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Stress Cardiac Magnetic Resonance Ischemia Burden and Cardiovascular Events: Post-Hoc Analysis From the ISCHEMIA
Raymond Y Kwong1, Bobby Heydari1, Siddique Abbasi2
1Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Insights
Stress cardiac magnetic resonance (CMR) showed a stronger association with cardiovascular outcomes than single-photon emission computed tomography/stress echocardiography (SPECT/echo) in the ISCHEMIA trial. This finding highlights CMR
Area of Science:
- Cardiology
- Medical Imaging
- Clinical Trials
Background:
- Limited research exists comparing the prognostic value of stress cardiac magnetic resonance (CMR) against other stress imaging modalities in patients with coronary artery disease.
- Prognostic accuracy of stress CMR versus SPECT/echo in established coronary artery disease requires further investigation.
Purpose of the Study:
- To compare the prognostic value of stress CMR with alternative stress testing modalities (SPECT/echo) in patients with coronary artery disease within the ISCHEMIA trial.
- To evaluate the association between ischemia severity, as assessed by CMR and SPECT/echo, and major adverse cardiovascular outcomes.
Main Methods:
- The ISCHEMIA trial randomized 3,909 patients with moderate-to-severe ischemia to compare invasive versus conservative management.
- Ischemia and infarct extent were measured using CMR and SPECT/echo, with subsequent analysis of their association with the primary outcome (cardiovascular death, MI, or hospitalization for unstable angina, heart failure, or cardiac arrest) over a median follow-up of 3.37 years.
Main Results:
- Stress CMR identified a higher proportion of patients with severe ischemia compared to SPECT/echo (57% vs 38%).
- Ischemia severity assessed by CMR was significantly associated with the primary outcome (P=0.042) and cardiovascular death/MI (P=0.041), whereas SPECT/echo ischemia severity was not.
- Each additional ischemic segment on CMR was associated with a 13% increase in hazard for the primary endpoint after adjustment, indicating a stronger prognostic association compared to SPECT/echo (interaction P=0.02).
Conclusions:
- Ischemia severity determined by stress CMR demonstrated a stronger association with cardiovascular outcomes in the ISCHEMIA trial compared to SPECT/echo.
- These findings suggest that stress CMR may offer superior prognostic information in patients with coronary artery disease.
Background:
Research comparing the prognostic value of stress cardiac magnetic resonance (CMR) to other stress modalities in patients with coronary disease is limited.
Objectives:
The authors compared the prognostic value of stress CMR vs alternative testing by either single-photon emission computed tomography or stress echocardiography (SPECT/echo) in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial.
Methods:
CMR vs SPECT/echo was compared in 3,909 patients randomized in ISCHEMIA after sites' interpretation of moderate to severe ischemia. Ischemia and infarct extent, measured by either CMR or SPECT/echo, were each associated with the trial's primary outcome of cardiovascular death, nonfatal myocardial infarction (MI), or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest, at a median follow-up of 3.37 years (Q1-Q3: 2.20-4.56 years).
Results:
Compared with SPECT/echo (n = 5,627), CMR participants (n = 313) were not different in key demographic factors but were more likely to have severe ischemia (57% vs 38%; P < 0.001) and to be randomized (n = 257, 82%, vs n = 3,652, 65%; P < 0.001). Ischemia severity (no/mild, moderate, severe) by CMR core laboratory was associated with cumulative 4-year event rates of all trial-specific endpoints, including the primary outcome (P = 0.042), cardiovascular death/MI (P = 0.041), and nonfatal MI (P = 0.03), but SPECT/echo ischemia severity was not. No/mild, moderate, and severe ischemia by CMR were associated with 0%, 14%, and 23% 4-year primary outcome rates, respectively, compared with 18%, 15%, and 16%, by SPECT/echo. After adjustment for age, estimated glomerular filtration rate, and diabetes, the association between ischemia extent and the primary endpoint differed by imaging modality, with each additional ischemic segment on CMR associated with a 13% increase in hazard (interaction P = 0.02). In participants assigned to initial conservative management who had no/mild ischemia on imaging, 4-year rates of invasive referral and coronary revascularization were lower in the CMR than SPECT/echo group (16.7% and 0%, respectively, for CMR; and 31% and 13.3%, respectively, for SPECT/echo).
Conclusions:
Ischemia severity by CMR had a stronger association with all ISCHEMIA trial endpoints compared with SPECT/echo. (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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