Detection of coronary artery disease in postmenopausal women: the significance of integrated stress imaging tests in a 4-year prognostic study

Diagnostic and Prognostic Value of Stress Cardiovascular Magnetic Resonance Imaging in Patients With Known or Suspected Coronary Artery Disease: A Systematic Review and Meta-analysis

Importance

The clinical utility of stress cardiovascular magnetic resonance imaging (CMR) in stable chest pain is still debated, and the low-risk period for adverse cardiovascular (CV) events after a negative test result is unknown.

Objective

To provide contemporary quantitative data synthesis of the diagnostic accuracy and prognostic value of stress CMR in stable chest pain.

Data Sources

PubMed and Embase databases, the Cochrane Database of Systematic Reviews, PROSPERO, and the ClinicalTrials.gov registry were searched for potentially relevant articles from January 1, 2000, through December 31, 2021.

Study Selection

Selected studies evaluated CMR and reported estimates of diagnostic accuracy and/or raw data of adverse CV events for participants with either positive or negative stress CMR results. Prespecified combinations of keywords related to the diagnostic accuracy and prognostic value of stress CMR were used. A total of 3144 records were evaluated for title and abstract; of those, 235 articles were included in the full-text assessment of eligibility. After exclusions, 64 studies (74 470 total patients) published from October 29, 2002, through October 19, 2021, were included.

Data Extraction and Synthesis

This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Main Outcomes and Measures

Diagnostic odds ratios (DORs), sensitivity, specificity, area under the receiver operating characteristic curve (AUROC), odds ratio (OR), and annualized event rate (AER) for all-cause death, CV death, and major adverse cardiovascular events (MACEs) defined as the composite of myocardial infarction and CV death.

Results

A total of 33 diagnostic studies pooling 7814 individuals and 31 prognostic studies pooling 67 080 individuals (mean [SD] follow-up, 3.5 [2.1] years; range, 0.9-8.8 years; 381 357 person-years) were identified. Stress CMR yielded a DOR of 26.4 (95% CI, 10.6-65.9), a sensitivity of 81% (95% CI, 68%-89%), a specificity of 86% (95% CI, 75%-93%), and an AUROC of 0.84 (95% CI, 0.77-0.89) for the detection of functionally obstructive coronary artery disease. In the subgroup analysis, stress CMR yielded higher diagnostic accuracy in the setting of suspected coronary artery disease (DOR, 53.4; 95% CI, 27.7-103.0) or when using 3-T imaging (DOR, 33.2; 95% CI, 19.9-55.4). The presence of stress-inducible ischemia was associated with higher all-cause mortality (OR, 1.97; 95% CI, 1.69-2.31), CV mortality (OR, 6.40; 95% CI, 4.48-9.14), and MACEs (OR, 5.33; 95% CI, 4.04-7.04). The presence of late gadolinium enhancement (LGE) was associated with higher all-cause mortality (OR, 2.22; 95% CI, 1.99-2.47), CV mortality (OR, 6.03; 95% CI, 2.76-13.13), and increased risk of MACEs (OR, 5.42; 95% CI, 3.42-8.60). After a negative test result, pooled AERs for CV death were less than 1.0%.

Conclusion and Relevance

In this study, stress CMR yielded high diagnostic accuracy and delivered robust prognostication, particularly when 3-T scanners were used. While inducible myocardial ischemia and LGE were associated with higher mortality and risk of MACEs, normal stress CMR results were associated with a lower risk of MACEs for at least 3.5 years.

Cardiovascular Evaluation of Liver Transplant Patients by Using Coronary Calcium Scoring in ECG-Synchronized Computed Tomographic Scans

Background: The goal of cardiac evaluation of patients awaiting orthotopic liver transplantation (OLT) is to identify the patients at risk for cardiovascular events (CVEs) in the peri- and postoperative periods by opportunistic evaluation of coronary artery calcium (CAC) in non-gated abdominal computed tomographs (CT). Methods: We hypothesized that in patients with OLT, a combination of Lee’s revised cardiac index (RCRI) and CAC scoring would improve diagnostic accuracy and prognostic impact compared to non-invasive cardiac testing. Therefore, we retrospectively evaluated 169 patients and compared prediction of CVEs by both methods. Results: Standard workup identified 22 patients with a high risk for CVEs during the transplant period, leading to coronary interventions. Eighteen patients had a CVE after transplant and a CAC score > 0. The combination of CAC and RCRI ≥ 2 had better negative (NPV) and positive predictive values (PPV) for CVEs (NPV 95.7%, PPV 81.6%) than standard non-invasive stress tests (NPV 92.0%, PPV 54.5%). Conclusion: The cutoff value of CAC > 0 by non-gated CTs combined with RCRI ≥ 2 is highly sensitive for identifying patients at risk for CVEs in the OLT population.

Contemporary Role of Cardiac Magnetic Resonance in the Management of Patients with Suspected or Known Coronary Artery Disease

Cardiac magnetic resonance imaging (CMR) is a useful non-invasive radiation-free imaging modality for the management of patients with coronary artery disease (CAD). CMR cine imaging provides the “gold standard” assessment of ventricular function, late gadolinium enhancement (LGE) provides useful data for the diagnosis and extent of myocardial scar and viability, while stress imaging is an established technique for the detection of myocardial perfusion defects indicating ischemia. Beyond its role in the diagnosis of CAD, CMR allows accurate risk stratification of patients with established CAD. This review aims to summarize the data regarding the role of CMR in the contemporary management of patients with suspected or known coronary artery disease.

Role of exercise cardiogoniometry in coronary artery disease diagnostics

BACKGROUND

The use of noninvasive diagnostics in coronary artery disease remains underdeveloped. To date, there is no simple and inexpensive method that can lead to a reliable diagnosis. Aside from costly and elaborate imaging techniques, exercise ECG, with its rather moderate sensitivity and specificity, is the main diagnostic method available.

METHODS

In this prospective study of 109 patients, the diagnostic value of cardiogoniometry (CGM), a three-dimensional, computer-analyzed vector cardiogram, was determined before and after physical stress, and the results were compared with those obtained from a stress test. We also investigated whether the sensitivity and specificity of the classical bicycle stress test could be increased with the addition of measurements obtained by CGM. Coronary angiography was used as a reference method.

RESULTS

CGM had a sensitivity of 39% at rest and 42% after physical stress and a specificity of 63% at rest and 57% after stress. This method was found to be markedly inferior to pre-test probability (sensitivity 53%, specificity 81%), stress ECG (sensitivity 52%, specificity 81%), and resting ECG (sensitivity 50%, specificity 64%). The efficiency of exercise ECG testing was not improved by use of CGM results.

CONCLUSION

If CGM is to be established as a viable diagnostic method in daily clinical practice, it must undergo further development.

Left ventricular ejection fraction and presence of myocardial necrosis assessed by cardiac magnetic resonance imaging correctly risk stratify patients with stable coronary artery disease: a multi-center all-comers trial

BACKGROUND

Cardiac magnetic resonance imaging (CMR) has become a diagnostic modality that allows for prognostic risk stratification in various cardiac diseases. CMR derived detection of myocardial necrosis by late gadolinium enhancement (LGE) and assessment of left ventricular functional parameters such as left-ventricular ejection fraction (LVEF) have been proven to be significantly associated with outcome and prognosis. Our study focusses on the validation of specific thresholds for these parameters in a multi-center daily all-comers cohort of stable coronary artery disease (CAD) patients.

METHODS

Multi-center data from tertiary high-volume CMR centers were pooled. Patients referred for viability testing for known or suspected CAD were enrolled. Functional parameters of both ventricles and myocardial necrosis were assessed. The primary endpoint was defined as cardiac death and non-fatal myocardial infarction. A multi-model approach was used for the evaluation of the predictive power of several LVEF thresholds and LGE.

RESULTS

The study cohort consisted of 2422 patients. Median age was 66 years; 25.9 % were female. Median follow-up was 2.86 years. During the follow-up period, 187 primary endpoints occurred. On multi-model testing, optimal thresholds for LVEF could be defined at ≤50 and ≤35 %. The addition of LGE as categorical variable further lead to a significant improvement of each risk prediction model, whilst quantification of LGE affection had no additional prognostic impact.

CONCLUSION

LVEF thresholds at ≤50 and ≤35 % in combination with the assessment of LGE presence allows for excellent discrimination between low, mid and high prognostic risk in stable CAD.

The role of stress cardiac magnetic resonance in women

Coronary artery disease (CAD) is the leading cause of death in women. Nevertheless, extensive evidence demonstrates under-diagnosis and under-treatment of women for suspected or known ischemic heart disease (IHD). Stress cardiac magnetic resonance (CMR) is becoming readily available and offers significant advantages over other stress imaging modalities. The high spatial and temporal resolution of CMR provides the unique ability to identify subendocardial ischemia, viability, and the presence of microvascular disease. Furthermore, CMR is free from ionizing radiation, and image quality is not compromised by attenuation artifacts or patient size. Over the past two decades, evidence-based data have demonstrated the high diagnostic and prognostic performance of stress CMR in the context of IHD, often superior to other stress imaging techniques. Importantly, ad hoc studies confirmed these results in women with known or suspected IHD. Stress CMR warrants consideration as the modality of choice for women requiring an imaging test for ischemia given its strong evidence base, superior test characteristics, comprehensive nature, and unique ability to characterize both epicardial and microvascular disease.

Gender differences in therapeutic recommendation after diagnostic coronary angiography: insights from the Coronary Angiography and PCI Registry of the German Society of Cardiology

BACKGROUND

There is information suggesting differences and underuse of invasive coronary diagnostic and therapeutic procedures in women compared to men.

METHODS

Data from consecutive patients (pts) which were enrolled in the Coronary Angiography and PCI Registry of the German Society of Cardiology were analyzed. We compared gender-related differences in diagnosis and therapeutic recommendation of pts undergoing coronary angiography (XA) for stable coronary artery disease (CAD), non-ST elevation acute coronary syndromes (NSTE-ACS) and ST elevation myocardial infarction (STEMI).

RESULTS

From 2004 until the end of 2009, data of 1,060,542 invasive procedures in 1,014,996 pts were prospectively registered. One-third (34.6%) of them were female. Women less often had significant CAD, irrespective of the indication for XA. In pts with relevant CAD, percutaneous coronary interventions (PCI) were recommended in 87.1% of women versus 89.1% of men with STEMI [age-adjusted OR (aOR) 0.98, 95% CI 0.93-1.04], in 67.1 vs. 66.8% in NSTE-ACS (aOR 1.10, 1.07-1.12), and in 50.3 vs 49.4% in stable CAD (aOR 1.07, 1.05-1.09).

CONCLUSIONS

In pts with significant CAD, there was no difference in recommendation for PCI between the genders in stable CAD, whereas in STEMI and NSTE-ACS women were treated even more often with PCI. There were only minor differences in referral for CABG between women and men. Hence, our data provide strong evidence against a gender bias in use of invasive therapeutic procedures once the diagnosis of significant CAD has been confirmed.