Rapid rest/stress regadenoson ungated perfusion CMR for detection of coronary artery disease in patients with atrial fibrillation

Qualitative and Quantitative Stress Perfusion Cardiac Magnetic Resonance in Clinical Practice: A Comprehensive Review

Stress cardiovascular magnetic resonance (CMR) imaging is a well-validated non-invasive stress test to diagnose significant coronary artery disease (CAD), with higher diagnostic accuracy than other common functional imaging modalities. One-stop assessment of myocardial ischemia, cardiac function, and myocardial viability qualitatively and quantitatively has been proven to be a cost-effective method in clinical practice for CAD evaluation. Beyond diagnosis, stress CMR also provides prognostic information and guides coronary revascularisation. In addition to CAD, there is a large body of literature demonstrating CMR's diagnostic performance and prognostic value in other common cardiovascular diseases (CVDs), especially coronary microvascular dysfunction (CMD). This review focuses on the clinical applications of stress CMR, including stress CMR scanning methods, practical interpretation of stress CMR images, and clinical utility of stress CMR in a setting of CVDs with possible myocardial ischemia.

Long-term prognostic value of vasodilator stress cardiac magnetic resonance in patients with atrial fibrillation

AIMS

Although the prevalence of coronary artery disease (CAD) is high among patients with atrial fibrillation (AF), studies on stress perfusion cardiac magnetic resonance (CMR) imaging frequently exclude patients with AF, and its prognostic and diagnostic value in high-risk patients with suspected or known CAD remains unclear.

METHODS AND RESULTS

In this longitudinal cohort study, we included 164 consecutive patients with AF during vasodilator perfusion CMR. Diagnostic value was evaluated regarding invasive coronary angiography in a subset of patients. We targeted a follow-up of >5 years and used CMR results as stratification, and the primary outcome was major adverse cardiac events [MACE, cardiovascular (CV) death and myocardial infarction (MI)]. Secondary outcomes included late coronary revascularization or stroke and the components of the primary outcome. Of the whole cohort (73.8% male, mean age 72.2 years ± 7.8 SD), 99.4% were successfully scanned (163/164 patients). Median CHA2DS2-VASc score was 4 [interquartile range (IQR) 3-5], and median 10-year risk for CV events based on SMART risk score was high (24%, IQR 16-32%). Thirty-two patients (19.6%) presented with ischaemia and 52 patients (31.9%) with late gadolinium enhancement (LGE). A combination of LGE and inducible ischaemia was present in 20 patients (12.3%). Diagnostic accuracy was 86.2% [confidence interval (CI) 68.3-96.1%]. The median follow-up was 6.6 years (IQR 3.6-7.8). Ischaemia in vasodilator perfusion CMR was significantly associated with the occurrence of MACE [P < 0.01; hazard ratio (HR) 2.65, CI 1.39-5.08], as well as LGE (P = 0.03; 1.74, CI 1.07-3.64) and the combination of both (P < 0.01; HR 2.67, CI 1.59-5.62). After adjustment by age, left ventricular ejection fraction, and the presence of diabetes, ischaemia in vasodilator perfusion CMR remained significantly associated with the occurrence of MACE (2.10, CI 1.08-4.10; P = 0.03). In secondary endpoint analysis, there was a significant association of ischaemia in CMR with CV death (P < 0.05; HR 1.93, CI 0.95-3.9) and MI (P < 0.01; HR 13, CI 1.35-125.4), while no significant association was found regarding the occurrence of revascularization (P = 0.45; HR 1.43, CI 0.57-3.58) or stroke (P = 0.99; HR 0.99, CI 0.21-2.59).

CONCLUSIONS

Vasodilator stress perfusion CMR demonstrated an excellent diagnostic and significant prognostic value at long-term follow-up in high-risk patients with persistent AF and suspected or known CAD.

Feasibility and Prognostic Value of Vasodilator Stress Perfusion CMR in Patients With Atrial Fibrillation

OBJECTIVES

The aim of this study was to assess the feasibility and prognostic value of vasodilator stress perfusion cardiovascular magnetic resonance (CMR) in patients with atrial fibrillation (AF).

BACKGROUND

Because most studies have excluded arrhythmic patients, the prognostic value of stress perfusion CMR in patients with AF is unknown.

METHODS

Between 2008 and 2018, consecutive patients with suspected or stable chronic coronary artery disease and AF referred for vasodilator stress perfusion CMR were included and followed for the occurrence of major adverse cardiovascular event(s) (MACE), defined as cardiovascular death or nonfatal myocardial infarction. The diagnosis of AF was defined by 12-lead electrocardiography before and after CMR. Univariate and multivariate Cox regressions were performed to determine the prognostic value of inducible ischemia or late gadolinium enhancement (LGE) by CMR.

RESULTS

Of 639 patients (mean age 72 ± 9 years, 77% men), 602 (94%) completed the CMR protocol, and 538 (89%) completed follow-up (median 5.1 years); 80 had MACE. Using Kaplan-Meier analysis, the presence of ischemia (hazard ratio [HR]: 7.56; 95% confidence interval [CI]: 4.86 to 11.80) or LGE (HR: 2.41; 95% CI: 1.55 to 3.74) was associated with the occurrence of MACE (p < 0.001 for both). In a multivariate Cox regression including clinical and CMR indexes, the presence of ischemia (HR: 5.98; 95% CI: 3.68 to 9.73) or LGE (HR: 2.61; 95% CI: 1.89 to 3.60) was an independent predictor of MACE (p < 0.001 for both).

CONCLUSIONS

In patients with AF, stress perfusion CMR is feasible and has good discriminative prognostic value to predict the occurrence of MACE.