A Novel Clinical and Stress Cardiac Magnetic Resonance (C-CMR-10) Score to Predict Long-Term All-Cause Mortality in Patients with Known or Suspected Chronic Coronary Syndrome

Abstract

Vasodilator stress cardiac magnetic resonance (stressCMR) has shown robust diagnostic and prognostic value in patients with known or suspected chronic coronary syndrome (CCS). However, it is unknown whether integration of stressCMR with clinical variables in a simple clinical-imaging score can straightforwardly predict all-cause mortality in this population. We included 6187 patients in a large registry that underwent stressCMR for known or suspected CCS. Several clinical and stressCMR variables were collected, such as left ventricular ejection fraction (LVEF) and ischemic burden (number of segments with stress-induced perfusion defects (PD)). During a median follow-up of 5.56 years, we registered 682 (11%) all-cause deaths. The only independent predictors of all-cause mortality in multivariable analysis were age, male sex, diabetes mellitus (DM), LVEF and ischemic burden. Based on the weight of the chi-square increase at each step of the multivariable analysis, we created a simple clinical-stressCMR (C-CMR-10) score that included these variables (age ≥ 65 years = 3 points, LVEF ≤ 50% = 3 points, DM = 2 points, male sex = 1 point, and ischemic burden > 5 segments = 1 point). This 0 to 10 points C-CMR-10 score showed good performance to predict all-cause annualized mortality rate ranging from 0.29%/year (score = 0) to >4.6%/year (score ≥ 7). The goodness of the model and of the C-CMR-10 score was separately confirmed in 2 internal cohorts (n > 3000 each). We conclude that a novel and simple clinical-stressCMR score, which includes clinical and stressCMR variables, can provide robust prediction of the risk of long-term all-cause mortality in a population of patients with known or suspected CCS.

Sex Effect in the Decision to Perform Invasive Coronary Angiography in Patients With Chronic Coronary Syndrome After Undergoing Vasodilator Stress MRI

“…In the present study, we show that significant overuse of ICA and revascularization can be observed in men compared with women in patients with no ischemia in stress cardiac MRI, even after adjustment for potential confounders. This overprotective attitude toward men (even with negative non‐invasive stress imaging) probably derives from several factors, the first being the previously mentioned perception regarding a higher risk of IHD and cardiac events in men with known or suspected CCS compared to women 17–19 . Second, due to the former factor, it could also be speculated that clinicians are more prone to distrust negative stress cardiac MRI in men with relapsing chest pain.…”

“…15 The prevalence and incidence of IHD have typically been reported as lower in women than in men, 16 and in routine practice, clinicians tend to perceive a higher risk of pretest IHD 6,17,18 and subsequent cardiac events in men compared to women. Indeed, according to recent European charts 6,17 and large registries 19 for estimating individual cardiovascular risk, the likelihood of confirmed IHD or future adverse events is commonly lower in women than among age-matched men for any given risk factor or combination.…”

“…This overprotective attitude toward men (even with negative non-invasive stress imaging) probably derives from several factors, the first being the previously mentioned perception regarding a higher risk of IHD and cardiac events in men with known or suspected CCS compared to women. [17][18][19] Second, due to the former factor, it could also be speculated that clinicians are more prone to distrust negative stress cardiac MRI in men with relapsing chest pain. Conversely, in the case of women (given the a priori lower risk of IHD and events), a more conservative strategy would be undertaken.…”

Contemporary Role of Cardiac Magnetic Resonance in the Management of Patients with Suspected or Known Coronary Artery Disease

“…Adding aortic stiffness (as expressed by pulse wave velocity) to stress CMR could improve prediction of mortality, acute coronary syndrome, heart failure, need for coronary revascularization and stroke [ 47 ]. Furthermore, it has been suggested that the implementation of a score combining clinical (age, sex, diabetes mellitus and left ventricular ejection fraction) and stress CMR data (ischemic burden defined as the number of segments with stress-induced perfusion defects) could predict the risk of long-term all-cause mortality in patients with known or suspected CAD [ 48 ]. Appreciating that adenosine can be contraindicated in some individuals, newer pharmacological vasodilators like regadenoson stress CMR can also be used to predict adverse events in patients with known or suspected CAD.…”

Coronary Revascularization and Long-Term Survivorship in Chronic Coronary Syndrome

“…Over the last couple of decades, our group has compiled a large prospective registry that has sequentially demonstrated the value of stress CMR for diagnosis, risk stratification, and decision-making in patients with known or suspected CCS [ 62 , 73 , 74 , 75 , 77 , 78 ]. In the most recent update [ 62 ], we analyzed 6389 consecutive CCS patients undergoing stress perfusion CMR and focused on the most unarguable event, namely all-cause death.…”