Stress cardiovascular magnetic resonance imaging provides accurate diagnosis and risk stratification in patients with known or suspected coronary artery disease

1. This systematic review and meta-analysis of 74470 patients with stable chest pain revealed that stress cardiovascular magnetic resonance imaging (CMR), particularly with 3-T MRI, offered highly accurate diagnostic capabilities and effective risk stratification in individuals with known or suspected coronary artery disease (CAD).

2. Stress-inducible ischemia and late gadolinium enhancement were associated with increased mortality and the likelihood of cardiovascular events, whereas normal stress CMR findings were linked to a reduced likelihood of cardiovascular events for a minimum of 3.5 years.

Evidence Rating Level: 2 (Good)

Study Rundown: Stress CMR has been increasingly used worldwide as a noninvasive imaging modality for one of its main indications, CAD, a condition that is known for its morbidity and mortality. Assessing perfusion reserve or regional wall motion abnormalities to evaluate stress-inducible myocardial ischemia plays a crucial role in the diagnostic evaluation of patients experiencing stable chest pain and having an intermediate to high pretest probability of CAD. This study sought to evaluate stress CMR’s diagnostic accuracy and prognostic value for symptomatic patients with known or suspected CAD, as there has been a lack of current data summarizing this. This systematic review and meta-analysis supported the value of stress CMR as findings showed high diagnostic accuracy in detecting CAD in patients with stable chest pain and known or suspected CAD. Additionally, stress CMR provided robust prognostic information and accurate risk stratification. Notably, the presence of ischemia and late gadolinium enhancement (LGE) was associated with increased cardiovascular risk and mortality, while normal stress CMR results were linked to a lower likelihood of major adverse cardiovascular events (MACEs) for a minimum of 3.5 years. Moreover, stress CMR’s favorable cost-effectiveness profile, when compared to other relevant comparators, suggests that providing access to CMR can benefit patients and lead to significant cost savings by reducing the need for unnecessary tests and revascularization procedures. One strength of this study is that it provides novel findings regarding the duration of the low-risk period after a normal stress CMR result for major adverse cardiovascular events (MACEs), potentially influencing future clinical guidelines for repeat imaging intervals and aiding in the management of assessment strategies for symptomatic patients with initial normal imaging results or subclinical disease. In conclusion, these findings highlight the value of combined assessment of inducible myocardial ischemia and LGE through stress CMR as an accurate method for diagnosing and risk-stratifying patients with known or suspected CAD.

Click to read the study in JAMA Cardiology

Relevant Reading: Cardiac Magnetic Resonance Stress Perfusion Imaging for Evaluation of Patients With Chest Pain

In-Depth [systematic review and meta-analysis]: This study followed the PRISMA guideline and Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. Eligibility criteria included full-length articles written in English, with prospective or retrospective study designs, at least 100 enrolled patients over 18, and reported estimates of the diagnostic accuracy of stress CMR and/or reported raw data for all-cause death, cardiovascular death, and MACEs for study participants. The meta-analysis included a total of 64 studies published between October 29, 2002, and October 19, 2021, consisting of 33 diagnostic studies with 7814 participants and 31 prognostic studies with 67080 participants, while the mean (SD) follow-up duration was 3.5 (2.1) years (range, 0.9-8.8 years), encompassing 381,357 person-years among 74,470 patients.

In the analysis of diagnostic studies, stress CMR showed a sensitivity of 84% and a specificity of 79% for detecting anatomically obstructive CAD when compared to ICA, with a pooled diagnostic odds ratio (DOR) of 19.1 (95% CI, 12.6-29.1) and an AUROC of 0.81. Compared to invasive FFR, stress CMR yielded a sensitivity of 81% and a specificity of 86% for detecting functionally obstructive CAD, with a pooled DOR of 26.4 (95% CI, 10.6-65.9) and an AUROC of 0.84.

In the prognostic analysis, the presence of inducible ischemia detected by stress CMR was associated with a roughly 2-fold increased all-cause mortality (OR, 1.97; 95% CI, 1.69-2.31; P = .002) and a roughly 6-fold increased cardiovascular mortality (OR, 6.40; 95% CI, 4.48-9.14; P < .001). The presence of LGE was also associated with a roughly 2-fold increased all-cause mortality (OR, 2.22; 95% CI, 1.99-2.47; P < .001) and a roughly 6-fold increased cardiovascular mortality (OR, 6.03; 95% CI, 2.76-13.13; P < .001). For the occurrence of MACEs, both inducible ischemia and LGE were associated with a roughly 5-fold higher likelihood of incident MACEs, with pooled ORs of 5.33 (95% CI, 4.04-7.04; P < .001) and 5.42 (95% CI, 3.42-8.60; P < .001), respectively. Combining ischemia and LGE information, the presence of both factors yielded a pooled all-cause event rate (AER) of 4.24%, while the absence of both factors resulted in a pooled AER of 0.58% (P < .001) at a mean follow-up of 3.5 years.

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