Key result
In patients with prior cryptogenic stroke, silent ischemia detected by stress CMR was an independent predictor of major adverse cardiovascular events (HR 8.08).
Why the study?
CAD is the main cause of death after stroke, but the utility of CAD screening in cryptogenic stroke remains debated.
Does stress cardiovascular magnetic resonance (CMR) provide incremental prognostic value beyond traditional risk factors for predicting cardiovascular events in patients with a prior cryptogenic ischemic stroke?
Cohort (n=542)
No
Does stress cardiovascular magnetic resonance (CMR) provide incremental prognostic value beyond traditional risk factors for predicting cardiovascular events in patients with a prior cryptogenic ischemic stroke?
Hazard Ratio: 8.08 (95% CI 4.21–15.5)
p-value: p=<0.001
In patients with prior cryptogenic stroke, the detection of silent ischemia and unrecognized MI by stress CMR provides significant incremental prognostic value for predicting major adverse cardiovascular events over traditional risk factors.
May support refined risk stratification after cryptogenic stroke; leaves open whether stress CMR alters outcomes in prospective trials.
Background One-third of ischemic strokes are “cryptogenic” without clearly identified etiology. Although coronary artery disease (CAD) is the main cause of death after stroke, the interest in CAD screening in patients with cryptogenic stroke is still debated. Aim The aim of the study was to assess the incremental prognostic value of stress cardiovascular magnetic resonance (CMR) beyond traditional risk factors for predicting cardiovascular events in patients with a prior cryptogenic ischemic stroke. Materials and methods Between 2008 and 2021, consecutive patients with prior cryptogenic strokes referred for stress CMR were included and followed for the occurrence of major adverse cardiovascular events (MACEs), defined by cardiovascular death or non-fatal myocardial infarction (MI). Univariable and multivariable Cox regressions were performed to determine the prognostic value of unrecognized MI and silent ischemia. Results Of 542 patients (55.2% male, mean age 71.4 ± 8.8 years) who completed the follow-up (median 5.9 years), 66 (12.2%) experienced MACE. Silent ischemia and unrecognized MI were detected in 18 and 17% of patients, respectively. Using Kaplan–Meier analysis, silent ischemia and unrecognized MI were associated with the occurrence of MACE [hazard ratio, HR: 8.43 (95% CI: 5.11–13.9); HR: 7.87 (95% CI: 4.80–12.9), respectively, p < 0.001]. In multivariable analysis, silent ischemia and unrecognized MI were independent predictors of MACE [HR: 8.08 (95% CI: 4.21–15.5); HR: 6.65 (95% CI: 3.49–12.7), respectively, p < 0.001]. After adjustment, stress CMR findings showed the best improvement in model discrimination and reclassification above traditional risk factors (C-statistic improvement: 0.13; NRI = 0.428; IDI = 0.048). Conclusion In patients with prior cryptogenic stroke, stress CMR findings have an incremental prognostic value to predict MACE over traditional risk factors.
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Toupin et al. (2022) conducted a cohort in Cryptogenic ischemic stroke (n=542). Silent ischemia detected by stress CMR vs. Absence of silent ischemia was evaluated on Major adverse cardiovascular events (MACE), defined as cardiovascular death or non-fatal myocardial infarction (HR 8.08, 95% CI 4.21-15.5, p=<0.001). In patients with prior cryptogenic stroke, silent ischemia detected by stress CMR was an independent predictor of major adverse cardiovascular events (HR 8.08).
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