Abstract
BackgroundWhile 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.MethodsBetween 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.ResultsOf 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.ConclusionsIn 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.
Highlights
Cardiovascular disease (CVD) mortality due to coronary artery disease (CAD) has recently increased, and CAD represents more than $500 million in annual health care costs in the United States alone [1]
Inconclusive stress test was defined by exercise electrocardiogram (ECG) or stress echocardiography or single photon emission computed tomography (SPECT) without positive or negative conclusion regarding the diagnosis of CAD [6, 13]
Patients without angina or dyspnea on exertion underwent the first stress test during the work-up of known CAD, or because of relatively high CVD risk defined by the presence of at least 2 CVD risk factors (age > 50 years for men or > 60 years for women, diabetes, hypertension, smoking, dyslipidemia, family history of CAD and obesity defined by body mass index (BMI) ≥ 30 kg/m2)
Summary
Cardiovascular disease (CVD) mortality due to coronary artery disease (CAD) has recently increased, and CAD represents more than $500 million in annual health care costs in the United States alone [1]. Pezel et al J Cardiovasc Magn Reson (2021) 23:89 guidelines recommend a non-invasive stress testing or coronary computed tomography angiography (CTA) for the initial diagnostic management of patients with angina and suspected CAD (class IA) [2, 3], stress tests are deemed inconclusive in up to 15% to 29% of cases [4, 5]. Some reports support that further testing after first inconclusive stress test may improve diagnostic accuracy of obstructive CAD and risk stratification [6], the management of such patients remain controversial because data are scarce [7]. While current guidelines recommend noninvasive testing to detect coronary artery disease, stress tests are deemed inconclusive in a quarter of cases. To assess the prognostic value of vasodilator stress cardiovascular magnetic resonance (CMR) parameters and CMR-based coronary revascularization in patients after inconclusive stress testing
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