Prediction of necessity for coronary artery revascularization by adenosine contrast-enhanced magnetic resonance imaging

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Abstract

Background

Assessing myocardial first-pass wash-in during pharmacological induced stress allows detection of perfusion deficits and indicates stenotic coronary arteries (CA). The aim of our study was to demonstrate clinical relevance of contrast-enhanced stress magnetic resonance imaging (CMR) by predicting necessity of CA intervention.

Methods

738 patients with scheduled coronary angiography (CXA) were scanned in a 1.5 Tesla CMR scanner. After 3 min of adenosine infusion (140 μg/kg/min), first-pass kinetic of contrast agent was evaluated. Myocardial necrosis was visualized with “myocardial late enhancement (MLE)”. Perfusion deficits were described as either “ischemia in viable myocardium”, or “no relevant ischemia in viable myocardium” or as “ischemia in chronic myocardial infarction (CMI)” based on spatial and temporal extent of ischemia and of MLE. CXA was performed in all patients within 48 h after CMR and revascularization, if applicable, was performed. Angiograms were read by two independent and blinded investigators and matched with CMR findings.

Results

539 patients (73%) showed “ischemia in viable myocardium” and revascularization was performed in 513 patients (95%). In 111 patients with “no relevant ischemia in viable myocardium”, revascularization was performed in only 5 patients (5%). In 88 patients classified as “ischemia in CMI”, revascularization was performed in 14 patients (16%). Positive predictive value of CMR for CA intervention was 0.95, negative predictive value was 0.89, sensitivity was 0.96, and specificity was 0.87.

Conclusion

CMR allows clinical useful prediction of relevant CA disease with need for revascularization prior to CXA and may be used as non-invasive test for myocardial ischemia and viability to guide further therapy.

Introduction

Diagnosis and quantification of coronary artery (CA) disease are essential for clinical decisions and indication for percutaneous coronary intervention or bypass surgery. Pharmacological provocative tests are commonly employed to detect myocardial ischemia prior to invasive coronary angiography (CXA). Stress electrocardiography and stress echocardiography are the most widely available tools. Both methods allow conclusions of myocardial ischemia during stress, but do not provide direct information about myocardial perfusion. Positron emission and single photon emission computed tomography are performed routinely in many centers, but suffer from attenuation artefacts and limited spatial resolution [1], [2], [3], [4], [5]. Contrast-enhanced magnetic resonance imaging (CMR) provides information about myocardial perfusion deficits, functional information of left and right ventricle and myocardial viability in a single protocol with acceptable duration. As shown in recently published studies, CMR offers higher spatial and temporal resolution as nuclear techniques [5], [6], [7], [8], [9]. Furthermore, “myocardial late enhancement (MLE)” imaging allows direct visualization of non-viable myocardial tissue with high accuracy and thus conclusion about chronic myocardial infarction (CMI) [1], [2], [5], [9], [10], [11], [12].

The aim of this study was to determine the predictive value of adenosine-stress CMR in routine patients with clinical indication for CXA regarding need for coronary revascularization.

Section snippets

Study population

We prospectively enrolled consecutive patients from a single center with given clinical indication for CXA over the period of 18 months. Exclusion criteria were unstable angina or myocardial infarction or CA revascularization within the last six months, higher degree of heart valve disease, higher degree of atrioventricular blocks, acute myocarditis, internal pacemaker or defibrillator, and the inability to give written informed consent. Study protocol was approved by the local ethic commission

Patients

752 patients with clinical indication for CXA were screened for enrollment to the study. 14 patients were excluded due to unstable angina (n = 1), significant valvular disease (n = 3), reluctance to give informed written consent (n = 7) or recent myocardial infarction (n = 3). 738 patients were included into the study group. Mean age was 63.7 ± 12.2 years. 457 (62%) were male, 281 (38%) female. Baseline characteristics including cardiovascular risk factors are given in Table 1.

Indication for CXA

Discussion

Indication for invasive CXA should be based on exact non-invasive testing to precisely predict subsequent need for revascularization. Patients with critically hypoperfused but still viable myocardial segments at rest or under stress conditions will profit from revascularization, whereas infarcted segments without additional inducible ischemia will not regain contractility after restoration of blood supply.

Due to its multi-modality abilities, CMR may answer most relevant aspects of CA disease

Acknowledgments

We thank Angela Weiss and Sylke Lindenau for helping in recruiting patients and excellent technical assistance.

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