Long-term prognostic value of ischaemia and cardiovascular magnetic resonance-related revascularization for stable coronary disease, irrespective of patient’s sex: a large retrospective study

Aims To assess the sex-specific, long-term prognostic value of myocardial ischaemia induced by stress cardiovascular magnetic resonance (CMR) and early CMR-related revascularization in consecutive patients from a large registry. Methods and results Between 2008 and 2010, all consecutive patients referred for stress CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular mortality or recurrent non-fatal myocardial infarction (MI). Early CMR-related revascularization was defined as any revascularization within 90 days after CMR. Among 3664 patients (56.9% male, mean age 69.9 ± 11.8 years), 472 (12.9%) had MACE (163 women and 309 men) after a median follow-up of 8.8 (IQR 6.9-9.5) years. Inducible ischaemia and late gadolinium enhancement (LGE) by CMR were associated with MACE in women and men (all P < 0.001). In multivariable Cox regression, inducible ischaemia, LGE, and CMR-related revascularization were independent predictors of MACE both in women [heart rate (HR) 4.79, 95% confidence interval (CI) 2.17–9.10; HR 1.82, 95% CI 1.22–2.71; HR 0.71, 95% CI 0.54–0.92, respectively; all P < 0.001] and men (HR 3.88, 95% CI 2.33–5.98; HR 1.48, 95% CI 1.16–1.89; HR 0.78, 95% CI 0.65–0.97, respectively; all P < 0.001). The addition of CMR-parameters led to improved model discrimination for MACE (C-statistic 0.61 vs. 0.71; NRI = 0.212; IDI = 0.032) for both women and men. CMR-related revascularization was associated with a lower incidence of MACE in patients with left ventricular ejection fraction (LVEF)<50%. Conclusion Inducible ischaemia and early CMR-related revascularization were good long-term predictors of MACE irrespective of sex. CMR-related revascularization was associated with a lower MACE incidence in the sole sub-set of patients with LVEF < 50%.

Echocardiography and detection of coronary artery disease

Non-invasive imaging modalities play an important role in the evaluation and management of patients with known or suspected coronary heart disease (CAD). This chapter will describe how we should use echocardiography in acute and chronic CAD at rest and during stress. In patients with established or suspected CAD, echocardiography provides useful information on the status of global and segmental myocardial function, the presence of functional mitral regurgitation and potentially of other signs of myocardial ischaemia. Echocardiography can be used to identify complications such as severe ventricular failure, acute mitral regurgitation, papillary muscle rupture, wall rupture, left ventricular (LV) thrombus, and cardiac tamponade. Inducible ischaemia is typically evaluated by stress echocardiography and will also be discussed in this chapter.

Vasodilatation stress cardiovascular magnetic resonance: feasibility and safety in a monocentric prospective study

Funding Acknowledgements Type of funding sources: None. BACKGROUND Cardiovascular magnetic resonance imaging (CMR) has emerged as an accurate technique that can assess ventricular function, stress myocardial perfusion, and viability, without radiation. Recent studies have shown that stress CMR would be the best test to predict obstructive coronary artery disease (CAD) with a good safety. PURPOSE The aim of our study was to assess the feasibility and incidence of immediate complications of stress CMR in a tertiary Cardiovascular Center with CMR Laboratory dedicated. METHODS Prospective registry of vasodilator stress CMR in a French center with CMR expertise included all consecutive patients referred for vasodilator stress perfusion CMR to detect an obstructive CAD between 2008 and 2020. Stress CMR was performed at 1.5 T using dipyridamole. The clinical and demographic data, quality of test, CMR findings, haemodynamic data, and complications were prospectively recorded. RESULTS Stress CMR was performed in 35,157 patients (98.2% of requested). The study could not be performed due to claustrophobia in 0.3%. Quality was optimal in 93.1%, suboptimal in 6.4%, and poor in 0.5% of studies. Images were diagnostic in 97.9% of patients. No patient died or had acute myocardial infarction during the test. Moreover, 56 patients (0.16%) had severe immediate complications, and one anaphylactic shock post-gadolinium. The only factor significantly associated with higher incidence of serious complications was the detection of inducible ischaemia (p < 0.001). Incidence of non-severe complications was low (1.5%), severe controlled chest pain being the most frequent. Minor symptoms occurred frequently (35.5%). CONCLUSION Performance of stress CMR is safe with very high image rate of satisfactory quality to perform the diagnosis in a referral population. Inducible ischaemia was the only factor identified which was associated with serious complications. Abstract Table. Final results after stress CMR

Resources and outcome impact of routine availability of computed tomography perfusion

Funding Acknowledgements Type of funding sources: None. Background Stress computed tomography perfusion (Stress-CTP) is a functional technique that can be added to coronary computed tomography angiography (cCTA) to improve the management of patients with suspected coronary artery disease (CAD). Purpose To determine the impact of routine availability of Stress-CTP added to cCTA in terms of downstream testing, radiation exposure and outcome in patients with high risk or known CAD. Methods Patients symptomatic for chest pain, known for CAD, with previous revascularization or with increased pre-test likelihood of CAD, referred for clinically indicated cCTA with Stress-CTP were prospectively enrolled. Data regarding evaluability, overall radiation exposure, invasive and non-invasive downstream testing, hospitalizations, revascularizations, major adverse cardiac events (MACE) as unstable angina, non-fatal myocardial infarction and cardiovascular death after index test were collected at follow-up. Results 263 consecutive patients were prospectively enrolled (mean age: 65 ± 9 years; male: 79%), of which 162 (62%) had previous revascularization. The mean follow-up was 323 ± 175 days. cCTA and Stress-CTP were fully evaluable in 95% and 99%, respectively. Obstructive CAD and inducible ischaemia were found in 170 (65%) and 129 (49%) subjects, respectively. No significant difference was found between patients with presence or absence of perfusion defects in terms of downstream non-invasive testing (p: 0.229), while patients with inducible ischaemia had more downstream invasive testing, increased overall radiation exposure, more hospitalizations for cardiovascular reasons and revascularization (all endpoints with p: < 0.001). No differences were detected between patients with inducible ischaemia treated with revascularization after index test and patients without inducible ischaemia, even if with obstructive CAD, treated medically in terms of MACE. Conclusions Routine implementation of cCTA with Stress-CTP is associated with subsequent low rate of other non-invasive testing, low overall radiation exposure in case of negative Stress-CTP and good prognosis if clinical management is based on combined anatomical and functional information.

Prognostic value of vasodilator stress perfusion CMR in patients with previous coronary artery bypass graft

Aims The accuracy and prognostic value of stress perfusion cardiac magnetic resonance (CMR) are established in coronary artery disease (CAD) patients. Because myocardial contrast kinetics may be altered after coronary artery bypass graft (CABG), most studies excluded CABG patients. This study aimed to assess the prognostic value of vasodilator stress perfusion CMR in CABG patients. Methods and results Consecutive CABG patients referred for stress CMR were retrospectively included and followed for the occurrence of major adverse cardiovascular events (MACE) including cardiovascular (CV) death or non-fatal myocardial infarction (MI). Cox regression analyses were performed to determine the prognostic association of inducible ischaemia and late gadolinium enhancement (LGE) by CMR. Of 866 consecutive CABG patients, 852 underwent the stress CMR protocol and 771 (89%) completed the follow-up [median (interquartile range) 4.2 (3.3–6.2) years]. There were 85 MACE (63 CV deaths and 22 non-fatal MI). Using Kaplan–Meier analysis, the presence of inducible ischaemia identified the occurrence of MACE [hazard ratio (HR) 3.52, 95% confidence interval (CI): 2.27–5.48; P < 0.001] and CV death (HR 2.55, 95% CI: 1.52–4.25; P < 0.001). In a multivariable stepwise Cox regression including clinical characteristics and CMR indexes, the presence of inducible ischaemia was an independent predictor of a higher incidence of MACE (HR 3.22, 95% CI: 2.06–5.02; P < 0.001) and CV death (HR 2.15, 95% CI: 1.28–3.62; P = 0.003), and the same was observed for LGE (both P = 0.02). Conclusion Stress CMR has a good discriminative prognostic value in patients after CABG, with a higher incidence of MACE and CV death in patients with inducible ischaemia and/or LGE.

Abstract 13467: Vasodilatation Stress Cardiovascular Magnetic Resonance: Feasibility and Safety in a Monocentric Prospective Study

Introduction: Cardiovascular magnetic resonance imaging (CMR) has emerged as an accurate technique that can assess ventricular function, stress myocardial perfusion, and viability, without radiation. Recent studies have shown that stress CMR would be the best test to predict obstructive coronary artery disease (CAD) with a good safety. Hypothesis: To assess the feasibility and incidence of immediate complications of stress CMR in a tertiary Cardiovascular Center with CMR Laboratory dedicated. Methods: Prospective registry of vasodilator stress CMR in a French center with CMR expertise included all consecutive patients referred for vasodilator stress perfusion CMR to detect an obstructive CAD between 2008 and 2020. Stress CMR was performed at 1.5 T using dipyridamole. The clinical and demographic data, quality of test, CMR findings, haemodynamic data, and complications were prospectively recorded. Results: Stress CMR was performed in 35,157 patients (98.2% of requested). The study could not be performed due to claustrophobia in 0.3%. Quality was optimal in 93.1%, suboptimal in 6.4%, and poor in 0.5% of studies. Images were diagnostic in 97.9% of patients. No patient died or had acute myocardial infarction during the test. Moreover, 56 patients (0.16%) had severe immediate complications, and one anaphylactic shock post-gadolinium. The only factor significantly associated with higher incidence of serious complications was the detection of inducible ischaemia (p<0.001). Incidence of non-severe complications was low (1.5%), severe controlled chest pain being the most frequent. Minor symptoms occurred frequently (35.5%). Conclusions: Performance of stress CMR is safe with very high image rate of satisfactory quality to perform the diagnosis in a referral population. Inducible ischaemia was the only factor identified which was associated with serious complications.

Non-invasive myocardial work: characterising the normal and ischaemic response to exercise

Background/Introduction Myocardial work and work efficiency are new parameters for assessing left ventricular function. They have been shown to have value in a range of clinical settings but have not previously been applied to exercise stress echocardiography. Purpose We aim to characterize the normal myocardial work and work efficiency response to exercise in a mixed population and determine if myocardial work could be used to identify patients with inducible ischaemia. Methods Patients were retrospectively enrolled from an existing database of exercise stress echocardiography. Inclusion criteria were a clinical indication of possible ischemia and technical suitability to calculate myocardial work. Exclusion criteria were abnormal baseline left ventricular function or inadequate image quality. Echocardiograms positive for ischaemia were defined by independent visual assessment and compared with angiographic findings where available. Myocardial work and work efficiency were calculated using a proprietary algorithm. Results A total of 177 patients met inclusion criteria, 117 were excluded leaving 40 normal and 20 positive tests for analysis. During normal exercise global work increased 54% and efficiency remained at 96%. Segmental work showed a basal to apical gradient which became more prominent at peak exercise. In patients with inducible ischaemia during exercise there was a significant difference in response; work decreased by 1.9% and efficiency dropped to 87%. Receiver operating characteristic curve for myocardial work had an area under the curve of 0.94. Youden's J statistic suggested an optimum cut point of a 25% increase in work to define a normal test. Conclusion During normal exercise myocardial work increased and efficiency remained unchanged, however during exercise induced ischaemia both myocardial work and efficiency decreased. We have demonstrated that myocardial work can be applied to stress echocardiography to identify ischemia but the utility of this remains uncertain. Further research compared to an objective measure of functional ischemia is needed. Response to exercise Funding Acknowledgement Type of funding source: None

Transcatheter occlusion of an anomalous origin of left coronary artery from pulmonary artery in an adult as an alternative to surgery

Anomalous origin of the left coronary artery from the pulmonary artery causes heart failure and death in infancy. In rare adult survivors with well-developed collaterals, surgical left coronary ligation to arrest steal is often combined with bypass grafting. Transcatheter left coronary artery closure in a symptomatic adult as an alternative to surgical ligation resulted in complete resolution of inducible ischaemia on myocardial perfusion imaging.

P1400 Improving ischemia diagnosis: 3D speckle-tracking stress echocardiography

Background 2D stress echocardiography (SE) is based in the visual analysis of wall motion abnormalities and it requires a trained operator. This operator-dependence has promoted the search for a semiautomatic method to reduce SE limitations and improve test accuracy. The aim of this study was to evaluate the value of 3D speckle tracking (3DSTE) in SE in patients with chest pain. Methods 44 consecutive patients with chest pain and pathological findings on CCTA (&gt;50% stenosis or high calcium score (&gt;400 HU) with undetermined severity) were included. These patients underwent SE with acquisition of 3DSTE at rest and at peak stress. Results Mean age was 63.9 ± 9.9 years. 90% were men. The images of the 44 patients were processed with automatic tracking and manual corrections. 11 patients developed inducible ischaemia during SE. Patients with ischaemic response showed significant reductions in 3D area strain (AS) compared to resting values. The 33 patients without inducible ischaemia showed, however, a significant increase in this parameter. Results are shown in table 1. Conclusion 3D area strain SE could help to identify patients with inducible ischemia. However, further studies are need to confirm these data. Ischemia + (n = 11) Ischemia - (n = 33) P 2D LVEF rest 57.2; 5.5 61.4; 6.0 0.04 2D LVEF peak stress 56.9; 11.7 70.0; 9.0 &lt;0.01 3D LVEF at rest 54.3; 6.9 64.3; 9.7 0.17 3D LVEF peak stress 51.9; 22.5 66.0; 8.6 0.17 AS rest 38.3; 5.1 40.4; 5.7 0.29 AS peak stress 37.2; 11.3 43.6; 7.2 0.03 LVEF: left ventricle ejection fracion; AS: area strain.

Safety and efficacy of physiologist-led dobutamine stress echocardiography: experience from a tertiary cardiac centre

Background Dobutamine stress echocardiography (DSE) services have traditionally been medically led. In some UK institutions, DSE lists are led by physiologists with medical support. In our tertiary cardiac centre at New Cross Hospital (NCH), the DSE service was established by a consultant echocardiographer. Following intensive training and assessment, the Trust approved drug administration by named senior cardiac physiologists. We believe this is the first report of a cardiac physiologist-managed DSE service, including physiologist drug administration. We have assessed the feasibility, safety and validity of this physiologist-led DSE service. Methods Retrospective analysis of 333 patients undergoing stress echocardiogram for inducible reversible ischaemia, myocardial viability and valvular heart disease over 6 months. Patients’ case notes review after 18–24 months. Results Overall, 92% of all cases (306) were performed by physiologists. In 300 studies, dobutamine was administered. The majority of the referrals were for coronary artery disease (CAD) assessment (281). In 235 cases, the study was uncomplicated. Sixty-seven patients developed dobutamine-related side effects. In 16 cases, complications led to early termination of the study. In two cases, urgent medical review was needed. Of the 281 studies for CAD assessment, 239 were negative for ischaemia, 28 were positive and 14 inconclusive. In 5 out of 28 cases with echocardiogram, evidence of inducible ischaemia, coronary angiography revealed unobstructed coronary arteries. Conclusion This study demonstrates the safety and effectiveness of this practice and provides potential for the expansion of the physiologists’ role and physiologist-led DSE services in other hospitals.