Impact of coronary revascularisation in patients undergoing stress cardiovascular magnetic resonance in primary prevention

Background The impact of coronary revascularisation after stress cardiovascular magnetic resonance (CMR) in orimary prevention of cardiovascular disease remains controversial. Purpose To assess the long-term prognostic impact of coronary revascularisation after CMR on all-cause mortality in consecutive patients without any history of cardiovascular disease undergoing primary prevention from a multicentric study. Methods From 2008 to 2022, we included all consecutive patients who underwent stress CMR for primary prevention in three centres in France. Inducible ischaemia was defined as a subendocardial or transmural perfusion defect that (1) occurred in at least one myocardial segment, (2) persisted for at least three phases beyond peak contrast enhancement, (3) followed a coronary distribution, and (4) in the absence of colocation with late gadolinium enhancement (LGE). Coronary revascularisation after stress CMR was defined as any percutaneous coronary intervention performed within 90 days following stress CMR. The primary outcome was all-cause mortality using the electronic French National Registry of All-cause mortality (INSEE). Results A total of 36,778 patients were included (mean age 64±12 years, 68% male). Over a median follow-up of 7.2 years (interquartile range 3-11 years), 2,102 deaths (5.7%) occurred. Inducible ischaemia was detected in 5,232 patients (14.2%) referred for primary prevention stress-CMR and revascularisation was performed in 4,661 patients (89%, Figure 1). Patient who underwent revascularisation after stress CMR were younger (63±12 vs 64±12 years), but had similar traditional cardiovascular risk factors, LVEF and number of inducible ischaemic segments (all p-value=0.8). After adjustment for traditional prognosticators, inducible ischaemia was an independent predictor of mortality (hazard ratio [HR] 3.72, 95% confidence interval [CI] 3.18-4.35, p<0.001). In multivariable analysis, revascularisation after stress CMR was an independent predictor of improved survival in the ischaemic population (HR 0.32; 95% CI, 0.26–0.39, p<0.001) after adjustment for age, gender, traditional cardiovascular risk factors, centre, chronic kidney disease, peripheral atheroma presence, history of heart failure, history of atrial fibrillation, stress CMR indication, number of inducible ischaemic segments and LGE presence. Revascularisation after stress CMR was associated with a significantly improved survival rate in patients with a low amount of inducible ischaemia (1-4 segments) and in patients with a high inducible amount of ischaemia (5-8 segments) (HR 0.29; 99% CI 0.20-0.41, p<0.001 and OR 0.21; 99% CI 0.15-0.30, p<0.001 respectively). Survival curves according to revascularisation after stress CMR assessment are shown in Figure 2. Conclusion In this multicentre registry of consecutive patients in primary prevention referred for stress CMR, revascularisation was associated with a lower rate of all-cause mortality.Figure 1 Figure 2