Evaluation of stress cardiac magnetic resonance imaging in risk reclassification of patients with suspected coronary artery disease

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Item Type:	Article
Title:	Evaluation of stress cardiac magnetic resonance imaging in risk reclassification of patients with suspected coronary artery disease
Creators Name:	Antiochos, P., Ge, Y., Steel, K., Chen, Y.Y., Bingham, S., Abdullah, S., Mikolich, J.R., Arai, A.E., Bandettini, W.P., Patel, A.R., Farzaneh-Far, A., Heitner, J.F., Shenoy, C., Leung, S.W., Gonzalez, J.A., Shah, D.J., Raman, S.V., Ferrari, V.A., Schulz-Menger, J., Stuber, M., Simonetti, O.P., Murthy, V.L. and Kwong, R.Y.
Abstract:	IMPORTANCE: The role of stress cardiac magnetic resonance (CMR) imaging in clinical decision-making by reclassification of risk across American College of Cardiology/American Heart Association guideline–recommended categories has not been established. OBJECTIVE: To examine the utility of stress CMR imaging for risk reclassification in patients without a history of coronary artery disease (CAD) who presented with suspected myocardial ischemia. DESIGN, SETTING, AND PARTICIPANTS: A retrospective, multicenter cohort study with median follow-up of 5.4 years (interquartile range, 4.6-6.9) was conducted at 13 centers across 11 US states. Participants included 1698 consecutive patients aged 35 to 85 years with 2 or more coronary risk factors but no history of CAD who presented with suspected myocardial ischemia to undergo stress CMR imaging. The study was conducted from February 18, 2019, to March 1, 2020. MAIN OUTCOMES AND MEASURES: Cardiovascular (CV) death and nonfatal myocardial infarction (MI). Major adverse CV events (MACE) including CV death, nonfatal MI, hospitalization for heart failure or unstable angina, and late, unplanned coronary artery bypass graft surgery. RESULTS: Of the 1698 patients, 873 were men (51.4%); mean (SD) age was 62 (11) years, accounting for 67 CV death/nonfatal MIs and 190 MACE. Clinical models of pretest risk were constructed and patients were categorized using guideline-based categories of low (<1% per year), intermediate (1%-3% per year), and high (>3% year) risk. Stress CMR imaging provided risk reclassification across all baseline models. For CV death/nonfatal MI, adding stress CMR-assessed left ventricular ejection fraction, presence of ischemia, and late gadolinium enhancement to a model incorporating the validated CAD Consortium score, hypertension, smoking, and diabetes provided significant net reclassification improvement of 0.266 (95% CI, 0.091-0.441) and C statistic improvement of 0.086 (95% CI, 0.022-0.149). Stress CMR imaging reclassified 60.3% of patients in the intermediate pretest risk category (52.4% reclassified as low risk and 7.9% as high risk) with corresponding changes in the observed event rates of 0.6% per year for low posttest risk and 4.9% per year for high posttest risk. For MACE, stress CMR imaging further provided significant net reclassification improvement (0.361; 95% CI, 0.255-0.468) and C statistic improvement (0.092; 95% CI, 0.054-0.131), and reclassified 59.9% of patients in the intermediate pretest risk group (48.7% reclassified as low risk and 11.2% as high risk). CONCLUSIONS AND RELEVANCE: In this multicenter cohort of patients with no history of CAD presenting with suspected myocardial ischemia, stress CMR imaging reclassified patient risk across guideline-based risk categories, beyond clinical risk factors. The findings of this study support the value of stress CMR imaging for clinical decision-making, especially in patients at intermediate risk for CV death and nonfatal MI.
Keywords:	Cohort Studies, Coronary Artery Disease, Exercise Test, Magnetic Resonance Imaging, Myocardial Ischemia, Retrospective Studies, Risk Assessment
Source:	JAMA Cardiology
ISSN:	2380-6583
Publisher:	American Medical Association
Volume:	5
Number:	12
Page Range:	1401-1409
Date:	December 2020
Additional Information:	Copyright 2020 American Medical Association. All Rights Reserved.
Official Publication:	https://doi.org/10.1001/jamacardio.2020.2834
External Fulltext:	View full text on PubMed Central
PubMed:	View item in PubMed

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