Prognostic value of vasodilator stress perfusion cardiovascular magnetic resonance after inconclusive stress testing.
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.
['Pezel|Théo|T|', 'Unterseeh|Thierry|T|', 'Garot|Philippe|P|', 'Hovasse|Thomas|T|', 'Kinnel|Marine|M|', 'Champagne|Stéphane|S|', 'Toupin|Solenn|S|', 'Sanguineti|Francesca|F|', 'Garot|Jérôme|J|0000-0003-3714-1256']
D003287:Contrast Media D005080:Exercise Test D005260:Female D005682:Gadolinium D006801:Humans D019028:Magnetic Resonance Imaging, Cine D009682:Magnetic Resonance Spectroscopy D008297:Male D010477:Perfusion D011237:Predictive Value of Tests D011379:Prognosis D018570:Risk Assessment D012307:Risk Factors D014665:Vasodilator Agents
Cardiovascular magnetic resonance Inconclusive stress test Stress testing Revascularization Cardiovascular events Dipyridamole