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Prognostic Value of Stress Cardiac Magnetic Resonance in Patients With Known Coronary Artery Disease
Panagiotis Antiochos1, Yin Ge1, Bobak Heydari2
1Noninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Insights
Stress cardiac magnetic resonance (CMR) effectively identifies high-risk patients with coronary artery disease (CAD), improving risk prediction for major adverse cardiovascular events. This noninvasive imaging tool significantly reclassifies patient risk, guiding better clinical management for better outcomes.
Area of Science:
- Cardiology
- Medical Imaging
- Diagnostic Tools
Background:
- Patients with established coronary artery disease (CAD) remain at high risk for cardiovascular (CV) events despite advances in treatment.
- Noninvasive stress testing in this population presents challenges for accurate risk stratification.
- Stress cardiac magnetic resonance (CMR) is explored for its potential to improve risk assessment in known CAD.
Purpose of the Study:
- To evaluate if stress CMR offers clinically relevant risk reclassification in patients with known CAD.
- To assess the prognostic value of myocardial ischemia detected by stress CMR.
- To determine the impact of stress CMR findings on major adverse cardiovascular events (MACE).
Main Methods:
- Utilized data from the Stress Perfusion Imaging in the United States (SPINS) registry.
- Included consecutive patients with documented CAD referred for stress CMR.
- Primary outcome: nonfatal myocardial infarction (MI) or CV death. Secondary outcome: MACE.
- Analyzed prognostic association and net reclassification improvement by ischemia.
Main Results:
- In 755 patients followed for 5.3 years, ischemia on stress CMR strongly predicted MI/CV death (HR: 2.30) and MACE (HR: 2.24).
- Ischemia remained a significant predictor after adjusting for CV risk factors (MI/CV death HR: 1.84; MACE HR: 1.77).
- Stress CMR reclassified risk in 95% of intermediate-risk patients, shifting 62% to low risk and 33% to high risk.
Conclusions:
- Stress CMR-assessed ischemia is a powerful independent predictor of adverse outcomes in patients with known CAD.
- The imaging modality significantly reclassifies cardiovascular risk, particularly in intermediate-risk individuals.
- Absence of ischemia on stress CMR indicates a favorable prognosis with <2% annual MI/CV death rate.
Objectives:
This study sought to determine whether stress cardiac magnetic resonance (CMR) provides clinically relevant risk reclassification in patients with known coronary artery disease (CAD) in a multicenter setting in the United States.
Background:
Despite improvements in medical therapy and coronary revascularization, patients with previous CAD account for a disproportionately large portion of CV events and pose a challenge for noninvasive stress testing.
Methods:
From the Stress Perfusion Imaging in the United States (SPINS) registry, we identified consecutive patients with documented CAD who were referred to stress CMR for evaluation of myocardial ischemia. The primary outcome was nonfatal myocardial infarction (MI) or cardiovascular (CV) death. Major adverse CV events (MACE) included MI/CV death, hospitalization for heart failure or unstable angina, and late unplanned coronary artery bypass graft. The prognostic association and net reclassification improvement by ischemia for MI/CV death were determined.
Results:
Out of 755 patients (age 64 ± 11 years, 64% male), we observed 97 MI/CV deaths and 210 MACE over a median follow-up of 5.3 years. Presence of ischemia demonstrated a significant association with MI/CV death (HR: 2.30; 95% CI: 1.54-3.44; P < 0.001) and MACE (HR: 2.24 ([95% CI: 1.69-2.95; P < 0.001). In a multivariate model adjusted for CV risk factors, ischemia maintained strong association with MI/CV death (HR: 1.84; 95% CI: 1.17-2.88; P = 0.008) and MACE (HR: 1.77; 95% CI: 1.31-2.40; P < 0.001) and reclassified 95% of patients at intermediate pretest risk (62% to low risk, 33% to high risk) with corresponding changes in the observed event rates of 1.4% and 5.3% per year for low and high post-test risk, respectively.
Conclusions:
In a multicenter cohort of patients with known CAD, CMR-assessed ischemia was strongly associated with MI/CV death and reclassified patient risk beyond CV risk factors, especially in those considered to be at intermediate risk. Absence of ischemia was associated with a <2% annual rate of MI/CV death. (Stress CMR Perfusion Imaging in the United States [SPINS] Study; NCT03192891).
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