Clinical Outcomes and Prognosis
Saadia Qazi, DO, MPH
Fellow
Brigham and Women's Hospital, Massachusetts, United States
Saadia Qazi, DO, MPH
Fellow
Brigham and Women's Hospital, Massachusetts, United States
Yin Ge, MD
Cardiologist
University of Toronto
Cambridge, Massachusetts, Canada
Bobby Heydari, MD
Associate Professor
University of Calgary
Calgary, Alberta, Canada
Panagiotis Antiochos, MD
Cardiologist
University Hospital of Lausanne (CHUV), Switzerland
Sabeeh Islam, MBBS
Research Fellow
Brigham and Women's Hospital, United States
Ryan Longmore, DO
Fellow
Brigham and Women's Hospital, United States
Krishna K. Patel, MD, MSc
Assistant Professor
Icahn School of Medicine at Mount Sinai
New York, New York, United States
Kevin Steel, MD
Cardiologist
St Joseph Medical Center
Bellingham, Washington, United States
Scott E. Bingham, MD
Cardiologist
Revere Health
Provo, Utah, United States
J. Ronald Mikolich, MD
Professor
Northeast Ohio Medical University
Sharon, Pennsylvania, United States
Andrew E. E. Arai, MD
Cardiologist
NIH
Kensington, Maryland, United States
W. Patricia Bandettini, MD
Cardiologist
NIH, Maryland, United States
Sujata Shanbhag, MD
Cardiologist
NIH
Bethesda, Maryland, United States
Amit R. Patel, MD
Professor
University of Virginia Health System
Charlottesville, Virginia, United States
Afshin Farzaneh-Far, MD
Cardiologist
University of Illinois
Chicago, Illinois, United States
John F. Heitner, MD
Cardiologist
New York University Grossman School of Medicine
Brooklyn, New York, United States
Chetan Shenoy, MBBS, MS
Associate Professor of Medicine
University of Minnesota
Minneapolis, Minnesota, United States
Steve W. Leung, MD, FSCMR
Associate Professor
University of Kentucky
Lexington, Kentucky, United States
Jorge A. Gonzalez, MD
Cardiologist
Scripps Clinic Medical Group
La Jolla, California, United States
Dipan J. Shah, MD
Chief, Division of Cardiovascular Imaging
Houston Methodist DeBakey Heart & Vascular Center
Houston, Texas, United States
Subha Raman, MD
Professor
IU Health/IU School of Medicine
Indianapolis, Indiana, United States
Orlando P. Simonetti, PhD
Professor, Medicine and Radiology
The Ohio State University
Columbus, Ohio, United States
Victor A. Ferrari, MD
Chair, Penn Cardiovascular Imaging Council
Hospital of the University of Pennsylvania and Penn Cardiovascular Institute
Phila., Pennsylvania, United States
Matthias Stuber, PhD
Professor
University Hospital (CHUV) and University of Lausanne (UNIL)
Lausanne, Switzerland
Jeanette Schulz-Menger, MD
Professor
Charité – Universitätsmedizin Berlin, ECRC, MDC, Helios Klinikum Berlin Buch, DZHK, Berlin, Germany
Berlin, Berlin, Germany
Raymond Y. Kwong, MD, MPH, FSCMR
Director of Cardiac Magnetic Resonance Imaging
Brigham and Women's Hospital
Boston, Massachusetts, United States
Patients with left ventricular (LV) dysfunction represent a high-risk clinical cohort who may benefit from coronary revascularization. Stress CMR is an accurate diagnostic and prognostic noninvasive imaging modality for evaluating underlying coronary artery disease in LV dysfunction; however, its effectiveness as a management tool across common patient demographic and coronary risk factors has not been well characterized. In this multicenter registry, we assessed the robustness of cardiac prognostication by stress CMR across various demographic and coronary artery disease (CAD) risk factors. We also assessed the utility of a negative stress CMR for major cardiac events and significant coronary disease where invasive referral could be safely deferred.
Methods:
Patients presenting with stable chest pain syndromes were drawn from the 13 US-centers included in the SPINS Registry. All patients had CMR evidence of cardiomyopathy (LVEF< 50%) and no documented evidence of CAD. They were followed for cardiovascular disease (CVD) death, non-fatal myocardial infarction (MI), and significant coronary stenosis either on invasive coronary or computed tomography angiography (CT) for a minimum of 4 years. Multivariable Cox models evaluated the adjusted association of the presence of ischemia or late gadolinium enhancement (LGE), with adverse outcomes. Patient age, sex, race, body habitus, diabetes, hypertension, LV size, and severity of LV dysfunction was evaluated as effect modifiers to prognosis.
Results:
Over a median follow-up of 4.7 (IQR: 2.2-6.5), among 601 adults (64% men), aged 61 ± 13 years, there were 105 adverse events. Median LVEF was 37% (IQR: 27-44%). Participants with ischemia/LGE (n=315) had an annual event rate for CVD mortality of 3.4% vs 0.58% for those without. Patients with ischemia/LGE had an event rate of 4.5% versus 0.84% in those with no ischemia/LGE for non-fatal MI or CVD mortality. Patients with ischemia/LGE had a 6.8% annual event rate, 6-fold higher than patients with no ischemia/LGE (event rate= 1.1%) for the composite of non-fatal MI, CVD mortality, or significant stenosis on coronary angiography (all p< 0.001). In a stepwise multivariable model, the presence of ischemia/LGE resulted in a nearly 5-fold increase in the risk of adverse events compared to patients with no ischemia/LGE (Hazard Ratio 4.9; 95% Confidence Interval 2.8-8.5). Age< 65, sex, BMI ≥ 30 kg/m2, white race, hypertension, diabetes, degree of LV dysfunction, or LV dilation did not modify this association.
Conclusion:
In patients with suspected ischemic cardiomyopathy, a negative stress CMR confers a low risk of cardiac events or subsequent diagnosis of significant coronary disease which supports that invasive referral can be safely deferred. In addition, neither age, sex, race, obesity, hypertension, diabetes, degree of LV dysfunction, nor LV dilation alters the robustness of cardiac prognostication by stress CMR.