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Stress Perfusion CMR to Prognosticate for Left Main and High Risk Multivessel Coronary Artery Disease and Major
Benedikt Bernhard1, Marianna Daibes2, Isabela Reis Marques2
1Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany.
Insights
Stress perfusion cardiac magnetic resonance (CMR) effectively rules out high-risk coronary artery disease, including left main (LM) and multivessel disease (MVD). Absence of ischemia on CMR predicts a very low likelihood of future adverse cardiac events.
Area of Science:
- Cardiovascular Imaging
- Non-invasive Cardiac Diagnostics
- Coronary Artery Disease Assessment
Background:
- Left main (LM) and multivessel coronary disease (MVD) are high-risk conditions often requiring surgical revascularization.
- Conventional imaging may miss these critical coronary artery disease diagnoses.
- Vasodilator stress perfusion cardiac magnetic resonance (CMR) shows promise for detecting endocardial ischemia but lacks extensive multicenter data.
Purpose of the Study:
- To evaluate the reliability of stress perfusion CMR in ruling out LM/MVD.
- To assess the predictive value of stress perfusion CMR for adverse cardiac outcomes.
- To establish the diagnostic accuracy of CMR in high-risk coronary artery disease.
Main Methods:
- A large, multicenter cohort (13 centers) from the Stress CMR Perfusion Imaging in the United States Study (SPINS) was analyzed.
- Study outcomes included new LM disease diagnosis, high-risk MVD, acute myocardial infarction (MI), and cardiovascular death.
- Statistical analysis adjusted for clinical risk factors and late gadolinium enhancement.
Main Results:
- Among 4,144 patients, 18.3% had ischemia and 27.2% had prior infarct.
- Over 4 years, 8.1% experienced the composite outcome, including new LM/MVD diagnoses (4.4%), acute MI (2.3%), and cardiovascular death (1.4%).
- Ischemia on stress perfusion CMR was the strongest predictor of adverse outcomes (adjusted HR: 4.55), with abnormal perfusion indicating a 10-fold increase in event rates.
Conclusions:
- Absence of ischemia on vasodilator stress perfusion CMR is associated with a very low likelihood of angiographically verified high-risk coronary artery disease.
- Stress perfusion CMR is a reliable tool for excluding significant LM/MVD and predicting cardiac events.
- This study provides robust multicenter data supporting the use of stress perfusion CMR in clinical practice.
Background:
Left main (LM) and multivessel coronary disease (MVD) are high-risk conditions in which surgical revascularization may be preferred over medical or percutaneous therapies, yet may be missed by conventional imaging. Vasodilator stress perfusion cardiac magnetic resonance (CMR) appeared promising in resolving endocardial ischemia, but large multicenter data are lacking.
Objectives:
This study aims to assess whether stress perfusion CMR reliably rules out LM/MVD and predicts adverse cardiac outcomes.
Methods:
Consecutive patients from the expanded cohort of the 13-center SPINS (Stress CMR Perfusion Imaging in the United States Study) were included. Study outcomes were composites of angiographic new diagnosis of LM disease (>50% stenosis), high-risk MVD (significant 3-vessel disease or MVD treated with surgical revascularization), acute nonfatal myocardial infarction (MI), and cardiovascular death.
Results:
Among 4,144 patients (60.5 ± 13.1 years of age, 54.3% male), ischemia and prior infarct were present in 760 (18.3%) and 1,128 (27.2%) patients, respectively. During 4-year follow-up, 336 (8.1%) patients experienced the primary composite outcome, including 182 (4.4%) new diagnoses of LM/MVD, 96 (2.3%) acute MI, and 58 (1.4%) cardiovascular deaths. The presence of ischemia was the strongest multivariable predictor of the composite outcome (HRadjusted: 4.55; 95% CI: 3.32-6.25; P < 0.001) and for the combination of acute MI and cardiovascular death (HRadjusted: 4.31; 95% CI: 3.08-6.05; P < 0.001), adjusted for clinical risk factors and late gadolinium enhancement. The presence of abnormal stress perfusion portended a 10-fold increase in the annualized primary event rate compared with those without ischemia (10.6% vs 0.9%), whereas annual event rates were 0.9% vs 0.08% for LM disease, and 5.6% vs 0.3% for high-risk MVD, respectively.
Conclusions:
The absence of ischemia on vasodilator stress perfusion CMR was associated with a very low likelihood of angiographically verified high-risk coronary artery disease and its associated events.
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