Incremental Prognostic Significance of Combined Cardiac Magnetic Resonance Imaging, Adenosine Stress Perfusion, Delayed Enhancement, and Left Ventricular Function Over Preimaging Information for the Prediction of Adverse Events

BACKGROUND: Although cardiac magnetic resonance imaging (CMR) is capable of yielding extensive data in routine practice, the relative incremental prognostic value of adenosine stress perfusion, myocardial delayed enhancement (DE), and left ventricular volumes and function is unclear. METHODS AND RESULTS: We followed up 908 consecutive patients who underwent combined CMR for suspicion of coronary stenosis and/or ischemia at 2.6 ± 1.2 years, during which 101 total cardiac events occurred (all-cause death, myocardial infarction, or late revascularization). Increase in Cox proportional-hazards model global χ² (χ²) with the addition of CMR data after adjustment for clinical data defined incremental prognostic value. Cardiac magnetic resonance imaging without abnormalities had a 2.4% event rate per year (<1% cardiac death or myocardial infarction). Abnormal CMR was associated with event rates of 5.6% to 7.0% per year, varying with which and how many components were abnormal. After adjusting for the pre-CMR data (age, dyspnea, prior coronary artery disease, resting heart rate, renal disease, and diabetes mellitus, χ²:43.6, P<0.0001; C index 0.695), the addition of left ventricular ejection fraction, aortic flow, delayed enhancement, and stress perfusion data all incrementally increased χ² (55.2, 63.3, 68.0, and 68.9, respectively; all P<0.00001; C indices 0.717, 0.722, 0.747, and 0.736). The number of abnormal CMR domains both added incremental prognostic value and risk stratified patients with respect to risk of events. CONCLUSIONS: CMR analysis of ventricular volume, aortic flow, myocardial viability, and stress perfusion all add incremental value for prediction of adverse events over pre-CMR data and can be combined to further enhance prognostication. Normal combined CMR confers a low risk of subsequent cardiac events.