Value of a coronary CT angiography plus stress cardiac MRI strategy for the evaluation of patients with CCS in the real world

Abstract Background Limited information is available regarding the use of a coronary computed tomography angiography (CCTA) plus stress cardiac magnetic resonance imaging (S-CMR) strategy in patients with chronic coronary syndrome (CCS). Purpose We sought to evaluate safety and efficacy of a CCTA plus S-CMR strategy in CCS patients. Methods At our tertiary care center, 115 patients with suspected CCS at low-intermediate risk first underwent CCTA. Subsequently, those showing intermediate coronary plaques (stenosis 30-70%) underwent S-CMR. Patients with a positive S-CMR were referred for invasive coronary angiopraphy (ICA) plus instantaneous wave-free ratio (iFR), and myocardial revascularization if recommended. All patients received guideline-directed medical therapy (GDMT), including high-dose statins, regardless of myocardial revascularization. The primary endpoint was a composite of death from cardiovascular causes, non-fatal myocardial infarction and unplanned revascularization. Results According to the results of CCTA, 62 patients showing intermediate coronary plaques underwent S-CMR, which resulted positive for myocardial perfusion deficit in n=17 (27%) and negative in n=45 (73%) patients. According to the results of ICA­ plus iFR, revascularization was performed in 13 patients. No differences in the primary endpoint between the positive and negative S-CMR groups were observed at 1 year (1 5.9% vs. 1 2.2%, P=0.485) and after a median of 33.4 months (2 11.8% vs. 3 6.7%; P=0.605). Throughout the follow-up, no events were observed in patients with no/minimal plaques at CCTA. Conclusions Our study suggests that a CCTA plus S-CMR strategy is effective for the evaluation of patients with suspicion of CCS at low-intermediate risk, and it may help to refine the selection of patients with intermediate coronary plaques at CCTA needing coronary revascularization.