Key result
Greater stress-CMR ischemic extent in LVEF <50% linked to ~11% higher mortality risk per segment.
Why the study?
The incremental prognostic value of stress perfusion cardiovascular magnetic resonance in patients with left ventricular systolic dysfunction remains uncertain.
Does ischemic burden on stress CMR predict long-term mortality in patients with left ventricular systolic dysfunction (LVEF <50%)?
Cohort (n=5,977)
Yes
Does ischemic burden on stress CMR predict long-term mortality in patients with left ventricular systolic dysfunction (LVEF <50%)?
Hazard Ratio: 1.11 (95% CI 1.06–1.15)
p-value: p=<0.001
In patients with left ventricular systolic dysfunction (LVEF <50%), ischemic burden assessed by stress CMR provides incremental prognostic value for long-term mortality beyond standard clinical factors and LVEF.
Ischemic burden on stress CMR may refine mortality risk models in LV systolic dysfunction; hypothesis-generating pending randomized validation.
BACKGROUND: Stress perfusion cardiovascular magnetic resonance (CMR) integrates assessment of myocardial ischemia, scar, and function. Its incremental prognostic value in patients with left ventricular (LV) systolic dysfunction remains uncertain. METHODS: We analyzed a prospective multicenter registry of consecutive patients undergoing vasodilator stress perfusion CMR at three French centers (2008-2024). Patients with CMR-derived LVEF <50% were included. The primary end point was all-cause mortality. Associations were estimated with multivariable Cox models. Incremental prognostic value of ischemia and late gadolinium enhancement (LGE) beyond clinical factors and LVEF was assessed by likelihood-ratio χ2, continuous net reclassification improvement (NRI), and integrated discrimination improvement (IDI). RESULTS: Among 5,977 patients (79% men; age 66±12 years, mean LVEF 42±7%), inducible ischemia was present in 19% (mean extent 2.4±1.2 segments). Over a median follow-up of 9 years, 1,343 patients (22%) died. Ischemic segment extent was independently associated with mortality (HR per segment 1.11; 95% CI, 1.06-1.15; p<0.001). Adding ischemia and LGE to clinical factors and LVEF improved model fit and reclassification (global χ2 increased from 707 to 728; NRI 0.217; IDI 0.004; all p<0.001). Findings were consistent across LVEF subgroups (40-50% and <40%). In secondary analyses among patients with ischemia, outcomes differed by subsequent revascularization status; these findings are observational and hypothesis-generating. CONCLUSIONS: In patients with LVEF <50%, ischemic burden on stress-CMR is independently associated with long-term mortality beyond clinical factors, LVEF and LGE. Integrating ischemia and scar metrics provides incremental prognostic information that may aid risk stratification using stress-CMR in LV systolic dysfunction.
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Pfeffer et al. (2026) conducted a cohort in Left ventricular systolic dysfunction (n=5,977). Ischemic segment extent on stress-CMR was evaluated on All-cause mortality (HR 1.11, 95% CI 1.06-1.15, p=<0.001). In patients with LVEF <50%, ischemic segment extent on stress-CMR was independently associated with all-cause mortality (HR per segment 1.11; 95% CI 1.06-1.15; p<0.001).
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