Systematic review and meta-analysis
Key points What is the diagnostic and prognostic value of stress cardiovascular magnetic resonance imaging (CMR) for the evaluation of stable chest pain? Findings In this systematic review and meta-analysis involving 74,470 patients with stable chest pain over 381,357 person-years of follow-up, stress CMR yielded high diagnostic accuracy and accurate risk stratification in patients with known or suspected coronary artery disease. particularly when 3-T imaging was used. The presence of stress-inducible ischemia and late gadolinium enhancement was associated with a higher mortality and probability of cardiovascular events, while normal stress CMR results were associated with a lower probability of cardiovascular events for at least 3.5 years. Meaning These findings suggest that combined evaluation of inducible myocardial ischemia and late gadolinium enhancement by stress CMR is an accurate method for diagnosing and risk stratifying patients with stable chest pain and known or suspected coronary artery disease. |
Importance
The clinical utility of stress cardiovascular magnetic resonance imaging (CMR) in stable chest pain is still debated, and the period of low risk for adverse cardiovascular (CV) events after a negative test result is unknown.
Aim
To provide a synthesis of contemporary quantitative data on the diagnostic accuracy and prognostic value of stress CMR in stable chest pain.
Data sources
The PubMed and Embase databases, the Cochrane Database of Systematic Reviews, PROSPERO, and the ClinicalTrials.gov registry were searched for potentially relevant articles from January 1, 2000 to December 31, 2021.
Study selection
Selected studies evaluated CMR and reported estimates of diagnostic accuracy and/or raw data of adverse cardiovascular events for participants with positive or negative stress CMR results.
Pre-specified combinations of keywords related to the diagnostic accuracy and prognostic value of stress CMR were used. A total of 3144 records were evaluated for title and abstract; of these, 235 articles were included in the full-text eligibility assessment.
After exclusions, 64 studies (74,470 patients in total) published from October 29, 2002 to October 19, 2021 were included.
Data extraction and synthesis
This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Main results and measures
Diagnostic odds ratios (DOR), sensitivity, specificity, area under the receiver operating characteristic curve (AUROC), odds ratio (OR) and annualized event rate (AER) for all causes of death, CV death and disease severe, adverse cardiovascular events (MACE) defined as the combination of myocardial infarction and CV death.
Results
A total of 33 diagnostic studies involving 7,814 people and 31 prognostic studies involving 67,080 people were identified (mean [SD] follow-up, 3.5 [2.1] years; range, 0.9-8. 8 years; 381,357 person-years).
Stress CMR yielded a DOR of 26.4 (95% CI, 10.6-65.9), sensitivity of 81% (95% CI, 68%-89%), specificity of 86% ( 95% CI, 75%-93%), and an AUROC of 0.84 (95% CI, 0.77-0.89) for detection of functionally obstructive coronary artery disease.
In subgroup analysis, stress CMR yielded greater diagnostic accuracy in the setting of suspected coronary artery disease (DOR, 53.4; 95% CI, 27.7-103.0) or when 3-degree images were used. -T (DOR, 33.2; 95% CI, 19.9-55.4).
The presence of stress-inducible ischemia was associated with higher all-cause mortality (OR, 1.97; 95% CI, 1.69-2.31), CV mortality (OR, 6.40; 95% CI, 4.48-9.14) and MACE (OR, 5.33; 95% CI, 4.04-7.04).
The presence of late gadolinium enhancement (LGE) was associated with increased all-cause mortality (OR, 2.22; 95% CI, 1.99-2.47), CV mortality (OR, 6.03; 95%, 2.76-13.13) and increased risk of MACE (OR, 5.42; 95% CI, 3.42-8.60). After a negative test result, the pooled AERs for CV death were less than 1.0%.
Conclusion and relevance In this study, stress CMR produced high diagnostic accuracy and robust prognosis, particularly when 3-T scanners were used. While inducible myocardial ischemia and late gadolinium enhancement (LGE) were associated with increased mortality and risk of MACE, normal stress CMR results were associated with decreased risk of MACE for at least 3.5 years. |
