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

Abstract

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.

Keywords: Atrial fibrillation; Cardiac magnetic resonance; Ischaemia; Late gadolinium enhancement; Perfusion; Prognosis.

Conflict of interest statement

Dr Anker reports personal fees from Servier, outside the submitted work. All other authors have no conflicts of interest to declare that are relevant to the content of this article.

© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.

Figures

Figure 1

The middle column indicates patient flow during the study with one patient being excluded due to bradycardia after adenosine and seven patients being excluded from the follow‐up cohort. Smaller boxes demonstrate results of vasodilator cardiac magnetic resonance (CMR) and invasive coronary angiography (ICA).

Figure 2

Case example of a patient with typical angina pectoris and a history of myocardial infarction with percutaneous intervention of the LAD. (A) Mid‐ventricle short‐axis view of vasodilator CMR shows induced hypoperfusion inferoseptal, inferior, and inferolateral (white arrows). (B) Short‐axis LGE imaging shows a subendocardial scar tissue inferior, anterior, and anterolateral (black arrows). Of note, the inferior perfusion deficit in image (A) exceeds the scar tissue seen in the relevant region in image (B), thus fulfilling the criteria of relevant ischaemia in this patient. (C) shows a coronary angiogram of the right coronary artery at a 45° right anterior‐oblique rotation in the same patient, revealing relevant stenosis in Segments 1 and 2 (white arrowheads).

Figure 3

(A) Proportion of cumulative incidence of MACE in cohorts stratified by CMR result: without ischaemia and late gadolinium enhancement (LGE), without ischaemia and with LGE, with ischaemia and without LGE, and with both ischaemia and LGE. The P‐value for trend is given, assuming a linear trend for odds ratio (OR: 1.5; confidence interval 1.1–2.1). (B) Cumulative hazard for MACE in cohorts stratified by CMR result. The hazard ratio is calculated using Cox regression analysis.

Figure 4

Kaplan–Meier analysis on ischaemia, LGE, or the combination of both for the occurrence of MACE. P‐value is calculated using the log‐rank test. The shaded area behind the graphs illustrates confidence intervals. (A) Kaplan–Meier curves for MACE in vasodilator perfusion CMR for patients with a positive result for ischaemia (red line) or a negative CMR result (green line). (B) Kaplan–Meier curve for MACE for patients with a presence of LGE (yellow line) or without LGE (green line). (C) Kaplan–Meier curve for MACE for patients with a combination of LGE and ischaemia in vasodilator perfusion CMR (orange line) and a normal CMR result (green line).

Figure 5

Hazard ratios for patients with inducible ischaemia in vasodilator CMR according to CHA2DS2‐VASc score and SMART score, LVEF, and age. Panel (A) shows the hazard ratio in patients in comparison with their 10% year risk for recurrent vascular events (as assessed by SMART score), and panel (B) shows the hazard ratio for inducible ischaemia in patients in relation to their age at baseline. Panel (C) shows the correlation with the CHA2DS2‐VASc score, while panel (D) shows the correlation with LVEF at rest (baseline). Grey area indicates 95% confidence interval; blue dashed is drawn at a hazard ratio of 1 for orientation. Small lines at the top of the x‐axis indicate the actual cases.