Gabriella Vincenti1, Pier Giorgio Masci1, Pierre Monney1, Tobias Rutz1, Sarah Hugelshofer2, Mirdita Gaxherri2, Olivier Muller2, Juan F Iglesias2, Eric Eeckhout2, Valentina Lorenzoni3, Cyril Pellaton4, Christophe Sierro5, Juerg Schwitter6. 1. Division of Cardiology University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Cardiac MR Center, University Hospital of Lausanne (CHUV), Lausanne, Switzerland. 2. Division of Cardiology University Hospital of Lausanne (CHUV), Lausanne, Switzerland. 3. Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy. 4. Cardiac MR Center, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Division of Cardiology, Department of Internal Medicine, Neuchâtel, Switzerland. 5. Division of Cardiology University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Cardiac MR Center, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Division of Cardiology, Centre Hospitalier du Valais Romand (CHVR), Sion, Switzerland. 6. Division of Cardiology University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Cardiac MR Center, University Hospital of Lausanne (CHUV), Lausanne, Switzerland. Electronic address: jurg.schwitter@chuv.ch.
Abstract
OBJECTIVES: This study sought to determine the ischemia threshold and additional prognostic factors that identify patients for safe deferral from revascularizations in a large cohort of all-comer patients with known or suspected coronary artery disease (CAD). BACKGROUND: Stress-perfusion cardiac magnetic resonance (CMR) is increasingly used in daily practice for ischemia detection. However, there is insufficient evidence about the ischemia burden that identifies patients who benefit from revascularization versus those with a good prognosis who receive drugs only. METHODS: All patients with known or suspected CAD referred to stress-perfusion CMR for myocardial ischemia assessment were prospectively enrolled. The CMR examination included standard functional adenosine stress first-pass perfusion (gadobutrol 0.1 mmol/kg Gadovist, Bayer AG, Zurich, Switzerland) and late gadolinium enhancement (LGE) acquisitions. Presence of ischemia and ischemia burden (number of ischemic segments on a 16-segment model), and of scar and scar burden (number and transmurality of scar segments in a 17-segment model) were assessed. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction (MI), and late coronary revascularization (>90 days post-CMR); the secondary endpoint was a composite of cardiac death and nonfatal MI. RESULTS: During a follow-up of 2.5 ± 1.0 years, 86 and 32 of 1,024 patients (1,103 screened patients) experienced the primary and secondary endpoints, respectively. On Kaplan-Meier curves for the primary and secondary endpoints, patients without ischemia had excellent outcomes that did not differ from patients with <1.5 ischemic segments. In multivariate Cox regression analyses of the entire population and of the subgroups, ischemia burden (threshold: ≥1.5 ischemic segments) was consistently the strongest predictor of the primary and secondary endpoints with hazard ratios (HRs) of 7.42 to 8.72 (p < 0.001), whereas age (≥67 years), left ventricular ejection fraction (≤40%), and scar burden (LGE score ≥0.03) contributed significantly, but to a lesser extent, in all models with HRs of 2.01 to 3.48, 1.75 to 1.96, and 1.66 to 1.76, respectively. CONCLUSIONS: In a large all-comer patient cohort with known and suspected CAD, an ischemia burden of ≥1.5 ischemic segments on stress-perfusion CMR was the strongest predictor of the primary and secondary endpoints. Patients with zero or 1 ischemic segment can be safely deferred from revascularizations.
OBJECTIVES: This study sought to determine the ischemia threshold and additional prognostic factors that identify patients for safe deferral from revascularizations in a large cohort of all-comer patients with known or suspected coronary artery disease (CAD). BACKGROUND: Stress-perfusion cardiac magnetic resonance (CMR) is increasingly used in daily practice for ischemia detection. However, there is insufficient evidence about the ischemia burden that identifies patients who benefit from revascularization versus those with a good prognosis who receive drugs only. METHODS: All patients with known or suspected CAD referred to stress-perfusion CMR for myocardial ischemia assessment were prospectively enrolled. The CMR examination included standard functional adenosine stress first-pass perfusion (gadobutrol 0.1 mmol/kg Gadovist, Bayer AG, Zurich, Switzerland) and late gadolinium enhancement (LGE) acquisitions. Presence of ischemia and ischemia burden (number of ischemic segments on a 16-segment model), and of scar and scar burden (number and transmurality of scar segments in a 17-segment model) were assessed. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction (MI), and late coronary revascularization (>90 days post-CMR); the secondary endpoint was a composite of cardiac death and nonfatal MI. RESULTS: During a follow-up of 2.5 ± 1.0 years, 86 and 32 of 1,024 patients (1,103 screened patients) experienced the primary and secondary endpoints, respectively. On Kaplan-Meier curves for the primary and secondary endpoints, patients without ischemia had excellent outcomes that did not differ from patients with <1.5 ischemic segments. In multivariate Cox regression analyses of the entire population and of the subgroups, ischemia burden (threshold: ≥1.5 ischemic segments) was consistently the strongest predictor of the primary and secondary endpoints with hazard ratios (HRs) of 7.42 to 8.72 (p < 0.001), whereas age (≥67 years), left ventricular ejection fraction (≤40%), and scar burden (LGE score ≥0.03) contributed significantly, but to a lesser extent, in all models with HRs of 2.01 to 3.48, 1.75 to 1.96, and 1.66 to 1.76, respectively. CONCLUSIONS: In a large all-comer patient cohort with known and suspected CAD, an ischemia burden of ≥1.5 ischemic segments on stress-perfusion CMR was the strongest predictor of the primary and secondary endpoints. Patients with zero or 1 ischemic segment can be safely deferred from revascularizations.
Authors: Patrick Krumm; Stefanie Mangold; Sergios Gatidis; Konstantin Nikolaou; Felix Nensa; Fabian Bamberg; Christian la Fougère Journal: Jpn J Radiol Date: 2018-03-10 Impact factor: 2.374
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Authors: Raymond Y Kwong; Yin Ge; Kevin Steel; Scott Bingham; Shuaib Abdullah; Kana Fujikura; Wei Wang; Ankur Pandya; Yi-Yun Chen; J Ronald Mikolich; Sebastian Boland; Andrew E Arai; W Patricia Bandettini; Sujata M Shanbhag; Amit R Patel; Akhil Narang; Afshin Farzaneh-Far; Benjamin Romer; John F Heitner; Jean Y Ho; Jaspal Singh; Chetan Shenoy; Andrew Hughes; Steve W Leung; Meera Marji; Jorge A Gonzalez; Sandeep Mehta; Dipan J Shah; Dany Debs; Subha V Raman; Avirup Guha; Victor A Ferrari; Jeanette Schulz-Menger; Rory Hachamovitch; Matthias Stuber; Orlando P Simonetti Journal: J Am Coll Cardiol Date: 2019-10-08 Impact factor: 24.094
Authors: Panagiotis Antiochos; Yin Ge; Kevin Steel; Yi-Yun Chen; Scott Bingham; Shuaib Abdullah; J Ronald Mikolich; Andrew E Arai; W Patricia Bandettini; Amit R Patel; Afshin Farzaneh-Far; John F Heitner; Chetan Shenoy; Steve W Leung; Jorge A Gonzalez; Dipan J Shah; Subha V Raman; Victor A Ferrari; Jeanette Schulz-Menger; Matthias Stuber; Orlando P Simonetti; Venkatesh L Murthy; Raymond Y Kwong Journal: JAMA Cardiol Date: 2020-12-01 Impact factor: 14.676