Transcript 12350_2016_597_MOESM1_ESMx

Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology
The Role of Stress Cardiac Magnetic
Resonance in Women
Andrea Cardona, MD1,2, Karolina M. Zareba, MD1, Subha V. Raman, MD1
1-Ohio State University, Division of Cardiovascular Medicine. Columbus - USA
2- University of Perugia, Division of Cardiology, Perugia - Italy
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Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology
BACKGROUND
1
Ischemic heart disease (IHD) is the leading cause of death in
women.
2
An overwhelming body of evidence indicates under-diagnosis and
under-treatment of women for suspected or known ischemic heart
disease (IHD), incurring preventable IHD events and adverse
outcomes.
3
Appropriate evaluation of IHD in women requires recognition of the
range of myocardial sequelae to upstream abnormalities in
epicardial coronaries and microcirculation.
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Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology
Stress CMR - Why
Several aspects of CMR make it an appealing and useful stress imaging
modality for women with known or suspected IHD:
A. No ionizing radiation, especially important in pre-menopausal
women and those with genetic susceptibility to breast cancer.
B. Image formation is not affected by soft tissue attenuation or acoustic
window, which prevents body habitus from reducing diagnostic
accuracy.
C. High spatial resolution images afford reliable visualization of
subendocardial ischemia and non-transmural infarct scar.
D. Standard CMR exam provides comprehensive information on
ischemia, myocardial scar and tissue characteristics and ventricular
function which can explain symptoms in the absence of ischemia.
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Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology
Stress CMR - How
Two main classes of pharmacologic agents are used for stress CMR:
Vasodilators
Inotropes
•
Vasodilator stress myocardial perfusion
imaging with CMR employs rapid
dynamic imaging during the first pass
of a gadolinium-based contrast agent.
•
Dobutamine stress CMR can be
performed without contrast, though
addition of contrast can delineate extent
of myocardial fibrosis.
•
Stress perfusion CMR performs well in
detecting ischemia in patients with
known or suspected IHD due to
epicardial coronary artery stenosis.
•
Perfusion image acquisition at peak
dobutamine stress provides
complementary information to regional
wall motion assessment.
•
Beyond epicardial CAD, perfusion
CMR has established value in
diagnosing microvascular disease that
is all too common in women.
•
Dobutamine CMR can be used in high
dose to detect stress-induced ischemia
and in low dose to identify contractile
reserve.
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Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology
Stress CMR – Diagnostic and Prognostic Value
Overall
Women
Diagnostic Accuracy ⃰
Sensitivity
Specificity
Vasodilators
90%
81%
Dobutamine
83%
86%
Prognostic Value ⃰
In a meta-analysis with > 11,000 patients
with known or suspected IHD, positive
stress CMR was strongly associated with
the outcome (CV death and non-fatal MI):
OR: 6.47; 95% CI 4.42-9.46 (perfusion)
OR: 6.20; 95% CI 2.61-14.73 (dobutamine)
⃰ see main text for references
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In the CE-MARC study ⃰ analysis by gender
showed that CMR offers women referred
for stress perfusion imaging both higher
sensitivity (88.7% vs. 50.9%, p<0.0001) and
diagnostic accuracy compared to SPECT
(AUC, 0.90 vs. 0.67; p<0.0001)
In a study of gender-related prognostic
value of either adenosine perfusion or
dobutamine CMR with a median follow-up
of 5.3 years, multivariate analysis revealed
the presence of inducible perfusion defects
or WMA as independent predictors of hard
cardiac events. In women, a negative
stress CMR demonstrated an event-free
survival of 100%.
Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology
CONCLUSIONS
•
Stress CMR has several decades of evidence supporting its diagnostic
accuracy, prognostic value, safety and utility.
•
Considerable growth and education of providers over just the past few years
is helping to ensure widespread availability.
•
Superior diagnostic accuracy and lack of exposure to ionizing radiation, plus
the unique ability to characterize both epicardial coronary as well as
microvascular disease make stress CMR an appealing imaging modality for
the assessment of IHD in women.
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