Inducible Ischemia in Asymptomatic Patients With Coronary Chronic Total Occlusions: A Stress CMR Study
Giuseppe Pinto1,2, Mauro Chiarito1,2, Gaetano Liccardo1,2
1IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy.
Insights
One-third of asymptomatic patients with chronic total occlusions (CTOs) have significant inducible ischemia. Stress cardiac magnetic resonance (CMR) may help identify these patients for potential revascularization benefits.
Area of Science:
- Cardiology
- Medical Imaging
- Ischemic Heart Disease
Background:
- Guidelines differ on revascularizing chronic total occlusions (CTOs) based on inducible ischemia.
- Asymptomatic CTO patients' ischemia prevalence and prognostic impact need further investigation.
- Integrating collateralization and viability assessment with stress cardiac magnetic resonance (CMR) is crucial.
Purpose of the Study:
- To determine the prevalence and prognostic impact of significant inducible ischemia in asymptomatic CTO patients.
- To evaluate the role of stress CMR in assessing ischemia, viability, and collateralization in CTO.
- To inform revascularization decisions by understanding ischemia in asymptomatic CTO.
Main Methods:
- Retrospective analysis of 111 asymptomatic CTO patients undergoing adenosine stress CMR.
- Quantification of inducible ischemia, assessment of myocardial viability, and collateralization status.
- Composite endpoint: cardiovascular mortality and non-fatal myocardial infarction.
Main Results:
- 33% of patients (37/111) had significant inducible ischemia (≥10% LV mass ischemic burden).
- No significant difference in adverse cardiovascular events between revascularized and non-revascularized CTO patients.
- Stress CMR effectively integrated ischemia, viability, and collateralization assessment.
Conclusions:
- A substantial proportion (33%) of asymptomatic CTO patients exhibit significant inducible ischemia.
- Stress CMR is valuable for assessing inducible ischemia in asymptomatic CTO patients.
- Findings suggest a potential expanded role for stress CMR in managing asymptomatic CTOs.
Background:
Given the divergence in recommendations regarding the relevance of inducible ischemia regarding the indication to revascularize chronic total occlusions (CTOs) among European and North American guidelines, we aim at investigating the prevalence and the prognostic impact of significant inducible ischemia in an unselected cohort of asymptomatic CTO patients, integrating collateralization status and viability assessment with stress cardiac magnetic resonance (CMR).
Methods:
From a cohort of 749 patients referred to our center with a diagnosis of CTO, we retrospectively analyzed 111 asymptomatic individuals who underwent an adenosine stress CMR. The amount of inducible ischemia subtended by the CTO was calculated, as well as the presence of viable myocardium and the collateralization status. The decision to revascularize the CTO was based on a multiparametric assessment conducted by the Heart Team, taking into consideration the vessels' anatomy and the amount of inducible ischemia. A composite endpoint of cardiovascular mortality and non-fatal myocardial infarction was considered.
Results:
Thirty-seven patients out of 111 (33%) showed a significant amount of inducible ischemia, indicated by an ischemic burden of at least 10% of the left ventricular (LV) mass. The risk of cardiovascular adverse events was similar among patients who received or not revascularization of the CTO.
Conclusions:
Among asymptomatic patients with CTO undergoing stress CMR, one out of three patients exhibited a substantial amount of inducible ischemia. Considering the possible benefit of revascularization in patients with a significant amount of inducible ischemia, these observations may suggest a possible broader role of stress-CMR within asymptomatic CTO patients.
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