Comparison of Stress-Rest and Stress-LGE Analysis Strategy in Patients Undergoing Stress Perfusion Cardiovascular Magnetic Resonance

Abstract

BACKGROUND: Stress perfusion cardiovascular magnetic resonance can be performed without rest perfusion for the quantification of ischemia burden. However, the optimal method of analysis is uncertain. METHODS: We identified 666 patients from CE-MARC (Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease) with complete stress perfusion, rest perfusion, late gadolinium enhancement (LGE), and quantitative coronary angiography data. For each segment of the 16-segment model, perfusion was visually graded during stress and rest imaging, with infarct transmurality assessed from LGE imaging. In the stress-LGE analysis, a segment was defined as ischemic if it had a subendocardial perfusion defect with no infarction. Rest perfusion was not used in this analysis. We compared the diagnostic accuracy of stress-LGE analysis against quantitative coronary angiography and the stress-rest method validated in the original CE-MARC analysis. The diagnostic accuracy of the stress-LGE method was evaluated with different thresholds of infarct transmurality used to define whether an infarcted segment had peri-infarct ischemia. RESULTS: The optimal stress-LGE analysis classified all segments with a stress perfusion defect as ischemic unless they had >75% infarct transmurality (area under the curve, 0.843; sensitivity, 75.6%; specificity, 93.1%; P <0.001). This analysis method has superior diagnostic accuracy to the stress-rest method (area under the curve, 0.834; sensitivity, 73.6%; specificity, 93.1%; P <0.001, P value for difference=0.02). Patients were followed-up for median 6.5 years for major adverse cardiovascular events, with the presence of inducible ischemia by either the stress-LGE or stress-rest analysis being similar and strongly predictive (hazard ratio, 2.65; P <0.001, for both). CONCLUSIONS: In this analysis of CE-MARC, the optimum definition of inducible ischemia was the presence of a stress-induced perfusion defect without transmural infarction. This definition improved the diagnostic accuracy compared with the stress-rest analysis validated in the original study. The absence of ischemia by either analysis strategy conferred a favorable long-term prognosis.