Dataset Information

Prognostic value of perfusion cardiovascular magnetic resonance with adenosine triphosphate stress in stable coronary artery disease.

ABSTRACT:

Background

Adenosine triphosphate (ATP) has been predominantly used in the Asia-Pacific region for stress perfusion cardiovascular magnetic resonance (CMR). We evaluated the prognosis of patients stressed using ATP, for which there are no current data.

Methods

We performed a retrospective longitudinal study from January 2016 to December 2020 and included 208 subjects with suspected obstructive coronary artery disease (CAD) who underwent ATP stress perfusion CMR. An inducible stress perfusion defect was defined as a subendocardial dark rim involving ≥ 1.5 segments that persisted for ≥ 6 beats during stress but not at rest. The primary outcome measure was a composite of major adverse cardiovascular events (MACE) including (1) cardiac death, (2) nonfatal myocardial infarction, (3) cardiac hospitalization, (4) late coronary revascularization. We compared outcomes in patients with and without perfusion defect using Kaplan-Meier and log rank tests. Significant predictors of MACE were identified using multivariable Cox regression analysis.

Results

Median follow-up was 3.3 years. Patients with no stress perfusion defect had a lower incidence of MACE (p < 0.001), including lower cardiac hospitalization (p = 0.004), late coronary revascularization (p = 0.001) and cardiac death (p = 0.003). Significant independent predictors for MACE were stress induced perfusion defect (p < 0.001, hazard ratio [HR] = 3.63), lower left ventricular ejection fractino (LVEF) (p < 0.001, HR = 0.96) and infarct detected by late gadolinium enhancement (LGE) (p = 0.001, HR = 2.92).

Conclusion

Perfusion defects on ATP stress are predictive of MACE which is driven primarily by cardiac hospitalization, late coronary revascularization and cardiac death. Significant independent predictors of MACE were stress induced perfusion defect, lower LVEF and infarct detected by LGE.

SUBMITTER: Ng MY

PROVIDER: S-EPMC8223349 | biostudies-literature | 2021 Jun

REPOSITORIES: biostudies-literature

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Publications

Prognostic value of perfusion cardiovascular magnetic resonance with adenosine triphosphate stress in stable coronary artery disease.

Ng Ming-Yen MY Chin Chi Yeung CY Yap Pui Min PM Wan Eric Yuk Fai EYF Hai JoJo Siu Han JSH Cheung Stephen S Tse Hung Fat HF Bucciarelli-Ducci Chiara C Pennell Dudley John DJ Yiu Kai-Hang KH

Journal of cardiovascular magnetic resonance : official journal of the Society for Cardiovascular Magnetic Resonance 20210624 1

<h4>Background</h4>Adenosine triphosphate (ATP) has been predominantly used in the Asia-Pacific region for stress perfusion cardiovascular magnetic resonance (CMR). We evaluated the prognosis of patients stressed using ATP, for which there are no current data.<h4>Methods</h4>We performed a retrospective longitudinal study from January 2016 to December 2020 and included 208 subjects with suspected obstructive coronary artery disease (CAD) who underwent ATP stress perfusion CMR. An inducible stres ...[more]

PMID: 34162392

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Project description: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.

Project description:Perfusion-cardiovascular magnetic resonance (CMR) is generally accepted as an alternative to SPECT to assess myocardial ischemia non-invasively. However its performance vs gated-SPECT and in sub-populations is not fully established. The goal was to compare in a multicenter setting the diagnostic performance of perfusion-CMR and gated-SPECT for the detection of CAD in various populations using conventional x-ray coronary angiography (CXA) as the standard of reference.In 33 centers (in US and Europe) 533 patients, eligible for CXA or SPECT, were enrolled in this multivendor trial. SPECT and CXA were performed within 4 weeks before or after CMR in all patients. Prevalence of CAD in the sample was 49% and 515 patients received MR contrast medium. Drop-out rates for CMR and SPECT were 5.6% and 3.7%, respectively (ns). The study was powered for the primary endpoint of non-inferiority of CMR vs SPECT for both, sensitivity and specificity for the detection of CAD (using a single-threshold reading), the results for the primary endpoint were reported elsewhere. In this article secondary endpoints are presented, i.e. the diagnostic performance of CMR versus SPECT in subpopulations such as multi-vessel disease (MVD), in men, in women, and in patients without prior myocardial infarction (MI). For diagnostic performance assessment the area under the receiver-operator-characteristics-curve (AUC) was calculated. Readers were blinded versus clinical data, CXA, and imaging results.The diagnostic performance (= area under ROC = AUC) of CMR was superior to SPECT (p = 0.0004, n = 425) and to gated-SPECT (p = 0.018, n = 253). CMR performed better than SPECT in MVD (p = 0.003 vs all SPECT, p = 0.04 vs gated-SPECT), in men (p = 0.004, n = 313) and in women (p = 0.03, n = 112) as well as in the non-infarct patients (p = 0.005, n = 186 in 1-3 vessel disease and p = 0.015, n = 140 in MVD).In this large multicenter, multivendor study the diagnostic performance of perfusion-CMR to detect CAD was superior to perfusion SPECT in the entire population and in sub-groups. Perfusion-CMR can be recommended as an alternative for SPECT imaging.ClinicalTrials.gov, Identifier: NCT00977093.

Project description:To examine factors associated with false-negative cardiovascular magnetic resonance (MR) perfusion studies within the large prospective Clinical Evaluation of MR imaging in Coronary artery disease (CE-MARC) study population. Myocardial perfusion MR has excellent diagnostic accuracy to detect coronary heart disease (CHD). However, causes of false-negative MR perfusion studies are not well understood.CE-MARC prospectively recruited patients with suspected CHD and mandated MR, myocardial perfusion scintigraphy, and invasive angiography. This subanalysis identified all patients with significant coronary stenosis by quantitative coronary angiography (QCA) and MR perfusion (1.5T, T1 -weighted gradient echo), using the original blinded image read. We explored patient and imaging characteristics related to false-negative or true-positive MR perfusion results, with reference to QCA. Multivariate regression analysis assessed the likelihood of false-negative MR perfusion according to four characteristics: poor image quality, triple-vessel disease, inadequate hemodynamic response to adenosine, and Duke jeopardy score (angiographic myocardium-at-risk score).In all, 265 (39%) patients had significant angiographic disease (mean age 62, 79% male). Thirty-five (5%) had false-negative and 230 (34%) true-positive MR perfusion. Poor MR perfusion image quality, triple-vessel disease, and inadequate hemodynamic response were similar between false-negative and true-positive groups (odds ratio, OR [95% confidence interval, CI]: 4.1 (0.82-21.0), P = 0.09; 1.2 (0.20-7.1), P = 0.85, and 1.6 (0.65-3.8), P = 0.31, respectively). Mean Duke jeopardy score was significantly lower in the false-negative group (2.6 ± 1.7 vs. 5.4 ± 3.0, OR 0.34 (0.21-0.53), P < 0.0001).False-negative cardiovascular MR perfusion studies are uncommon, and more common in patients with lower angiographic myocardium-at-risk. In CE-MARC, poor image quality, triple-vessel disease, and inadequate hemodynamic response were not significantly associated with false-negative MR perfusion.

Project description: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.

Dataset Information

Prognostic value of perfusion cardiovascular magnetic resonance with adenosine triphosphate stress in stable coronary artery disease.

Background

Methods

Results

Conclusion

Publications

Prognostic value of perfusion cardiovascular magnetic resonance with adenosine triphosphate stress in stable coronary artery disease.

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