BACKGROUND Stress cardiac magnetic resonance imaging (CMR) has demonstrated excellent diagnostic and prognostic value in single-center studies. OBJECTIVES This study sought to investigate the prognostic value of stress CMR and downstream costs from subsequent cardiac testing in a retrospective multicenter study in the United States. METHODS In this retrospective study, consecutive patients from 13 centers across 11 states who presented with a chest pain syndrome and were referred for stress CMR were followed for a target period of 4 years. The authors associated CMR findings with a primary outcome of cardiovascular death or nonfatal myocardial infarction using competing risk-adjusted regression models and downstream costs of ischemia testing using published Medicare national payment rates. RESULTS In this study, 2,349 patients (63 ± 11 years of age, 47% female) were followed for a median of 5.4 years. Patients with no ischemia or late gadolinium enhancement (LGE) by CMR, observed in 1,583 patients (67%), experienced low annualized rates of primary outcome (<1%) and coronary revascularization (1% to 3%), across all years of study follow-up. In contrast, patients with ischemia+/LGE+ experienced a >4-fold higher annual primary outcome rate and a >10-fold higher rate of coronary revascularization during the first year after CMR. Patients with ischemia and LGE both negative had low average annual cost spent on ischemia testing across all years of follow-up, and this pattern was similar across the 4 practice environments of the participating centers. CONCLUSIONS In a multicenter U.S. cohort with stable chest pain syndromes, stress CMR performed at experienced centers offers effective cardiac prognostication. Patients without CMR ischemia or LGE experienced a low incidence of cardiac events, little need for coronary revascularization, and low spending on subsequent ischemia testing. (Stress CMR Perfusion Imaging in the United States [SPINS]: A Society for Cardiovascular Resonance Registry Study; NCT03192891 )

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Introduction Ejection fraction is the principal measure used clinically to assess cardiac mechanics and provides significant prognostic information. However, echocardiographic strain imaging has shown significant abnormalities of myocardial deformation can be present despite preserved ejection fraction, which maybe associated with adverse prognosis. Cardiac-Magnetic-Resonance (CMR) feature-tracking techniques now allow assessment of strain from routine cine-images, without specialized pulse sequences. Whether abnormalities of strain measured using CMR feature-tracking have prognostic value in patients with preserved ejection fraction is unknown. Purpose To evaluate the prognostic value of CMR feature-tracking derived global longitudinal strain (GLS) in a large multicenter population of patients with preserved ejection fraction. Methods Consecutive patients with preserved ejection fraction (EF ≥50%) and a clinical indication for CMR at four US medical centers were included in this study. Feature-tracking GLS was calculated from 3 long-axis-cine-views. The primary endpoint was all-cause death. Cox proportional hazards regression modeling was used to examine the independent association between GLS and death. The incremental prognostic value of GLS was assessed in nested models. Results Of the 1274 patients in this study, 115 died during a median follow-up of 6.2 years. By Kaplan-Meier analysis, patients with GLS ≥ median (−20%) had significantly reduced event free survival compared to those with GLS < median (log-rank p<0.001) (Figure, top panel). The continuous relationship between GLS and the hazard of death is shown in the cubic spline (Figure, lower panel). By Cox multivariable regression modeling, each 1% worsening in GLS was associated with a 23.6% increased risk-of-death after adjustment for clinical and imaging risk factors (HR=1.236 per %; p<0.001). Addition of GLS in this model resulted in significant-improvement in the global-chi-square (67 to 168; p<0.0001) and Harrel's C-statistic (0.716 to 0.825; p<0.0001). Conclusions CMR feature-tracking derived GLS is a powerful independent predictor of mortality in patients with preserved ejection fraction, incremental to common clinical and imaging risk factors.

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