Myocardial Perfusion Reserve in Aortic Stenosis

Mar 13, 2017
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Authors:
Singh A, Greenwood JP, Berry C, et al.
Citation:
Comparison of Exercise Testing and CMR Measured Myocardial Perfusion Reserve for Predicting Outcome in Asymptomatic Aortic Stenosis: The PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) Study. Eur Heart J 2017;Feb 13:[Epub ahead of print].
Summary By:
Troy M LaBounty, MD, FACC

Study Questions:

Does myocardial perfusion reserve (MPR) by cardiac magnetic resonance (CMR) identify patients with moderate to severe aortic stenosis (AS) at risk of adverse cardiac events or valve replacement?

Methods:

PRIMID AS study investigators performed adenosine stress CMR, symptom-limited exercise tolerance testing (ETT), and echocardiography in 174 patients with moderate to severe asymptomatic AS, and compared MPR by CMR to ETT for prediction of adverse cardiac events (symptoms prompting referral for valve replacement, cardiovascular death, or hospitalization for heart failure, chest pain, syncope, or arrhythmia).

Results:

Median follow-up was 374 days. Events occurred in 47 subjects (27%); deaths occurred in two subjects, and the rest of the events were due to symptoms prompting referral for valve replacement. Both MPR (area under curve 0.61, p = 0.02) and ETT (area under curve 0.59, p = 0.03) had moderate association with events, with no statistically significant difference between these tests. For prediction of events, the sensitivity and specificity of MPR was 59% and 63%, while the sensitivity and specificity of ETT using conventional criteria was 46% and 73%, respectively.

Conclusions:

Both MPR measured by CMR and ETT have a moderate ability to identify patients with asymptomatic moderate to severe AS at risk of adverse events.

Perspective:

This multicenter study finds that MPR measured by CMR is not superior to ETT for identification of patients with moderate to severe AS at risk of developing symptoms prompting referral for valve replacement or other adverse events. Both tests had only a moderate ability to risk-stratify patients, suggesting that better approaches to risk stratification may be helpful. Given the higher costs and limited availability of CMR, ETT remains a better choice for assessment of these patients.

Keywords: Aortic Valve Stenosis, Arrhythmias, Cardiac, Cardiac Imaging Techniques, Cardiac Surgical Procedures, Chest Pain, Echocardiography, Exercise Test, Exercise Tolerance, Heart Failure, Heart Valve Diseases, Magnetic Resonance Spectroscopy, Syncope


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