Prognostic role of stress-CMR and SPECT-MPI in patients undergoing intermediate-to-high risk non-cardiac surgery

Abstract

Funding Acknowledgements Type of funding sources: None. Introduction Data supporting the role of stress test myocardial perfusion imaging (MPI) before non-cardiac surgery (NCS) are sparse and out of date. In particular, there is no specific evidence on the use of stress cardiac magnetic resonance (sCMR) in this setting. The aim of the present study was to evaluate the impact MPI stress test with sCMR and single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) on surgery-related cardiac events. Method In this single-centre retrospective study, we included all patients with CAD or at least two cardiovascular risk factors undergoing intermediate-to-high-risk non-cardiac surgery. After a pre-operative cardiological assessment, including EKG and echocardiography, the indication to perform a pre-operative MPI-stress-test relied on the clinical judgement of the cardiologist. Cardiac events occurring within 30 days from surgery were evaluated. A composite primary endpoint included myocardial infarction, unstable angina, cardiac death, cardiogenic shock and pulmonary oedema. The secondary endpoint was the rate of acute coronary syndromes. Results A total of 1590 patients were included, of whom 669 underwent an MPI stress test strategy (287 sCMR, 382 SPECT-MPI). The rate of 30-day cardiac events was lower in the stress test group vs. the non-stress test group (1.2% vs 3.4%; p 0,006; figure 1). Adopting a stress test strategy showed a significant reduction of composite endpoint (OR: 0.334, IC: 0.155 – 0.766, p 0.009) and acute coronary syndrome (OR: 0.414, IC: 0.174 – 0.984, p 0.046) at multivariable analysis. Stress CMR was non-inferior to SPECT in predicting cardiac events and showed a greater accuracy to predict coronary artery revascularizations (AUC for sCMR: 0.95 with a percentage of myocardial ischemia cut-point of 5.5%; figure 2). Conclusions A stress-test strategy is associated with a lower incidence of cardiac events in high-risk patients candidate to intermediate-to-high-risk non-cardiac surgery. The rate of cardiac complications is similarly predicted by sCMR and SPECT-MPI, although sCMR is more accurate in predicting coronary artery revascularizations.