Diagnostic and Prognostic Value of Stress Cardiovascular Magnetic Resonance Imaging in Patients With Known or Suspected Coronary Artery Disease

Abstract

ImportanceThe clinical utility of stress cardiovascular magnetic resonance imaging (CMR) in stable chest pain is still debated, and the low-risk period for adverse cardiovascular (CV) events after a negative test result is unknown.ObjectiveTo provide contemporary quantitative data synthesis of the diagnostic accuracy and prognostic value of stress CMR in stable chest pain.Data SourcesPubMed and Embase databases, the Cochrane Database of Systematic Reviews, PROSPERO, and the ClinicalTrials.gov registry were searched for potentially relevant articles from January 1, 2000, through December 31, 2021.Study SelectionSelected studies evaluated CMR and reported estimates of diagnostic accuracy and/or raw data of adverse CV events for participants with either positive or negative stress CMR results. Prespecified combinations of keywords related to the diagnostic accuracy and prognostic value of stress CMR were used. A total of 3144 records were evaluated for title and abstract; of those, 235 articles were included in the full-text assessment of eligibility. After exclusions, 64 studies (74 470 total patients) published from October 29, 2002, through October 19, 2021, were included.Data Extraction and SynthesisThis systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.Main Outcomes and MeasuresDiagnostic odds ratios (DORs), sensitivity, specificity, area under the receiver operating characteristic curve (AUROC), odds ratio (OR), and annualized event rate (AER) for all-cause death, CV death, and major adverse cardiovascular events (MACEs) defined as the composite of myocardial infarction and CV death.ResultsA total of 33 diagnostic studies pooling 7814 individuals and 31 prognostic studies pooling 67 080 individuals (mean [SD] follow-up, 3.5 [2.1] years; range, 0.9-8.8 years; 381 357 person-years) were identified. Stress CMR yielded a DOR of 26.4 (95% CI, 10.6-65.9), a sensitivity of 81% (95% CI, 68%-89%), a specificity of 86% (95% CI, 75%-93%), and an AUROC of 0.84 (95% CI, 0.77-0.89) for the detection of functionally obstructive coronary artery disease. In the subgroup analysis, stress CMR yielded higher diagnostic accuracy in the setting of suspected coronary artery disease (DOR, 53.4; 95% CI, 27.7-103.0) or when using 3-T imaging (DOR, 33.2; 95% CI, 19.9-55.4). The presence of stress-inducible ischemia was associated with higher all-cause mortality (OR, 1.97; 95% CI, 1.69-2.31), CV mortality (OR, 6.40; 95% CI, 4.48-9.14), and MACEs (OR, 5.33; 95% CI, 4.04-7.04). The presence of late gadolinium enhancement (LGE) was associated with higher all-cause mortality (OR, 2.22; 95% CI, 1.99-2.47), CV mortality (OR, 6.03; 95% CI, 2.76-13.13), and increased risk of MACEs (OR, 5.42; 95% CI, 3.42-8.60). After a negative test result, pooled AERs for CV death were less than 1.0%.Conclusion and RelevanceIn this study, stress CMR yielded high diagnostic accuracy and delivered robust prognostication, particularly when 3-T scanners were used. While inducible myocardial ischemia and LGE were associated with higher mortality and risk of MACEs, normal stress CMR results were associated with a lower risk of MACEs for at least 3.5 years.

Diagnostic and prognostic value of angiography-derived index of microvascular resistance: a systematic review and meta-analysis

“…The pooled HR for A-IMR in predicting long-term MACE was 2.73 (95% CI: 2.16, 3.45), and consistent in both populations with and without STEMI. Compared with other CMD diagnosis methods, A-IMR did not manifest clear inferiority to T-IMR [HR MACE ranges from 2.2 to 4.1 (43)] or electrocardiography [HR MACE ranges from 1.43 to 1.68 (44)]; contrarily, in comparison to CMR (44,45) and cardiac PET (46), the HR MACE of A-IMR was comparatively lower.…”

Stress-Only CMR Perfusion: Ready for Clinical Application?

“…These challenges for CMR include factors such as its still limited availability, the relatively lengthy scan duration, the requirement for a well-trained, multidisciplinary team, and the absence of consistent standardization, particularly concerning the definition of myocardial ischemia. In a recent meta-analysis investigating the diagnostic and prognostic capabilities of stress CMR, 3 encompassing data from over 74 000 patients and >381 000 person-years of follow-up, the stress CMR high diagnostic accuracy and outstanding risk stratification abilities were confirmed among patients with both established and suspected CAD. Importantly, included studies exhibited a lack of uniformity in their definition of ischemia, with some studies defining ischemia using rest perfusion and others only LGE, underscoring the need for standardization and uniformity in this regard.…”

Moderate aortic stenosis: Navigating the uncharted

“…The safety profile and incidence of adverse events for stress CMR are comparable to other indications for this test and to other pharmacological stress methods. 75,76 Notably, adenosine perfusion CMR is associated with significantly fewer complications and milder symptoms compared to dobutamine stress CMR, underscoring its utility and safety. Before AVR, severe aortic stenosis often results in marked hypoperfusion under adenosine stress, especially in the subendocardial regions, which is early and largely reversible after AVR.…”