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Stress Cardiovascular MRI: What a New Meta-Analysis Reveals
For the detection of obstructive coronary artery disease (CAD), stress cardiovascular magnetic resonance imaging (MRI) demonstrated a sensitivity rate of 81 percent and a specificity rate of 86 percent, according to a meta-analysis of 64 studies and data from 74,470 patients with stable chest pain.
In a new meta-analysis, researchers found that stress cardiovascular magnetic resonance imaging (MRI) not only has strong capability for diagnosing obstructive coronary artery disease (CAD), it can also provide robust prognosis of major adverse cardiovascular events (MACEs) and related mortality.
For the meta-analysis, recently published in JAMA Cardiology, researchers reviewed data from 33 diagnostic studies and 31 prognostic studies published between 2002 and 2021. The mean follow-up period was 3.5 years and data from a total of 74,470 patients with stable chest pain were included in the meta-analysis.
The researchers found an 84 percent area under the receiver operating characteristic curve (AUROC), a sensitivity rate of 81 percent and a specificity rate of 86 percent for the diagnosis of obstructive CAD.
The meta-analysis authors found that stress cardiovascular MRI had an 84 percent area under the receiver operating characteristic curve (AUROC), a sensitivity rate of 81 percent and a specificity rate of 86 percent for the diagnosis of obstructive CAD.
Stress-inducible ischemia on MRI was associated with a greater than sixfold higher likelihood of cardiovascular mortality, a greater than fivefold higher likelihood of MACEs and nearly double the likelihood of all-cause mortality, according to the meta-analysis. The researchers also noted that late gadolinium enhancement (LGE) on stress cardiovascular MRI resulted in a greater than sixfold likelihood of cardiovascular mortality, a greater than fivefold higher risk of MACEs and more the double the likelihood of all-cause mortality.
“Our findings 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,” wrote lead meta-analysis author Fabrizio Ricci, M.D., Ph.D., MSc, who is affiliated with the Department of Neuroscience, Imaging and Clinical Sciences at Gabriele d’Annunzio University of Chieti-Pescara in Chieti, Italy.
While stress cardiovascular MRI had an overall diagnostic odds ratio (DOR) of 26.4 for people with known or suspected obstructive CAD, the meta-analysis authors noted higher DORs for those with suspected CAD (53.4 DOR) and in the use of 3T MRI (33.2 DOR). In addition to improved contrast resolution, 3T MRI facilitated quantitative perfusion assessment, according to the researchers.
“(Quantitative perfusion assessment) can be advantageous to better identify the extent of disease or peri-infarction ischemia in multivessel CAD compared with visual assessment alone and can more accurately detect microvascular disease and the effectiveness of the stressor agents,” noted Dr. Ricci and colleagues.
In their review of the literature, the meta-analysis authors noted the use of stress cardiovascular MRI led to less referrals of patients for invasive coronary angiography (ICA) in comparison to coronary CT angiography or other non-invasive imaging. Separate studies examining cost-effectiveness of cardiovascular imaging also found stress cardiovascular MRI favorable in comparison to coronary CT angiography and single-photon emission CT.
“Thus, having access to (cardiovascular MRI) is a beneficial situation for patients and may lead to substantial cost savings by reducing the need for additional unnecessary tests and revascularization procedures,” added Dr. Ricci and colleagues.
In regard to study limitations, the authors acknowledged they did not compare the results of stress cardiovascular MRI with other imaging modalities. They conceded a lack of patient information on the degree of myocardial fibrosis, the extent of inducible ischemia, medications, and the prevalence of microvascular dysfunction.
Noting that the reviewed studies were published between 2002 and 2021, Ricci and colleagues pointed out that a variety of changes have occurred during the last two decades, including updated thresholds for coronary stenosis, the advent of cardiovascular MRI protocols that include quantitative perfusion assessment, and recalibration of methods for estimating pre-test probabilities of obstructive CAD.
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