Key result
The presence of inducible ischemia on vasodilator stress CMR independently predicted a higher incidence of major adverse cardiovascular events (HR 2.53) in patients with a prior inconclusive stress test.
Why the study?
Stress tests are inconclusive in a quarter of cases, and the strategy for risk stratification after inconclusive stress testing is not well standardized.
Does vasodilator stress cardiovascular magnetic resonance (CMR) predict major adverse cardiovascular events in patients with a first non-CMR inconclusive stress test?
Cohort (n=1,402)
No
Does vasodilator stress cardiovascular magnetic resonance (CMR) predict major adverse cardiovascular events in patients with a first non-CMR inconclusive stress test?
Vasodilator stress CMR provides significant incremental prognostic value over traditional risk factors for predicting MACE in patients with a prior inconclusive non-CMR stress test.
Supports incremental prognostic value of stress CMR after inconclusive tests; leaves open impact on management or outcomes.
BACKGROUND: While current guidelines recommend noninvasive testing to detect coronary artery disease, stress tests are deemed inconclusive in a quarter of cases. The strategy for risk stratification after inconclusive stress testing is not well standardized. To assess the prognostic value of vasodilator stress cardiovascular magnetic resonance (CMR) parameters and CMR-based coronary revascularization in patients after inconclusive stress testing. METHODS: Between 2008 and 2020, consecutive patients with a first non-CMR inconclusive stress test referred for vasodilator stress perfusion CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. CMR-related coronary revascularization was defined as any revascularisation occurring within 90 days after CMR. Univariable and multivariable Cox regressions were performed to determine the prognostic value of each parameter. RESULTS: Of 1563 patients who completed the CMR protocol, 1402 patients (66.7% male, 69.5 ± 11.0 years) completed the follow-up (median [interquartile range], 6.5 [5.6-7.5] years); 197 experienced a MACE (14.1%). Vasodilator stress CMR was well tolerated without severe adverse events. Using Kaplan-Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (hazard ratio, HR: 2.88 [95% CI 2.18-3.81]; and HR: 1.46 [95% CI 1.16-1.89], both p < 0.001; respectively). In multivariable Cox regression, the presence and extent of inducible ischemia were independent predictors of a higher incidence of MACE (HR: 2.53 [95% CI 1.89-3.40]; and HR: 1.58 [95% CI 1.47-1.71]; both p < 0.001; respectively). After adjustment, the extent of inducible ischemia showed the best improvement in model discrimination above traditional risk factors (C-statistic 0.75 [95% CI 0.69-0.81] with C-statistic improvement: 0.12). The study suggested no benefit of CMR-related coronary revascularization in reducing MACE. CONCLUSIONS: In patients with a first non-CMR inconclusive stress test, vasodilator stress CMR has good prognostic value to predict MACE offering an incremental prognostic value over traditional risk factors.
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Pezel et al. (2021) conducted a cohort in Suspected or known coronary artery disease with a first inconclusive stress test (n=1,402). Inducible ischemia on vasodilator stress CMR vs. No inducible ischemia was evaluated on Major adverse cardiovascular events (MACE), defined as cardiovascular mortality or nonfatal myocardial infarction (HR 2.53, 95% CI 1.89-3.40, p=<0.001). The presence of inducible ischemia on vasodilator stress CMR independently predicted a higher incidence of major adverse cardiovascular events (HR 2.53) in patients with a prior inconclusive stress test.
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