Objective To determine the prognostic and therapeutic implications of stress perfusion cardiovascular magnetic resonance (CMR) on the basis of the ischemic cascade.
Setting Single centre study in a teaching hospital in Spain.
Patients Dipyridamole stress CMR was performed in 601 patients with ischemic chest pain and known or suspected coronary artery disease. On the basis of the ischemic cascade, patients were categorized in C1 (no evidence of ischemia, n=354), C2 (isolated perfusion deficit at stress first-pass perfusion imaging, n=181) and C3 (simultaneous perfusion deficit and inducible wall motion abnormalities, n=66). CMR-related revascularization (n=102, 17%) was regarded as those procedures prompted by the CMR results and carried out within the following 3 months.
Results During a median follow-up of 553 days, 69 major adverse cardiac events (MACE), including 21 cardiac deaths, 14 nonfatal myocardial infarctions and 34 admissions for unstable angina with documented abnormal angiography were detected. In non-revascularized patients (n=499), the MACE rate was 4% (14/340) in C1, 20% (26/128) in C2 and 39% (12/31) in C3 (adjusted p-value=0.004 ν C2 and <0.001 ν C1). CMR-related revascularization had neutral effects in C2 (20% ν 19%, 1.1 [0.5-2.4], p=0.7) but independently reduced the risk of MACE in C3 (39% ν 11%, 0.2 [0.1-0.7], p=0.01).
Conclusions Dypiridamole stress CMR is able to stratify risk on the basis of the ischemic cascade. A small group of patients with severe ischemia, namely simultaneous perfusion deficit and inducible WMA, are at the highest risk and benefit most from MACE reduction due to revascularization.
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