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Stress CMR and Mortality in Stable Ischemic Heart Disease
Quick Takes
- Among patients with known or suspected SIHD who underwent vasodilator stress CMR, a larger ischemic burden was associated with a higher risk of long-term, all-cause mortality.
- Only patients with an extensive ischemic burden (>5 segments out of 17) seemed to benefit from revascularization in terms of risk reduction for all-cause mortality.
- Revascularization should be considered in patients with SIHD after an individualized evaluation of symptoms, ischemia, and anatomy primarily in patients with extensive stress-induced ischemia.
Study Questions:
What is the association of ischemic burden, as measured by vasodilator stress cardiovascular magnetic resonance (CMR), with all-cause mortality and the effect of revascularization on all-cause mortality in patients with stable ischemic heart disease (SIHD)?
Methods:
The investigators used a large registry that included all consecutive patients who underwent vasodilator stress CMR for known or suspected SIHD in their health department from 2001 to 2016. The registry dataset consisted of 6,389 consecutive patients (mean age, 65 ± 12 years; 38% women) who underwent vasodilator stress CMR for known or suspected SIHD. The ischemic burden (at stress first-pass perfusion imaging) was computed (17-segment model). The effect of CMR-related revascularization (within the following 3 months) on all-cause mortality was retrospectively explored using the electronic regional health system registry. To minimize a potential selection bias, the effect of CMR-related revascularization on all-cause mortality was specifically addressed in a 1:1 (with CMR-related revascularization vs. without CMR-related revascularization) propensity score−matched population.
Results:
During a 5.75-year median follow-up, 717 (11%) deaths were documented. In multivariable analyses, more extensive ischemic burden (per 1-segment increase) was independently related to all-cause mortality (hazard ratio, 1.04; 95% confidence interval, 1.02-1.07; p < 0.001). In 1,032 1:1 matched patients using a limited number of variables (516 revascularized, 516 nonrevascularized), revascularization within the following 3 months was associated with less all-cause mortality only in patients with extensive CMR-related ischemia (>5 segments, n = 432; 10% vs. 24%; p = 0.01).
Conclusions:
The authors concluded that in a large retrospective registry of unselected patients with known or suspected SIHD who underwent vasodilator stress CMR, extensive ischemic burden was related to a higher risk of long-term, all-cause mortality.
Perspective:
This study reports that in patients with known or suspected SIHD who underwent vasodilator stress CMR, a larger ischemic burden was associated with a higher risk of long-term, all-cause mortality. An exploratory analysis suggested that only patients with an extensive ischemic burden (>5 segments out of 17) benefitted from revascularization in terms of reduction of all-cause mortality. These data support current guidelines that recommend revascularization after an individualized evaluation of symptoms, ischemia, and anatomy primarily in patients with extensive stress-induced ischemia. Furthermore, available data suggest that invasive management should be reserved for patients at the highest risk because overuse of these resources could potentially exert detrimental effects in low-risk patients with SIHD.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Cardiac Surgery and Arrhythmias, Interventions and Imaging, Magnetic Resonance Imaging, Nuclear Imaging
Keywords: Cardiac Surgical Procedures, Cardiology Interventions, Diagnostic Imaging, Magnetic Resonance Imaging, Myocardial Perfusion Imaging, Myocardial Ischemia, Myocardial Revascularization, Risk Reduction Behavior, Secondary Prevention, Vasodilator Agents
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