Individual component analysis of the multi-parametric cardiovascular magnetic resonance protocol in the CE-MARC trial
David P Ripley1, Manish Motwani2, Julia M Brown3
1Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK. d.ripley@leeds.ac.uk.
Insights
The full cardiovascular magnetic resonance (CMR) protocol is best for ruling out coronary artery disease (CAD), while late gadolinium enhancement (LGE) alone is optimal for ruling it in. Coronary MRA offers no additional benefit.
Area of Science:
- Cardiovascular Imaging
- Diagnostic Accuracy
- Medical Technology
Background:
- The CE-MARC study evaluated cardiovascular magnetic resonance (CMR) for diagnosing coronary artery disease (CAD).
- A multi-parametric CMR protocol assessing left ventricular function, myocardial perfusion, late gadolinium enhancement (LGE), and coronary magnetic resonance angiography (MRA) was employed.
- This sub-study focused on the diagnostic accuracy of individual CMR components and their combinations.
Purpose of the Study:
- To assess the diagnostic accuracy of individual and combined components of a multi-parametric CMR protocol for detecting significant CAD.
- To determine the optimal CMR strategy for ruling in and ruling out CAD.
- To evaluate the added diagnostic benefit of coronary MRA within the multi-parametric protocol.
Main Methods:
- Utilized data from 752 patients in the CE-MARC study.
- Analyzed the diagnostic performance of four individual CMR components (function, perfusion, LGE, MRA) separately and in paired/triplet combinations.
- Compared results against the full multi-parametric protocol and X-ray angiography as the reference standard.
Main Results:
- The full multi-parametric CMR protocol achieved the highest sensitivity (86.5%) for detecting significant CAD.
- Individual components like LGE (95.8%), function (93.7%), and perfusion (91.8%) showed higher specificity than the full protocol (83.4%).
- The full protocol was optimal for ruling out CAD (LR- 0.16), while LGE alone was best for ruling in CAD (LR+ 9.81). Coronary MRA provided no significant additional diagnostic benefit.
Conclusions:
- The multi-parametric CMR protocol is the optimal approach for ruling out significant CAD due to its high sensitivity.
- Late gadolinium enhancement (LGE) alone serves as the most effective strategy for ruling in CAD.
- Incorporating coronary MRA into the CMR protocol does not enhance diagnostic accuracy compared to combining perfusion, function, and LGE assessments.
Background:
The CE-MARC study assessed the diagnostic performance investigated the use of cardiovascular magnetic resonance (CMR) in patients with suspected coronary artery disease (CAD). The study used a multi-parametric CMR protocol assessing 4 components: i) left ventricular function; ii) myocardial perfusion; iii) viability (late gadolinium enhancement (LGE)) and iv) coronary magnetic resonance angiography (MRA). In this pre-specified CE-MARC sub-study we assessed the diagnostic accuracy of the individual CMR components and their combinations.
Methods:
All patients from the CE-MARC population (n = 752) were included using data from the original blinded-read. The four individual core components of the CMR protocol was determined separately and then in paired and triplet combinations. Results were then compared to the full multi-parametric protocol.
Results:
CMR and X-ray angiography results were available in 676 patients. The maximum sensitivity for the detection of significant CAD by CMR was achieved when all four components were used (86.5%). Specificity of perfusion (91.8%), function (93.7%) and LGE (95.8%) on its own was significantly better than specificity of the multi-parametric protocol (83.4%) (all P < 0.0001) but with the penalty of decreased sensitivity (86.5% vs. 76.9%, 47.4% and 40.8% respectively). The full multi-parametric protocol was the optimum to rule-out significant CAD (Likelihood Ratio negative (LR-) 0.16) and the LGE component alone was the best to rue-in CAD (LR+ 9.81). Overall diagnostic accuracy was similar with the full multi-parametric protocol (85.9%) compared to paired and triplet combinations. The use of coronary MRA within the full multi-parametric protocol had no additional diagnostic benefit compared to the perfusion/function/LGE combination (overall accuracy 84.6% vs. 84.2% (P = 0.5316); LR- 0.16 vs. 0.21; LR+ 5.21 vs. 5.77).
Conclusions:
From this pre-specified sub-analysis of the CE-MARC study, the full multi-parametric protocol had the highest sensitivity and was the optimal approach to rule-out significant CAD. The LGE component alone was the optimal rule-in strategy. Finally the inclusion of coronary MRA provided no additional benefit when compared to the combination of perfusion/function/LGE.
Trial Registration:
Current Controlled Trials ISRCTN77246133.
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