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Prognostic Value of Stress CMR Perfusion Imaging in Patients With Reduced Left Ventricular Function
Yin Ge1, Panagiotis Antiochos1, Kevin Steel2
1Noninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts.
Insights
Stress cardiac magnetic resonance imaging (CMR) effectively risk-stratifies patients with reduced left ventricular (LV) ejection fraction. Findings indicate its prognostic value in identifying patients at risk for cardiovascular events.
Area of Science:
- Cardiology
- Medical Imaging
- Diagnostic Tools
Background:
- Ischemic cardiomyopathy poses risks from both ischemia and heart failure.
- Invasive testing is common, but stress testing's role in risk stratification is under-researched.
- Limited evidence exists on stress testing's effectiveness for risk stratification in these patients.
Purpose of the Study:
- To investigate the prognostic value of stress cardiac magnetic resonance imaging (CMR).
- To assess stress CMR's ability to risk-stratify patients with reduced left ventricular (LV) systolic function.
- To evaluate stress CMR in patients with suspected myocardial ischemia and low LV ejection fraction.
Main Methods:
- A substudy of a multicenter registry (SPINS Study) included 582 patients with LV ejection fraction <50%.
- Patients were referred for stress CMR due to suspected myocardial ischemia.
- Primary outcome: cardiovascular death or nonfatal myocardial infarction. Secondary outcome: composite of major adverse cardiovascular events.
Main Results:
- At 5-year follow-up, 97 patients experienced the primary outcome and 182 the secondary outcome.
- Absence of ischemia or late gadolinium enhancement (LGE) on stress CMR was associated with a low annual primary outcome rate (1.1%).
- Ischemia and LGE were independent predictors of adverse outcomes, improving model discrimination and associated with increased healthcare utilization.
Conclusions:
- Stress CMR is effective for risk-stratifying patients with reduced LV ejection fractions.
- The presence and extent of ischemia on stress CMR predict adverse cardiovascular events.
- Stress CMR provides valuable prognostic information in patients with suspected myocardial ischemia and impaired LV function.
Objectives:
The aim of this study was to investigate the prognostic value of stress cardiac magnetic resonance imaging (CMR) in patients with reduced left ventricular (LV) systolic function.
Background:
Patients with ischemic cardiomyopathy are at risk from both myocardial ischemia and heart failure. Invasive testing is often used as the first-line investigation, and there is limited evidence as to whether stress testing can effectively provide risk stratification.
Methods:
In this substudy of a multicenter registry from 13 U.S. centers, patients with reduced LV ejection fraction (<50%), referred for stress CMR for suspected myocardial ischemia, were included. The primary outcome was cardiovascular death or nonfatal myocardial infarction. The secondary outcome was a composite of cardiovascular death, nonfatal myocardial infarction, hospitalization for unstable angina or congestive heart failure, and unplanned late coronary artery bypass graft surgery.
Results:
Among 582 patients (mean age 62 ± 12 years, 34% women), 40% had a history of congestive heart failure, and the median LV ejection fraction was 39% (interquartile range: 28% to 45%). At median follow-up of 5.0 years, 97 patients had experienced the primary outcome, and 182 patients had experienced the secondary outcome. Patients with no CMR evidence of ischemia or late gadolinium enhancement (LGE) experienced an annual primary outcome event rate of 1.1%. The presence of ischemia, LGE, or both was associated with higher event rates. In a multivariate model adjusted for clinical covariates, ischemia and LGE were independent predictors of the primary (hazard ratio [HR]: 2.63; 95% confidence interval [CI]: 1.68 to 4.14; p < 0.001; and HR: 1.86; 95% CI: 1.05 to 3.29; p = 0.03) and secondary (HR: 2.14; 95% CI: 1.55 to 2.95; p < 0.001; and HR 1.70; 95% CI: 1.16 to 2.49; p = 0.007) outcomes. The addition of ischemia and LGE led to improved model discrimination for the primary outcome (change in C statistic from 0.715 to 0.765; p = 0.02). The presence and extent of ischemia were associated with higher rates of use of downstream coronary angiography, revascularization, and cost of care spent on ischemia testing.
Conclusions:
Stress CMR was effective in risk-stratifying patients with reduced LV ejection fractions. (Stress CMR Perfusion Imaging in the United States [SPINS] Study; NCT03192891).
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