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Cardiac MR Stress Perfusion for Evaluating Chest Pain Patients
Study Questions:
What is the prognostic value of vasodilator stress perfusion cardiac magnetic resonance imaging (CMR) in patients with stable chest pain?
Methods:
The authors conducted a retrospective pooled cohort from 13 US centers sponsored by the Society of Cardiovascular Magnetic Resonance Imaging. Inclusion criteria were patients aged 35-85 years with clinical symptoms suggestive of myocardial ischemia and two coronary risk factors. Patients with prior coronary artery bypass grafting and recent myocardial infarction, severe valvular disease, nonischemic cardiomyopathy, infiltrative or hypertrophic cardiomyopathy, constrictive pericarditis, pregnancy, or limited expected survival were excluded. Vasodilation was affected with adenosine, regadenoson, or dipyridamole. The primary outcome was cardiovascular death or nonfatal myocardial infarction. The secondary outcome of major adverse cardiac events included cardiovascular death, myocardial infarction, hospitalization for angina or congestive heart failure, and late coronary bypass surgery (>6 months after index scan).
Results:
Overall, 2,370 patients qualified, although 21 were subsequently excluded for incomplete images. Of the final cohort of 2,349, 766 had evidence of ischemia or late gadolinium enhancement (LGE) indicating scar or fibrosis. Median follow-up was 5.4 years (interquartile range, 4.6-6.8) with successful follow-up in 97.7% of subjects. Overall, the primary outcome occurred in 153 patients. Patients without ischemia or LGE experienced cardiovascular death or myocardial infarction at an average of only 0.6% per patient-year, while those with both LGE and ischemia experienced this endpoint at 4.5% per patient-year. Event rates progressively rose with increasing amounts of ischemia with those with no, mild, moderate, and severe ischemia having event rates of 0.9%, 2.9%, 2.9%, and 3.1% per patient-year. In fully adjusted analyses, the presence of ischemia was associated with a hazard ratio of 1.96 for the primary endpoint, while the hazard ratio for LGE was 1.64 (both p < 0.05). Coronary angiography was the major driver of downstream costs in patients with ischemia, and downstream costs were low in patients without ischemia.
Conclusions:
The authors concluded that stress CMR offers excellent prognostic value and is associated with low downstream resource utilization in patients without ischemia.
Perspective:
These real-world multicenter data add to multiple prospective trials demonstrating the accuracy and clinical value of stress CMR, most notably the CE-MARC trial. This study demonstrates that accurate stress CMR can be performed reliably in a wide variety of practice settings and that normal stress CMR without ischemia or LGE can be relied upon to assure patients and clinicians of a low downstream event rate. Furthermore, downstream resource utilization was low in patients without ischemia, suggesting that clinical confidence is high.
Clinical Topics: Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Statins, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Magnetic Resonance Imaging, Nuclear Imaging
Keywords: Adenosine, Angina Pectoris, Coronary Angiography, Coronary Artery Disease, Diagnostic Imaging, Dipyridamole, Gadolinium, Heart Failure, Magnetic Resonance Imaging, Magnetic Resonance Spectroscopy, Myocardial Infarction, Myocardial Ischemia, Perfusion Imaging, Risk Factors, Vasodilation, Vasodilator Agents
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