Vol 24, No 3 (2017)
Original articles — Clinical cardiology
Published online: 2017-03-27
Cardiac magnetic resonance imaging derived quantification of myocardial ischemia and scar improves risk stratification and patient management in stable coronary artery disease
Abstract
Background: Quantification of myocardial ischemia and necrosis might ameliorate prognostic models and lead to improved patient management. However, no standardized consensus on how to assess and quantify these parameters has been established. The aim of this study was to quantify these variables by cardiac magnetic resonance imaging (CMR) and to establish possible incremental implications in cardiovascular risk prediction.
Methods: This study is a retrospective analysis of patients with known or suspected coronary artery disease (CAD) referred for adenosine perfusion CMR was performed. Myocardial ischemia and necrosis were assessed and quantified using an algorithm based on standard first-pass perfusion imaging and late gadolinium enhancement (LGE). The combined primary endpoint was defined as cardiac death, non-fatal myocardial infarction, and stroke.
Results: 845 consecutive patients were enrolled into the study. During the median follow-up of 3.64 [1.03; 10.46] years, 61 primary endpoints occurred. Patients with primary endpoint showed larger extent of ischemia (10.7 ± 12.25% vs. 3.73 ± 8.29%, p < 0.0001) and LGE (21.09 ± 15.11% vs. 17.73 ± 10.72%, p < 0.0001). A risk prediction model containing the extent of ischemia and LGE proved to be superior in comparison to all other models (χ² increase: from 39.678 to 56.676, integrated discrimination index: 0.3851, p = 0.0033, net reclassification index: 0.11516, p = 0.0071). The beneficial effect of revascularization tended to be higher in patients with greater extents of ischemia, though statistical significance was not reached.
Conclusions: Quantification of myocardial ischemia and LGE was shown to significantly improve existing risk prediction models and might thus lead to an improvement in patient management.
Keywords: cardiac magnetic resonance imagingquantification of ischemia and necrosiscoronary artery diseaserisk stratificationprognosis and outcomes
References
- Shay CM, Ning H, Daniels SR, et al. Status of cardiovascular health in US adolescents: prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2005-2010. Circulation. 2013; 127(13): 1369–1376.
- Fihn SD, Gardin JM, Abrams J, et al. American College of Cardiology Foundation, American Heart Association Task Force on Practice Guidelines, American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American College of Cardiology Foundation/American Heart Association Task Force, American College of Cardiology Foundation. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2012; 60(24): e44–e164.
- Hendel RC, Berman DS, Di Carli MF, et al. American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Nuclear Cardiology, American College of Radiology, American Heart Association, American Society of Echocardiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, Society of Nuclear Medicine. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol. 2009; 53(23): 2201–2229.
- Douglas PS, Garcia MJ, Haines DE, et al. American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians. J Am Coll Cardiol. 2011; 57(9): 1126–1166.
- Shaw LJ, Berman DS, Picard MH, et al. National Institutes of Health/National Heart, Lung, and Blood Institute-Sponsored ISCHEMIA Trial Investigators. Comparative definitions for moderate-severe ischemia in stress nuclear, echocardiography, and magnetic resonance imaging. JACC Cardiovasc Imaging. 2014; 7(6): 593–604.
- Lin GA, Dudley RA, Lucas FL, et al. Frequency of stress testing to document ischemia prior to elective percutaneous coronary intervention. JAMA. 2008; 300(15): 1765–1773.
- Proceedings from the National Summit on Overuse. www.ama-assn.org/ama/pub/news/news/2013/2013-07-10-strategies-to-minimize-overuse.page.
- Patel MR, Dehmer GJ, Hirshfeld JW, et al. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2012; 59(9): 857–881.
- Ronan G, Wolk MJ, Bailey SR, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014; 63(4): 380–406.
- Bruder O, Wagner A, Lombardi M, et al. European Cardiovascular Magnetic Resonance (EuroCMR) registry-multi national results from 57 centers in 15 countries. J Cardiovasc Magn Reson. 2013; 15: 9.
- Groothuis JGJ, Beek AM, Brinckman SL, et al. Combined non-invasive functional and anatomical diagnostic work-up in clinical practice: the magnetic resonance and computed tomography in suspected coronary artery disease (MARCC) study. Eur Heart J. 2013; 34(26): 1990–1998.
- Catalano O, Moro G, Perotti M, et al. Late gadolinium enhancement by cardiovascular magnetic resonance is complementary to left ventricle ejection fraction in predicting prognosis of patients with stable coronary artery disease. J Cardiovasc Magn Reson. 2012; 14: 29.
- Kwong RY, Chan AK, Brown KA, et al. Impact of unrecognized myocardial scar detected by cardiac magnetic resonance imaging on event-free survival in patients presenting with signs or symptoms of coronary artery disease. Circulation. 2006; 113(23): 2733–2743.
- Zemrak F, Petersen SE. Late gadolinium enhancement CMR predicts adverse cardiovascular outcomes and mortality in patients with coronary artery disease: systematic review and meta-analysis. Prog Cardiovasc Dis. 2011; 54(3): 215–229.
- Lo KY, Leung KF, Chu CM, et al. Prognostic value of adenosine stress myocardial perfusion by cardiac magnetic resonance imaging in patients with known or suspected coronary artery disease. QJM. 2011; 104(5): 425–432.
- Bernhardt P, Engels T, Levenson B, et al. Prediction of necessity for coronary artery revascularization by adenosine contrast-enhanced magnetic resonance imaging. Int J Cardiol. 2006; 112(2): 184–190.
- Buckert D, Dewes P, Walcher T, et al. Intermediate-term prognostic value of reversible perfusion deficit diagnosed by adenosine CMR: a prospective follow-up study in a consecutive patient population. JACC Cardiovasc Imaging. 2013; 6(1): 56–63.
- Coelho-Filho OR, Seabra LF, Mongeon FP, et al. Stress myocardial perfusion imaging by CMR provides strong prognostic value to cardiac events regardless of patient's sex. JACC Cardiovasc Imaging. 2011; 4(8): 850–861.
- Bingham SE, Hachamovitch R. Incremental prognostic significance of combined cardiac magnetic resonance imaging, adenosine stress perfusion, delayed enhancement, and left ventricular function over preimaging information for the prediction of adverse events. Circulation. 2011; 123(14): 1509–1518.
- Shin T, Hu HH, Pohost GM, et al. Three dimensional first-pass myocardial perfusion imaging at 3T: feasibility study. J Cardiovasc Magn Reson. 2008; 10: 57.
- Hachamovitch R, Berman DS, Shaw LJ, et al. Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction. Circulation. 1998; 97(6): 535–543.
- Bernhardt P, Spiess J, Levenson B, et al. Combined assessment of myocardial perfusion and late gadolinium enhancement in patients after percutaneous coronary intervention or bypass grafts: a multicenter study of an integrated cardiovascular magnetic resonance protocol. JACC Cardiovasc Imaging. 2009; 2(11): 1292–1300.
- Kramer CM, Barkhausen J, Flamm SD, et al. Society for Cardiovascular Magnetic Resonance Board of Trustees Task Force on Standardized Protocols. Standardized cardiovascular magnetic resonance (CMR) protocols 2013 update. J Cardiovasc Magn Reson. 2013; 15: 91.
- Schulz-Menger J, Bluemke DA, Bremerich J, et al. Standardized image interpretation and post processing in cardiovascular magnetic resonance: Society for Cardiovascular Magnetic Resonance (SCMR) board of trustees task force on standardized post processing. J Cardiovasc Magn Reson. 2013; 15: 35.
- Cerqueira MD, Weissman NJ, Dilsizian V, et al. American Heart Association Writing Group on Myocardial Segmentation and Registration for Cardiac Imaging, American Heart Association Writing Group on Myocardial Segmentation and Registration for Cardiac Imaging, American Heart Association Writing Group on Myocardial Segmentation and Registration for Cardiac Imaging. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation. 2002; 105(4): 539–542.
- Buckert D, Mariyadas M, Walcher T, et al. Angiographic validation of magnetic resonance assessment of myocardium at risk in non-ST-elevation myocardial infarction. Int J Cardiovasc Imaging. 2013; 29(6): 1295–1301.
- Thygesen K, Alpert J, Jaffe A, et al. Third Universal Definition of Myocardial Infarction. Global Heart. 2012; 7(4): 275–295.
- Kraemer HC, Greenland S, Chi YY, et al. Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond. Stat Med. 2008; 27(2): 157–172.
- Morise A, Evans M, Jalisi F, et al. A pretest prognostic score to assess patients undergoing exercise or pharmacological stress testing. Heart. 2007; 93(2): 200–204.
- Steel K, Broderick R, Gandla V, et al. Complementary prognostic values of stress myocardial perfusion and late gadolinium enhancement imaging by cardiac magnetic resonance in patients with known or suspected coronary artery disease. Circulation. 2009; 120(14): 1390–1400.
- Lipinski MJ, McVey CM, Berger JS, et al. Prognostic value of stress cardiac magnetic resonance imaging in patients with known or suspected coronary artery disease: a systematic review and meta-analysis. J Am Coll Cardiol. 2013; 62(9): 826–838.
- Jogiya R, Morton G, De Silva K, et al. Ischemic burden by 3-dimensional myocardial perfusion cardiovascular magnetic resonance: comparison with myocardial perfusion scintigraphy. Circ Cardiovasc Imaging. 2014; 7(4): 647–654.
- Boden WE, O'Rourke RA, Teo KK, et al. COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007; 356(15): 1503–1516.
- Shaw LJ, Berman DS, Maron DJ, et al. COURAGE Investigators. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation. 2008; 117(10): 1283–1291.
- Hachamovitch R, Hayes SW, Friedman JD, et al. Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation. 2003; 107(23): 2900–2907.
- Hachamovitch R, Rozanski A, Shaw LJ, et al. Impact of ischaemia and scar on the therapeutic benefit derived from myocardial revascularization vs. medical therapy among patients undergoing stress-rest myocardial perfusion scintigraphy. Eur Heart J. 2011; 32(8): 1012–1024.
- New York University School of Medicine; International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA). http://clinicaltrials.gov/show/NCT01471522 (2013-10-24).
