Incremental prognostic value of stress CMR in symptomatic patients with coronary stenosis on CCTA

Background

Noninvasive functional imaging is often performed in patients with obstructive coronary artery disease (CAD) on coronary computed tomography angiography (CCTA). However, the prognostic value of stress cardiovascular magnetic resonance (CMR) is unknown in patients with coronary stenosis of unknown significance on CCTA.

Purpose

To assess the prognostic value of stress CMR in symptomatic patients with obstructive CAD of unknown significance on CCTA.

Methods

Between 2008–2020, consecutive symptomatic patients without known CAD referred for CCTA were screened. Patients with obstructive CAD (at least 1 ≥50% stenosis on CCTA) were further referred for stress CMR and followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction.

Results

Of 2,210 patients who completed CMR, 2,038 (46.5% male, mean age 69.8±12.2 years) completed follow-up (median 6.8 [IQR 5.9–9.2] years); 281 experienced a MACE (13.8%). Inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with MACE (HR: 4.51, [95% CI: 3.55–5.74]; and HR: 3.32, [95% CI: 2.55–4.32], respectively; p<0.001). In multivariable Cox regression, number of segments with >70% stenosis, with noncalcified plaques and number of vessels with obstructive CAD were prognosticators (p<0.001). The presence of inducible ischemia and LGE were independent predictors of MACE (HR: 3.97, [95% CI: 3.43–5.13]; HR: 2.30, [95% CI: 1.52–3.33]; p<0.001). After adjustment, stress CMR showed the best improvement in model discrimination and reclassification above traditional risk factors and CCTA (C-statistic improvement: 0.04; NRI=0.421; IDI=0.047).

Conclusions

In symptomatic patients with obstructive CAD of unknown significance on CCTA, stress CMR had incremental prognostic value to predict MACE.

Funding Acknowledgement

Type of funding sources: None.

Phenotypic clustering of patients with newly diagnosed coronary artery disease using cardiovascular magnetic resonance and coronary computed tomography angiography

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Epidemiological characteristics and prognostic profiles of patients with newly diagnosed coronary artery disease (CAD) are heterogeneous. Thus, providing individualized cardiovascular (CV) risk stratification and tailored prevention is crucial.

PURPOSE

Phenotypic unsupervised clustering integrating clinical, coronary computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR) data was used to unveil pathophysiological differences between subgroups of patients with newly diagnosed CAD.

METHODS

Between 2008 and 2020, consecutive patients with newly diagnosed obstructive CAD on CCTA and further referred for vasodilator stress CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. A cluster analysis was performed on clinical, CCTA and CMR variables, and associations between phenogroups and outcomes were assessed.

RESULTS

Of 2,210 patients who underwent CMR, 2,015 (46% male, mean 70 ± 12 years) completed follow-up (median 6.8[IQR 5.9-9.2] years); 277 experienced a MACE (13.7%). Three mutually exclusive and clinically distinct phenogroups (PG) were identified based upon unsupervised hierarchical clustering of principal components: [PG1] CAD in elderly patients with few traditional risk factors; [PG2] women with metabolic syndrome, calcified plaques on CCTA and preserved left ventricular ejection fraction (LVEF); and [PG3] younger male smokers with proximal noncalcified plaques on CCTA, myocardial scar and reduced LVEF. Using survival analysis, the occurrence of MACE, cardiovascular mortality and all-cause mortality (all p < 0.001) differed among the three PG, PG3 having the worse prognosis. In each PG, inducible ischemia was associated with MACE (PG1, HR = 3.09, 95%CI, 1.70-5.62; PG2, HR = 3.62, 95%CI, 2.31-5.70; PG3, HR = 3.55, 95%CI, 2.30-5.49; all p < 0.001).

CONCLUSIONS

Cluster analysis of clinical, CCTA and CMR variables identified 3 phenogroups of patients with newly diagnosed CAD that were associated with distinct clinical and prognostic profiles. Inducible ischemia assessed by stress CMR remained associated with the occurrence of MACE within each phenogroup. Abstract Figure. Cluster analysis: Biplot representation  Abstract Figure. Kaplan Meier curves by Phenogroups

Incremental prognostic value of vasodilator stress cardiovascular magnetic resonance over coronary computed tomography angiography in symptomatic patients

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Current guidelines recommend to perform noninvasive functional imaging in patients with obstructive coronary artery disease (CAD) on coronary computed tomography angiography (CCTA). However, the prognostic value of stress cardiovascular magnetic resonance (CMR) over traditional risk factors and CCTA is not known.

PURPOSE

To assess the incremental prognostic value of stress CMR beyond traditional risk factors and CCTA in patients with obstructive CAD on CCTA.

METHODS

Between 2008 and 2020, consecutive symptomatic patients without known CAD referred for CCTA were screened. Among those, patients with obstructive CAD (at least 1 ≥50% stenosis on CCTA) and referred for functional stress CMR were included and followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. Univariable and multivariable Cox regressions were performed to determine the prognostic value of CCTA and CMR findings.

RESULTS

Of 2,210 patients who completed the CMR protocol, 2,038 patients (46.5% male, mean age 69.8 ± 12.2 years) completed the follow-up (median 6.8 [IQR 5.9-9.2] years); 281 experienced a MACE (13.8%). Stress CMR was well tolerated without severe adverse events. Using Kaplan-Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (hazard ratio, HR: 4.51, [95%CI: 3.55-5.74]; and HR: 3.32, [95%CI: 2.55-4.32], respectively; both p < 0.001). In multivariable Cox regression, the presence of inducible ischemia and LGE were independent predictors of a higher incidence of MACE (HR: 3.97, [95%CI: 3.43-5.13]; HR: 2.30, [95%CI: 1.52-3.33]; respectively, both p < 0.001). After adjustment, stress CMR findings showed the best improvement in model discrimination and reclassification above traditional risk factors and CCTA findings (C statistic improvement: 0.08; NRI = 0.421; IDI = 0.047).

CONCLUSIONS

In symptomatic patients with obstructive CAD of unknown significance on CCTA, stress CMR has an incremental prognostic value to predict MACE over traditional risk factors and CCTA findings. Abstract Figure. Kaplan-Meier curves for MACE  Abstract Figure. Competitive risk analysis

[TAVI in women, very encouraging results]

The population of elderly patients comprises a high percentage of women. This population is more vulnerable due to the presence of numerous comorbidities and is, therefore, particularly exposed to the risk of aortic valve degeneration, resulting in aortic valve stenosis whose symptoms are predictors of poor short-term outcomes. In the presence of symptomatic aortic stenosis, the recommended therapeutic option in this vulnerable population is the implementation of transcatheter aortic valve implantation, preferably via the femoral route. The outcomes of this procedure are better in women than in men despite a more frequent occurrence of vascular, bleeding and cerebral complications. Several hypotheses have been reported in the literature regarding the reasons for such differences. Among other reasons, it is likely that in female patients, the myocardium adjusts better to the occurrence of aortic stenosis and that recovery after valve treatment is also more optimal. Another explanation is the higher frequency of coronary artery disease in this older population. This has a considerable impact on the outcome even when coronary lesions are treated prior to valve implantation. There is still room for improvement and progress can be achieved by further reducing the size of the equipment used in order to decrease the diameter of the vascular access, and by continuing to simplify TAVI procedures. Less invasive techniques should result in decreased complication rates. In addition, dedicated studies should allow us to further improve our practice in this growing population of vulnerable patients.

Prognostic factors for patients with chronic myeloid leukaemia in chronic phase treated with imatinib mesylate after failure of interferon alfa

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Improving the management of chronic myeloid leukaemia

Until recently the therapeutic options available to patients diagnosed with chronic myeloid leukaemia hinged on their suitability for allogeneic bone marrow transplantation. With the advent of new agents targeting the specific molecular pathways involved in the disease, drug therapies may have an increasingly important role in improving outcome.

Long-term retention of heat training in Mongolian gerbils

Escape from heat was used to produce a black-white discrimination response in 60 gerbils. The animals were retested after 2, 4, or 6 calendar months from the date of original learning. The retest consisted of reversal learning for half the group and retraining for the other half. The relearning group showed significant savings and differed reliably from the reversal group which demonstrated no transfer at all. The originally learned response persisted, being unaffected by the passage of time. It was concluded that heat training results in the long-term retention of an acquired response.

Kinetic visual imagery

Movement of the hand in total darkness by 7 sighted Ss gave rise to a sense of motion visually. This phenomenon was called kinetic visual imagery. The kinetic imagery was followed by the impression of being able to see the hand. The phenomenal visualization of the hand was clearly distinguished from the images of imagination, memory, and hallucination. The conditions necessary to produce the effect were described, along with theoretical considerations and implications.