Stress Perfusion CMR to Prognosticate for Left Main and High Risk Multivessel Coronary Artery Disease and Major Cardiovascular Adverse Events: Outcomes From a 4,144-Patient Multicenter Cohort.

Abstract

Background: Left main (LM) and multivessel coronary disease (MVD) are high-risk conditions in which surgical revascularization may be preferred over medical or percutaneous therapies, yet may be missed by conventional imaging. Vasodilator stress perfusion cardiac magnetic resonance (CMR) appeared promising in resolving endocardial ischemia, but large multicenter data are lacking.

Objectives: This study aims to assess whether stress perfusion CMR reliably rules out LM/MVD and predicts adverse cardiac outcomes.

Methods: Consecutive patients from the expanded cohort of the 13-center SPINS (Stress CMR Perfusion Imaging in the United States Study) were included. Study outcomes were composites of angiographic new diagnosis of LM disease (>50% stenosis), high-risk MVD (significant 3-vessel disease or MVD treated with surgical revascularization), acute nonfatal myocardial infarction (MI), and cardiovascular death.

Results: Among 4,144 patients (60.5 ± 13.1 years of age, 54.3% male), ischemia and prior infarct were present in 760 (18.3%) and 1,128 (27.2%) patients, respectively. During 4-year follow-up, 336 (8.1%) patients experienced the primary composite outcome, including 182 (4.4%) new diagnoses of LM/MVD, 96 (2.3%) acute MI, and 58 (1.4%) cardiovascular deaths. The presence of ischemia was the strongest multivariable predictor of the composite outcome (HR_adjusted: 4.55; 95% CI: 3.32-6.25; P < 0.001) and for the combination of acute MI and cardiovascular death (HR_adjusted: 4.31; 95% CI: 3.08-6.05; P < 0.001), adjusted for clinical risk factors and late gadolinium enhancement. The presence of abnormal stress perfusion portended a 10-fold increase in the annualized primary event rate compared with those without ischemia (10.6% vs 0.9%), whereas annual event rates were 0.9% vs 0.08% for LM disease, and 5.6% vs 0.3% for high-risk MVD, respectively.

Conclusions: The absence of ischemia on vasodilator stress perfusion CMR was associated with a very low likelihood of angiographically verified high-risk coronary artery disease and its associated events.