Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Cardiology Division, University Hospital of Lausanne, Lausanne, Switzerland.
JAMA Cardiol. 2020 Dec 1;5(12):1401-1409. doi: 10.1001/jamacardio.2020.2834.
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.
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.
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.
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).
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.
在没有冠心病病史但出现疑似心肌缺血的患者中，通过美国心脏病学会/美国心脏协会指南推荐类别重新分类来改变风险的心脏磁共振（CMR）应激检测在临床决策中的作用尚未确定。
检查应激 CMR 成像在没有冠心病病史但出现疑似心肌缺血的患者中用于风险重新分类的效用。
设计、地点和参与者：这是一项回顾性、多中心队列研究，中位随访时间为 5.4 年（四分位间距，4.6-6.9），在 11 个美国州的 13 个中心进行。参与者包括 1698 名连续患者，年龄在 35 岁至 85 岁之间，有 2 个或更多的冠心病危险因素，但没有冠心病病史，出现疑似心肌缺血，需要进行应激 CMR 成像。该研究于 2019 年 2 月 18 日至 2020 年 3 月 1 日进行。
心血管（CV）死亡和非致死性心肌梗死（MI）。主要不良 CV 事件（MACE）包括 CV 死亡、非致死性 MI、因心力衰竭或不稳定型心绞痛住院以及后期、计划外的冠状动脉旁路移植术。
在 1698 名患者中，873 名是男性（51.4%）；平均（SD）年龄为 62（11）岁，占 67 例 CV 死亡/非致死性 MACE 和 190 例 MACE。构建了预先测试风险的临床模型，并根据指南推荐的低（<1%/年）、中（1%-3%/年）和高（>3%/年）风险类别对患者进行分类。应激 CMR 成像在所有基线模型中提供了风险重新分类。对于 CV 死亡/非致死性 MI，将验证后的 CAD 联合会评分、高血压、吸烟和糖尿病纳入的模型中加入应激 CMR 评估的左心室射血分数、缺血存在和晚期钆增强，提供了显著的净重新分类改善 0.266（95%CI，0.091-0.441）和 C 统计改善 0.086（95%CI，0.022-0.149）。应激 CMR 成像重新分类了 60.3%的中等预测试风险类别患者（52.4%重新分类为低风险，7.9%重新分类为高风险），相应的观察到的低风险后事件发生率为每年 0.6%，高风险后事件发生率为每年 4.9%。对于 MACE，应激 CMR 成像进一步提供了显著的净重新分类改善（0.361；95%CI，0.255-0.468）和 C 统计改善（0.092；95%CI，0.054-0.131），并重新分类了 59.9%的中等预测试风险组患者（48.7%重新分类为低风险，11.2%重新分类为高风险）。
在这项没有冠心病病史但出现疑似心肌缺血的多中心队列研究中，应激 CMR 成像在基于指南的风险类别中重新分类了患者的风险，超出了临床危险因素。这项研究的结果支持应激 CMR 成像在临床决策中的价值，特别是在心血管死亡和非致死性 MI 风险处于中等水平的患者中。
