Safety, feasibility and prognostic value of stress perfusion CMR in patients with pacemaker

Abstract Background The World's ageing population with a life expectancy that is steadily increasing raises the question of the benefit of screening for coronary artery disease (CAD) in very old patients with high risk of CAD. Current guidelines discourage the performance of stress testing in asymptomatic elderly. Purpose To assess the prognostic value of vasodilator stress perfusion cardiac magnetic resonance (CMR) in elderly patients aged >75 years without previous known CAD. Material Consecutive elderly patients >75 years without known CAD referred for vasodilator stress perfusion CMR were followed for major adverse cardiovascular events (MACE) defined as cardiac death, non-fatal myocardial infarction or stroke. Univariable and multivariable Cox regressions for MACE were performed to determine the prognostic association of inducible ischemia or late gadolinium enhancement (LGE) by CMR beyond traditional clinical risk indexes. Results Of 754 elderly high risk patients (82.0±3.9 years, 48.4% men), 747 (99%) completed the CMR protocol, and among those 659 (88.2%) completed the follow-up (median follow-up 5.7±2.5 years). Reasons for failure to complete CMR included claustrophobia (n=3), declining participation (n=2) and intolerance to stress agent (n=2). Stress CMR was well tolerated without occurrence of death or severe disabling adverse event. Patients without inducible ischemia or LGE experienced a substantially lower annual rate of MACE (5.5% vs. 9.9% for those with ischemia and vs. 6.9% for those with ischemia and/or LGE). In a multivariable stepwise Cox regression including clinical characteristics and CMR indexes, the absence of inducible ischemia was an independent predictor of a lower incidence of MACE at follow-up (hazard ratio 0.46; 95% confidence interval: 0.34 to 0.62; p<0.001) (Figure 1A) and all-cause mortality (hazard ratio 0.67; 95% confidence interval: 0.45 to 0.97; p=0.037). When patients with early coronary revascularization (within 30 days of CMR) were censored on the day of revascularization, both presence of inducible ischemia and ischemia extent per segment maintained a strong association with MACE. Using Kaplan-Meier analyses, the presence of myocardial ischemia identified the occurrence of future CV events (p<0.001). Moreover, the absence of inducible ischemia was a predictor of a lower incidence of MACE less significant in men than in women (p<0.01) (Figure 1B). Conclusion Stress CMR is safe and has discriminative prognostic value in very elderly patients, with a very low negative event rate in patients without ischemia or infarction. Among elderly patients without known CAD, the presence of myocardial ischemia on vasodilator stress CMR was predictive of future CV event or death.

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Prognostic Value of Vasodilator Stress Perfusion CMR in Morbidly Obese Patients (BMI ≥40 kg/m2) Without Known CAD

JACC Cardiovascular Imaging ◽

10.1016/j.jcmg.2019.12.002 ◽

2020 ◽

Vol 13 (5) ◽

pp. 1276-1277

Author(s):

Marine Kinnel ◽

Jérôme Garot ◽

Théo Pezel ◽

Thomas Hovasse ◽

Thierry Unterseeh ◽

...

Keyword(s):

Prognostic Value ◽

Vasodilator Stress ◽

Stress Perfusion ◽

Morbidly Obese ◽

Obese Patients ◽

Perfusion Cmr

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

JACC Cardiovascular Imaging ◽

10.1016/j.jcmg.2020.07.041 ◽

2020 ◽

Cited By ~ 1

Author(s):

Théo Pezel ◽

Francesca Sanguineti ◽

Marine Kinnel ◽

Valentin Landon ◽

Solenn Toupin ◽

...

Keyword(s):

Atrial Fibrillation ◽

Prognostic Value ◽

Vasodilator Stress ◽

Stress Perfusion ◽

Perfusion Cmr

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271Feasibility and prognostic value of vasodilator stress perfusion CMR in elderly patients > 75 years without known CAD

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez101.004 ◽

2019 ◽

Vol 20 (Supplement_2) ◽

Cited By ~ 1

Author(s):

T Pezel ◽

M Kinnel ◽

T Hovasse ◽

P Garot ◽

T Unterseeh ◽

...

Keyword(s):

Elderly Patients ◽

Prognostic Value ◽

Vasodilator Stress ◽

Stress Perfusion ◽

Perfusion Cmr

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Feasibility and prognostic value of stress-perfusion CMR in obesity

Journal of Cardiovascular Magnetic Resonance ◽

10.1186/1532-429x-14-s1-o2 ◽

2012 ◽

Vol 14 (S1) ◽

Author(s):

Ravi Shah ◽

Otavio R Coelho-Filho ◽

Tomas G Neilan ◽

Bobby Heydari ◽

Ron Blankstein ◽

...

Keyword(s):

Prognostic Value ◽

Stress Perfusion ◽

Perfusion Cmr

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Abstract 3093: Long Term Prognostic Value of Stress Perfusion CMR and Late Gadolinium Enhanced CMR for The Prediction of Major Adverse Cardiac Events.

Circulation ◽

10.1161/circ.116.suppl_16.ii_693-b ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Tairo Kurita ◽

Hajime Sakuma ◽

Katsuya Onishi ◽

Motonori Nagata ◽

Takeshi Takamura ◽

...

Keyword(s):

Myocardial Infarction ◽

Prognostic Value ◽

Prognostic Significance ◽

Hazard Ratio ◽

Stress Perfusion ◽

Adverse Cardiovascular Event ◽

Number Of Patients ◽

High Hazard Ratio ◽

Lge Cmr ◽

Perfusion Cmr

Background: Combined stress myocardial perfusion (S-PERF) and late gadolinium enhanced (LGE) CMR allows for the detection of myocardial ischemia and infarction. However, prognostic values of S-PERF and LGE CMR have not been determined in a large number of patients. In this study we determined the prognostic significance of combined S-PERF and LGE CMR study. Methods: We studied 826 patients who underwent both stress-rest perfusion CMR and LGE CMR. Stress-induced ischemia on S-PERF CMR and myocardial infarction on LGE CMR were qualitatively determined. Major adverse cardiovascular event (MACE) was defined as cardiac death, non-fatal acute myocardial infarction, heart failure on admission. Patients who underwent revascularization within 2 month after CMR were excluded. Results: During a median follow-up time of 34 months (range, 2 to 96 months), event-free survival rate was 89% in S-PERF(−)/LGE(−), 64% in S-PERF(−)/LGE(+), 49% in S-PERF(+)/LGE(−), and 38% in S-PERF(+)/LGE(+) group (P<0.001 between any combinations). Abnormality on S-PERT/LGE CMR was a significant negative prognostic factor of MACE with a high hazard ratio of 7.0 (95% CI 3.9–12.7, P<0.001). While LGE also predicted patients outcome, its hazard ratio (1.42, 95% CI 1.22–1.67, P<0.001) was lower than that by S-PERT/LGE CMR (FIgure 1 ). Normal S-PERF/LGE CMR was associated with lower event rate per year (1.6%) as compared with that by normal LGE alone (4.3%, P<0.001). Conclusions: Combined S-PERF and LGE CMR can provide improved prognostic value when compared with LGE CMR alone in patients with known or suspected coronary artery disease. Patients with normal S-PERF and LGE CMR were at low risk of adverse outcome. Figure 1: Kaplan- Meler survival distributions based on presence of LGE alone (left) and any abnormality on S-PER/LGE CMR (right)

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Safety and prognostic value of vasodilator stress CMR in patients with heart failure and reduced ejection fraction

European Heart Journal ◽

10.1093/ehjci/ehaa946.0252 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

T Pezel ◽

F Sanguineti ◽

M Kinnel ◽

V Landon ◽

P Garot ◽

...

Keyword(s):

Heart Failure ◽

Prognostic Value ◽

Cardiovascular Death ◽

Vasodilator Stress ◽

Stress Perfusion ◽

Inducible Ischemia ◽

Kaplan Meier ◽

Stress Cmr ◽

Perfusion Cmr

Abstract Background Recent data suggest that patients with HFrEF (heart failure with reduced left ventricular ejection fraction (LVEF) <40%) referred for stress cardiovascular magnetic resonance (CMR) may have a less optimal haemodynamic response to intravenous vasodilator. The prognostic value of stress CMR has been poorly investigated in this population. Purpose To assess the safety and the prognostic value of vasodilator stress perfusion CMR in patients with HFrEF. Material Between 2008 and 2018, we prospectively included consecutive patients with HFrEF referred for vasodilator stress perfusion CMR with dipyridamole. HFrEF was defined by a previous history of HF and known LVEF <40%. All patients with LVEF ≥40% measured by CMR were excluded. They were followed for the occurrence of major adverse cardiovascular events (MACE) defined by cardiovascular death or nonfatal myocardial infarction (MI). The secondary endpoint was a composite outcome of cardiovascular death or rehospitalization for acute HF defined by the use of intravenous diuretics. The safety of the stress perfusion CMR was assessed by clinical monitoring for 1 hour after the end of the CMR. Univariable and multivariable Cox regressions were performed to determine the prognostic association of inducible ischemia or late gadolinium enhancement (LGE) by CMR. Results Of 1084 patients with HFrEF (65±11 years, median LVEF 34.6±4.9%), 1049 (97%) completed the CMR protocol and among those 952 (91%) completed the follow-up (median 5.6±2.4 years). Reasons for failure to complete CMR included declining participation (n=11), renal failure (n=9), intolerance to stress agent (n=8), claustrophobia (n=4) and poor gating (n=3). Stress CMR was well tolerated without occurrence of death or severe disabling adverse event. Among patients who underwent CMR, 600 (57%) were diagnosed with MI defined by LGE. Patients without inducible ischemia or LGE experienced a substantially lower annual event rate of MACE (1.8%) than those with ischemia and without LGE (9.4%), or those with both ischemia and LGE (12.0%; p<0.001 for all). Using Kaplan-Meier analysis, the presence of inducible ischemia and LGE were significantly associated with the occurrence of MACE (hazard ratio [HR], 2.46 [95% CI, 1.69–3.59]; p<0.001) (Figure). In multivariable stepwise Cox regression including clinical characteristics and CMR, the inducible ischemia was an independent predictor of a higher incidence of MACE at follow-up (adjusted HR, 2.26 [95% CI, 1.52–3.35]; p<0.001). However, there was no significant difference between patients with or without ischemia for the secondary outcome (p=0.28). Conclusions Stress CMR is safe and has a good discriminative prognostic value to predict the occurrence of MACE in patients with HFrEF. Kaplan-Meier curves for MACE Funding Acknowledgement Type of funding source: None

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Prognostic value of vasodilator stress perfusion CMR in patients with known myocardial infarction

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa356.292 ◽

2021 ◽

Vol 22 (Supplement_1) ◽

Author(s):

T Pezel ◽

P Garot ◽

M Kinnel ◽

V Landon ◽

T Hovasse ◽

...

Keyword(s):

Myocardial Infarction ◽

Prognostic Value ◽

Cox Regression ◽

Vasodilator Stress ◽

Stress Perfusion ◽

Inducible Ischemia ◽

Kaplan Meier ◽

Stress Cmr ◽

Perfusion Cmr

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND Several studies have demonstrated the consistently high prognostic value of stress perfusion cardiovascular magnetic resonance (CMR). This prognostic value in patients with known myocardial infarction (MI) is poorly described. There remains some skepticism about the capacity of stress CMR in predicting the clinical outcome due to the technical challenge during image analysis causes by myocardial scar. PURPOSE The aim of our study was to assess the prognostic value of vasodilator stress perfusion CMR in patients with known MI. METHODS We prospectively included consecutive patients with known MI referred for vasodilator stress perfusion CMR with dipyridamole. They were followed for the occurrence of major adverse cardiovascular events (MACE) defined as cardiac death or recurrent non-fatal myocardial infarction (MI). Univariable and multivariable Cox regressions for MACE were performed to determine the prognostic value of inducible ischemia or late gadolinium enhancement (LGE) by CMR. RESULTS Of 1602 patients with known MI (68 ± 17 years, 78% men), 1556 (97%) completed the CMR protocol, and among those 1401 (90%) completed the follow-up (median follow-up 5.7 (3.9–7.6) years). Reasons for failure to complete CMR included ECG-gating problems (n = 13), intolerance to stress agent (n = 12), renal failure (n = 12), declining participation (n = 4) and claustrophobia (n = 5). Stress CMR was well tolerated without occurrence of death or severe adverse event. Patients without inducible ischemia experienced a substantially lower annual event rate of MACE (3.1%) than those with 1 or 2 segments of ischemia (4.5%), than those with 3 to 5 segments of ischemia (21.5%), than those with 6 or more segments of ischemia (45.7%, for all p < 0.01). Using Kaplan-Meier analysis, the presence of myocardial ischemia identified the occurrence of MACE (hazard ratio HR 3.52; 95% confidence interval CI: 2.67 – 4.65; p < 0.001). In a multivariable stepwise Cox regression including clinical characteristics and CMR indexes, the presence of inducible ischemia was an independent predictor of a higher incidence of MACE (HR 2.84; 95% CI: 2.14 to 3.78; p < 0.001). CONCLUSION Stress CMR is technically feasible and has a good discriminative prognostic value to predict the occurrence of MACE in patients with known MI. Abstract Figure. Kaplan-Meier curves for MACE

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