis with peak aortic valve velocity of 2.4 ms, and mild aortic regurgitation. First-pass stress perfusion imaging showed diffuse, circumferentially abnormal subendocardial perfusion prominent at the base and consistent with microvascular dysfunction. No wall motion abnormalities were detected. No significant scar/fibrosis was detected on late postgadolinium enhancement imaging (Figure 1 and Videos 1-6). Her CMRI appeared to be consistent with microvascular dysfunction.
Video 1: Rest perfusion image of apical left anterior descending (LAD).
Video 2: Rest perfusion image of mid-LAD with diffuse subendocardial perfusion abnormality.
Video 3: Rest perfusion image of basal LAD with diffuse subendocardial perfusion abnormality.
Video 4: Stress perfusion image of apical LAD.
Video 5: Stress perfusion image of mid-LAD with diffuse subendocardial perfusion abnormality.
Video 6: Stress perfusion image of basal LAD with diffuse subendocardial perfusion abnormality.
What is your opinion regarding her long-term CAD prognosis given the abnormal CMRI perfusion results?