Global Coronary Flow Reserve Measured During Stress Cardiac Magnetic Resonance Imaging Is an Independent Predictor of Adverse Cardiovascular Events

Indorkar, Raksha; Kwong, Raymond Y.; Romano, Simone; White, Brent E.; Chia, Richard; Trybula, Michael; Evans, Kaleigh L.; Shenoy, Chetan; Farzaneh‐Far, Afshin

doi:10.1016/j.jcmg.2018.08.018

Cited by 92 publications

(67 citation statements)

References 38 publications

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“…CMR has shown promising results to distinguish epicardial versus microvascular impairment compared to invasive FFR assessment [ 281 ]. Late gadolinium enhancement, detected by CMR, is correlated with higher risk of major CV events and mortality [ 282 , 283 , 284 ].…”

Section: Diagnosis Of Cmdmentioning

confidence: 99%

Coronary Microvascular Dysfunction

Vancheri¹,

Longo²,

Vancheri

et al. 2020

JCM

223

153

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Many patients with chest pain undergoing coronary angiography do not show significant obstructive coronary lesions. A substantial proportion of these patients have abnormalities in the function and structure of coronary microcirculation due to endothelial and smooth muscle cell dysfunction. The coronary microcirculation has a fundamental role in the regulation of coronary blood flow in response to cardiac oxygen requirements. Impairment of this mechanism, defined as coronary microvascular dysfunction (CMD), carries an increased risk of adverse cardiovascular clinical outcomes. Coronary endothelial dysfunction accounts for approximately two-thirds of clinical conditions presenting with symptoms and signs of myocardial ischemia without obstructive coronary disease, termed “ischemia with non-obstructive coronary artery disease” (INOCA) and for a small proportion of “myocardial infarction with non-obstructive coronary artery disease” (MINOCA). More frequently, the clinical presentation of INOCA is microvascular angina due to CMD, while some patients present vasospastic angina due to epicardial spasm, and mixed epicardial and microvascular forms. CMD may be associated with focal and diffuse epicardial coronary atherosclerosis, which may reinforce each other. Both INOCA and MINOCA are more common in females. Clinical classification of CMD includes the association with conditions in which atherosclerosis has limited relevance, with non-obstructive atherosclerosis, and with obstructive atherosclerosis. Several studies already exist which support the evidence that CMD is part of systemic microvascular disease involving multiple organs, such as brain and kidney. Moreover, CMD is strongly associated with the development of heart failure with preserved ejection fraction (HFpEF), diabetes, hypertensive heart disease, and also chronic inflammatory and autoimmune diseases. Since coronary microcirculation is not visible on invasive angiography or computed tomographic coronary angiography (CTCA), the diagnosis of CMD is usually based on functional assessment of microcirculation, which can be performed by both invasive and non-invasive methods, including the assessment of delayed flow of contrast during angiography, measurement of coronary flow reserve (CFR) and index of microvascular resistance (IMR), evaluation of angina induced by intracoronary acetylcholine infusion, and assessment of myocardial perfusion by positron emission tomography (PET) and magnetic resonance (CMR).

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Section: Diagnosis Of Cmdmentioning

confidence: 99%

Coronary Microvascular Dysfunction

Vancheri¹,

Longo²,

Vancheri

et al. 2020

JCM

223

153

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“…Stress perfusion CMR enables quantitative assessment of myocardial ischemia, and effectively reclassifies the risk of MACE in patients with DM [20]. PC cine CMR of the coronary sinus has emerged as a CMR method to evaluate global CFR, and its prognostic value of in patients with known or suspected CAD has been demonstrated [8,9]. Adding CFR to stress perfusion CMR resulted in improved accuracy in detecting multivessel CAD [21].…”

Section: Discussionmentioning

confidence: 99%

“…Validation studies have been performed using phantom models [6], animal experimental model using flow probes [7] and PET [3]. Recent studies have demonstrated the prognostic value of CMR-derived CFR for patients with known or suspected CAD [8,9]. In patients with DM, the prevalence of impaired CFR (< 2.0) was significantly higher compared with that in those without DM, and impairment of CFR was a significant predictor for adverse cardiac events [10].…”

Section: Introductionmentioning

confidence: 99%

Incremental prognostic value of coronary flow reserve determined by phase-contrast cine cardiovascular magnetic resonance of the coronary sinus in patients with diabetes mellitus

Kato

Fukui

Kodama

et al. 2020

Journal of Cardiovascular Magnetic Resonance

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Background Although non-invasive assessment of coronary flow reserve (CFR) by cardiovascular magnetic resonance (CMR) provides prognostic information for patients with diabetes mellitus (DM), the incremental prognostic value of CMR-derived CFR remains unclear. Purpose To evaluate the incremental prognostic value of CMR-derived CFR for patients with DM who underwent stress CMR imaging. Materials and methods A total of 309 patients with type 2 DM [69 ± 9 years; 244 (78%) male] assessed between 2009 and 2019 were retrospectively reviewed. Coronary sinus blood flow (CSBF) was measured using phase contrast (PC) cine CMR. CFR was calculated as the CSBF during adenosine triphosphate infusion divided by that at rest. Major adverse cardiac events (MACE) were defined as death, acute coronary syndrome, hospitalization due to heart failure exacerbation, or sustained ventricular tachycardia. The incremental prognostic value of CFR over clinical and CMR variables was assessed by calculating the C-index and net reclassification improvement (NRI). Results During a median follow-up of 3.8 years, 42 patients (14%) experienced MACE. The annualized event rate was significantly higher among patients with CFR < 2.0, regardless of the presence of late gadolinium enhancement (LGE) (1.4% vs. 9.8%, p = 0.011 in the LGE (−) group; 1.8% vs. 16.9%, p < 0.001 in the LGE (+) group). In addition, this trend was maintained in the subgroups stratified by presence or absence of ischemia (0.3% vs. 6.7%, p = 0.007 in the ischemia (−) group; 3.9% vs. 17.1%, p = 0.001 in the ischemia (+) group). Adding CFR to the risk model (age + gender + left ventricular ejection fraction + %LGE + %ischemia) resulted in a significant increase of the C-index from 0.838 to 0.870 (p = 0.038) and an NRI of 0.201 (0.004–0.368, p = 0.012). Conclusion PC cine CMR-derived CFR of the coronary sinus may be useful as a prognostic marker for DM patients, incremental to common clinical and CMR parameters. Due to the high prevalence of coronary microvascular dysfunction, the addition of CFR to conventional vasodilator stress CMR imaging may improve risk stratification for patients with DM.

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“…1081 According to a joint statement on dobutamine stress cardiac MRI from various Canadian academic societies (CCS/CAR/CANM/CNCS/CanSCMR Joint Position Statement on Advanced Noninvasive Cardiac Imaging), 1082 a meta-analysis of 13 studies with a total of 357 patients showed that LGE had a sensitivity of 81% and a specificity of 83% for predicting recovery of LV function, a result comparable to that for PET and superior to SPECT. 623,1089,1090…”

Section: Diagnostic Performancementioning

confidence: 99%

JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases

Yamagishi¹,

Tamaki²,

Akasaka³

et al. 2021

Circ J

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ABI ankle-brachial index ACC American College of Cardiology ACS acute coronary syndrome AHA American Heart Association APV averaged peak velocity ARH autosomal recessive hypercholesterolemia AS Agatston score ASO arteriosclerosis obliterans ATP adenosine triphosphate BMIPP β-methyl-p-iodophenyl-pentadecanoic acid BNP B-type natriuretic peptide CABG coronary artery bypass grafting CACS coronary artery calcium score CAD coronary artery disease CANM Canadian Association of Nuclear Medicine CanSCMR Canadian Society of Cardiovascular Magnetic Resonance CAR Canadian Association of Radiologists CCS Canadian Cardiovascular Society CCTA coronary CT angiography CDC Centers for Disease Control and Prevention CFR coronary flow reserve CFVR coronary flow velocity reserve CI confidence interval CKD chronic kidney disease CNCS Canadian Nuclear Cardiology Society CPAP continuous positive airway pressure CT computed tomography CTA computed tomography angiography CTDIvol computed omography dose index volume ▋ 2.2.1 Selection of the Lead System and Recording Time Appropriate ECG recording is essential for making a diagnosis of coronary heart disease. Care should be exercised with regard to selection of the electrodes, leads, paste, and lead system to obtain stable recordings during daily activities. The leads that are most likely to reflect ischemic changes are V5-like leads. In particular, lead CM5 is less affected by body movements and has a good detection rate for ischemic changes. 50 A 2-lead system is commonly used, and the AHA guidelines recommend a combination of leads that approximates leads V1 and V5. 51 For capturing ST elevation in patients with variant angina, vertical leads (II, III, and aVF) and approximations to lead V2 or V3 provide a high diagnostic rate. 52 Both circadian and diurnal (dayto-day) variations may exist in relation to the incidence and duration of myocardial ischemia and the extent of ST changes. However, it is difficult to evaluate the influence of diurnal variation based on 24-hour recording, which means that 48-hour recording is desirable for detecting myocardial ischemia and determining the response to treatment. ▋ 2.2.2 Criteria for ST-Segment Changes The diagnostic significance of persistent ST depression on Holter ECG is not high. Rather, detection and evaluation of transient ST-segment changes is more important. The criteria for ST depression are as follows: (1) horizontal or sagging depression of the ST segment by ≥0.1 mV; (2) reaching maximum ST depression after 1 min; and (3) ST depression of ≥0.1 mV lasting for ≥30-60 s compared with the baseline in a controlled state. 49,53-55 ST depression is measured at 0.08 s after the S or J point, and J-type ST depression is not judged to be ischemic ST depression. 52 When counting the number of ischemic episodes, the definition adopted is that each ischemic interval should last for at least 1 min. 56 The criterion for ST elevation is elevation of the ST segment by ≥0.1 mV lasting for ≥30-60 s in leads without Q waves. 49 In patients with chest pain ...

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Global Coronary Flow Reserve Measured During Stress Cardiac Magnetic Resonance Imaging Is an Independent Predictor of Adverse Cardiovascular Events

Cited by 92 publications

References 38 publications

Coronary Microvascular Dysfunction

Coronary Microvascular Dysfunction

Incremental prognostic value of coronary flow reserve determined by phase-contrast cine cardiovascular magnetic resonance of the coronary sinus in patients with diabetes mellitus

JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases

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