Key result
Ischemia on stress perfusion CMR is linked to a ~4.5-fold increase in major cardiovascular events.
Why the study?
Does the presence of ischemia on vasodilator stress perfusion CMR predict new diagnosis of left main/multivessel disease and major adverse cardiovascular events in patients undergoing stress CMR?
Cohort (n=4,144)
Yes
Does the presence of ischemia on vasodilator stress perfusion CMR predict new diagnosis of left main/multivessel disease and major adverse cardiovascular events in patients undergoing stress CMR?
Hazard Ratio: 4.55 (95% CI 3.32–6.25)
Absolute Event Rate: 10.6% vs 0.9%
p-value: p=< 0.001
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Our data show a clear, graded association between the extent of ischemia, quantified by the number of AHA segments involved, and the likelihood of adverse outcomes. This observation emphasizes that not only the presence but also the severity of ischemia carries independent prognostic value.”
The absence of ischemia on vasodilator stress perfusion CMR is associated with a very low annualized rate of high-risk coronary artery disease and major adverse cardiovascular events, supporting its utility as a reliable rule-out test.
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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Bernhard et al. (2026) conducted a cohort in Suspected coronary artery disease (n=4,144). Presence of ischemia on vasodilator stress perfusion CMR vs. Absence of ischemia was evaluated on Composite of angiographic new diagnosis of LM disease (>50% stenosis), high-risk MVD, acute nonfatal MI, and cardiovascular death (HR 4.55, 95% CI 3.32-6.25, p=< 0.001). The presence of ischemia on vasodilator stress perfusion CMR strongly predicted a composite of new left main/multivessel disease, MI, or cardiovascular death (HR 4.55; 95% CI 3.32-6.25; P<0.001).
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