Prognostic value of stress cardiac magnetic resonance imaging in patients with known or suspected coronary artery disease: a systematic review and meta-analysis

Abstract

Objectives: This study sought to perform a systematic review and meta-analysis to understand the role of stress cardiac magnetic resonance imaging (CMR) in assessing cardiovascular prognosis in patients with known or suspected coronary artery disease (CAD).

Background: Although stress CMR is excellent for the diagnosis of obstructive CAD, the prognostic value of stress CMR has been less well described.

Methods: PubMed, Cochrane CENTRAL, and metaRegister of Controlled Trials were searched for stress CMR studies with >6 months of prognostic data. Primary endpoints were cardiovascular death, myocardial infarction (MI), and a composite outcome of cardiovascular death or MI during follow-up. Summary effect estimates were generated with random-effects modeling, and annualized event rates were assessed.

Results: Nineteen studies (14 vasodilator, 4 dobutamine, and 1 that used both) involved a total of 11,636 patients with a mean follow-up of 32 months. Patients had a mean age of 63 ± 12 years, 63% were male, and 26% had previous MI; mean left ventricular ejection fraction was 61 ± 12%; and late gadolinium enhancement was present in 29% and ischemia in 32%. Patients with ischemia had a higher incidence of MI (odds ratio [OR]: 7.7; p < 0.0001), cardiovascular death (OR: 7.0; p < 0.0001), and the combined endpoint (OR: 6.5; p < 0.0001) compared with those with a negative study. The combined outcome annualized events rates were 4.9% for a positive versus 0.8% for a negative stress CMR (p < 0.0001), 2.8% versus 0.3% for cardiovascular death (p < 0.0001), and 2.6% versus 0.4% for MI (p < 0.0005). The presence of late gadolinium enhancement was also significantly associated with a worse prognosis.

Conclusions: A negative stress CMR study is associated with very low risk of cardiovascular death and MI. Stress CMR has excellent prognostic characteristics and may help guide risk stratification of patients with known or suspected CAD.

Keywords: AER; CAD; CMR; LGE; MACE; MI; OR; annualized event rate; cardiac magnetic resonance imaging; coronary artery disease; late gadolinium enhancement; major adverse cardiovascular event(s); myocardial infarction; myocardial perfusion; odds ratio; prognosis; stress cardiac MRI.

Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1. Flow Diagram of the Review Process

CMR = cardiac magnetic resonance imaging.

Figure 2. Individual and Pooled Risk of Cardiovascular Outcomes for Stress CMR

Forest plots comparing clinical outcomes of patients with known or suspected coronary artery disease (CAD) with positive stress cardiac magnetic resonance imaging (CMR) and negative stress CMR. Outcomes included (A)combined cardiovascular outcomes including cardiovascular death and nonfatal myocardial infarction (MI), (B) cardiovascular death, and(C) nonfatal MI. CI = confidence interval.

Figure 2. Individual and Pooled Risk of Cardiovascular Outcomes for Stress CMR

Forest plots comparing clinical outcomes of patients with known or suspected coronary artery disease (CAD) with positive stress cardiac magnetic resonance imaging (CMR) and negative stress CMR. Outcomes included (A)combined cardiovascular outcomes including cardiovascular death and nonfatal myocardial infarction (MI), (B) cardiovascular death, and(C) nonfatal MI. CI = confidence interval.

Figure 3. AERs of Cardiovascular Outcomes for Stress CMR

Weighted mean annualized event rates (AERs) for combined cardiovascular outcome of cardiovascular death and nonfatal MI, cardiovascular death, and non-fatal MI comparing patients with positive stress CMR (solid bars) and patients with a negative stress CMR (open bars). Abbreviations as in Figure 2.

Figure 4. Individual and Pooled Risk of Cardiovascular Outcomes Based on the Presence of LGE

Forest plots comparing clinical outcomes of patients with known or suspected CAD with late gadolinium enhancement (LGE) on CMR and without LGE on CMR. Outcomes included (A) combined cardiovascular outcomes including cardiovascular death and nonfatal MI, (B) cardiovascular death, and(C) nonfatal MI. Abbreviations as in Figure 2.

Figure 5. AERs of Cardiovascular Outcomes Based on the Presence of LGE

Weighted mean AERs for combined cardiovascular outcome of cardiovascular death and nonfatal MI, cardiovascular death, and nonfatal MI comparing patients with LGE on CMR (solid bars) and patients without LGE on CMR (open bars). Abbreviations as in Figures 2 to 4.