Introduction:
The current AATS and AHA/ACC guidelines recommend maximal exercise stress test (mEST) to identify ischemia and direct decision-making in patients (pts) with anomalous aortic origin of a coronary artery (AAOCA). Stress cardiac magnetic resonance imaging (sCMR) has reliably identified myocardial perfusion abnormalities.
Hypothesis:
We hypothesize that EST and sCMR do not agree in the detection of inducible ischemia in AAOCA.
Methods:
AAOCA pts <21 years old were prospectively enrolled and evaluated following a standardized approach from 12/2012-12/2019. mEST was performed in pts ≥6 years old, except those who presented with cardiac arrest or physical limitations. Demographic data, coronary anomaly type, EST (symptoms, ST changes, arrhythmias, metabolic parameters) and sCMR data were collected. A mEST was defined as max HR ≥85%ile with a subgroup defined as respiratory exchange ratio (RER) >1.05. Abnormal mEST included: significant ST changes (≥1 mm horizontal or downsloping ST-depression, ≥2 mm upsloping ST depression, ST elevation), high-grade arrhythmia, abnormal peak VO2 (<85% predicted). Continuous and categorical variables were compared using Wilcoxon-Rank sum and Fisher’s exact/χ2 respectively. McNemar’s test was used to determine the agreement between EST and sCMR.
Results:
Of 147 pts with AAOCA and both EST and sCMR, 140 achieved max HR ≥85%ile on EST. Table 1 compares demographics and EST parameters in pts with inducible ischemia on sCMR (+sCMR) vs without (-sCMR). Significant ST changes were seen in 2/26 (7.7%) pts with +sCMR compared to 8/114 (7%) pts with -sCMR. An abnormal mEST did not agree with sCMR in identifying inducible ischemia (McNemar p < 0.001) in all AAOCA patients who achieved max HR, nor in the sub-group with RER >1.05 (n = 88).
Conclusions:
mEST does not agree with sCMR in identifying inducible ischemia in patients with AAOCA. Our data suggest that mEST should not be used alone for the detection of inducible ischemia.
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