Stress CMR accurately stratifies risk and prognosis of patients with stable chest pain and known or suspected CAD

New research revealed that in patients with stable chest pain stress cardiovascular magnetic resonance imaging (CMR) produced great diagnostic accuracy and gave solid prognostication. Stable chest pain patients with known or suspected coronary artery disease can be accurately diagnosed and risk-stratified using a combination evaluation of inducible myocardial ischemia and late gadolinium enhancement by stress CMR. The study results were published in the Journal JAMA Cardiology.  

Coronary artery disease (CAD) is the foremost factor for cardiovascular (CV) morbidity and mortality globally. Recent guidelines suggest that Non-invasive imaging plays a crucial role. New recommendations suggest the use of stress cardiovascular magnetic resonance imaging (CMR) to detect ischemia and guide clinical decision-making in patients with a high intermediate pretest clinical likelihood of CAD. As the clinical utility of stress cardiovascular magnetic resonance imaging (CMR) in stable chest pain is still under discussion, and as there is uncertainty on the low-risk period for adverse cardiovascular (CV) events after a negative test result, researchers conducted a study to provide contemporary quantitative data synthesis of the diagnostic accuracy and prognostic value of stress CMR in stable chest pain. 

Using prespecified combinations of keywords related to the diagnostic accuracy and prognostic value of stress CMR databases like the PubMed and Embase, the Cochrane Database of Systematic Reviews, PROSPERO, and the ClinicalTrials.gov registry were searched for potentially relevant articles. Based on the selected studies' evaluation of the CMR and its reported estimates of diagnostic accuracy and/or raw data of adverse CV events for participants with either positive or negative stress CMR results was carried out. A total of 3144 records were evaluated from which 235 eligible articles were included and after exclusions, 64 studies (74 470 total patients) published from October 29, 2002, through October 19, 2021, were included. 

The review and analysis were carried out adhering to the PRISMA guidelines. The primary outcomes of measurement included the Diagnostic odds ratios (DORs), sensitivity, specificity, area under the receiver operating characteristic curve (AUROC), odds ratio (OR), and annualized event rate (AER) for all-cause death, CV death, and major adverse cardiovascular events (MACEs) defined as the composite of myocardial infarction and CV death. 

Key findings: 

• A total of 33 diagnostic studies pooling 7814 individuals and 31 prognostic studies pooling 67 080 individuals with a mean [SD] follow-up, of 3.5 [2.1] years were identified. 
• Stress CMR yielded a DOR of 26.4, a sensitivity of 81%, a specificity of 86%, and an AUROC of 0.84 for the detection of functionally obstructive coronary artery disease.
• Stress CMR yielded higher diagnostic accuracy in the setting of suspected coronary artery disease or when using 3-T imaging in the subgroup analysis. 
• Stress-inducible ischemia was associated with higher all-cause mortality, CV mortality, and MACEs. 
• Late gadolinium enhancement (LGE) was associated with higher all-cause mortality, CV mortality, and increased risk of MACEs.
• There was less than 1.0% pooled AERs for CV death, After a negative test result. 

Thus, the present study reaffirmed that stress CMR yields high diagnostic accuracy, robust cardiac prognostication, and accurate risk stratification in patients with stable chest pain and known or suspected CAD. 

Further reading: Ricci F, Khanji MY, Bisaccia G, et al. Diagnostic and Prognostic Value of Stress Cardiovascular Magnetic Resonance Imaging in Patients With Known or Suspected Coronary Artery Disease: A Systematic Review and Meta-analysis. JAMA Cardiol. Published online June 07, 2023. doi:10.1001/jamacardio.2023.1290