Abstract
BackgroundSeveral studies have established the prognostic value of vasodilator stress cardiovascular magnetic resonance (CMR) in broad population of patients with suspected or known coronary artery disease (CAD), but this specific population of asymptomatic patients with known CAD have never been formally evaluated. To assess the long-term prognostic value of vasodilator stress perfusion CMR in asymptomatic patients with obstructive CAD.MethodsBetween 2009 and 2011, consecutive asymptomatic patients with obstructive CAD referred for vasodilator stress CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular mortality or recurrent non-fatal myocardial infarction (MI). Uni- and multivariable Cox regressions were performed to determine the prognostic value of myocardial ischemia and myocardial infarction defined by late gadolinium enhancement (LGE) with ischemic pattern.ResultsAmong 1529 asymptomatic patients with obstructive CAD, 1342 (87.8%; 67.7 ± 10.5 years, 82.0% males) completed the follow-up (median 8.3 years), and 195 had MACE (14.5%). Patients without stress-induced myocardial ischemia had a low annualized rate of MACE (2.4%), whereas the annualized rate of MACE was higher for patients with mild, moderate, or severe ischemia (7.3%, 16.8%, and 42.2%, respectively; ptrend < 0.001). Using Kaplan–Meier analysis, myocardial ischemia and LGE were associated with MACE (hazard ratio, HR 2.52; 95% CI 1.90–3.34 and HR 2.04; 95% CI 1.38–3.03, respectively; both p < 0.001). In multivariable stepwise Cox regression, myocardial ischemia and LGE were independent predictors of MACE (HR 2.80 95% CI 2.10–3.73, p < 0.001 and HR 1.51; 95% CI 1.01–2.27, p = 0.045; respectively). The addition of myocardial ischemia and LGE led to improved model discrimination for MACE (change in C statistic from 0.61 to 0.68; NRI = 0.207; IDI = 0.021).ConclusionsVasodilator stress CMR-induced myocardial ischemia and LGE are good long-term predictors for the incidence of MACE in asymptomatic patients with obstructive CAD.
Highlights
Despite the decline in the rate of recurrent cardiovascular events over the past decades, recurrence remains a major cause of mortality and morbidity among patients with known obstructive coronary artery disease (CAD) [1, 2]
While risk stratification of asymptomatic patients can be useful in managing secondary prevention, the European and American guidelines do not recommend systematic stress testing in the follow-up of patients with CAD [7, 8], because they are mainly based on studies of symptomatic patients
Patients characteristics Among the 6,095 individuals referred for dipyridamole vasodilator stress cardiovascular magnetic resonance (CMR) during the inclusion period, 1,529 (25.1%) patients were asymptomatic with prior obstructive CAD
Summary
Despite the decline in the rate of recurrent cardiovascular events over the past decades, recurrence remains a major cause of mortality and morbidity among patients with known obstructive coronary artery disease (CAD) [1, 2]. Whereas the interest of coronary revascularization has been very recently debated in patients with stable CAD [3], secondary prevention therapy is key to decrease the rate of recurrent cardiovascular events in this population. Several studies have shown that asymptomatic patients with myocardial ischemia have at least similar risk for adverse cardiovascular events and mortality as symptomatic patients with typical angina [5, 6]. Several studies have established the prognostic value of vasodilator stress cardiovascular magnetic resonance (CMR) in broad population of patients with suspected or known coronary artery disease (CAD), but this specific population of asymptomatic patients with known CAD have never been formally evaluated.
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