What Is the Clinical Impact of Stress CMR After the ISCHEMIA Trial?
After progressively receding for decades, cardiovascular mortality due to coronary artery disease has recently increased, and the associated healthcare costs are projected to double by 2030. While the 2019 European Society of Cardiology guidelines for chronic coronary syndromes recommend non-invasiv...
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doaj-864f7580e75c471380f1ef3ce269e3642021-06-07T13:51:07ZengFrontiers Media S.A.Frontiers in Cardiovascular Medicine2297-055X2021-06-01810.3389/fcvm.2021.683434683434What Is the Clinical Impact of Stress CMR After the ISCHEMIA Trial?Théo Pezel0Théo Pezel1Luis Miguel Silva2Adriana Aparecia Bau3Adherbal Teixiera4Michael Jerosch-Herold5Otávio R. Coelho-Filho6Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, United StatesDepartment of Cardiology, Lariboisiere Hospital, University of Paris, Inserm, UMRS 942, Paris, FranceDiscipline of Cardiology, Faculty of Medical Science – State University of Campinas – UNICAMP, Campinas, São Paulo, BrazilDiscipline of Cardiology, Faculty of Medical Science – State University of Campinas – UNICAMP, Campinas, São Paulo, BrazilDiscipline of Cardiology, Faculty of Medical Science – State University of Campinas – UNICAMP, Campinas, São Paulo, BrazilNoninvasive Cardiovascular Imaging Program and Department of Radiology, Brigham and Women's Hospital, Boston, MA, United StatesDiscipline of Cardiology, Faculty of Medical Science – State University of Campinas – UNICAMP, Campinas, São Paulo, BrazilAfter progressively receding for decades, cardiovascular mortality due to coronary artery disease has recently increased, and the associated healthcare costs are projected to double by 2030. While the 2019 European Society of Cardiology guidelines for chronic coronary syndromes recommend non-invasive cardiac imaging for patients with suspected coronary artery disease, the impact of non-invasive imaging strategies to guide initial coronary revascularization and improve long-term outcomes is still under debate. Recently, the ISCHEMIA trial has highlighted the fundamental role of optimized medical therapy and the lack of overall benefit of early invasive strategies at a median follow-up of 3.2 years. However, sub-group analyses excluding procedural infarctions with longer follow-ups of up to 5 years have suggested that patients undergoing revascularization had better outcomes than those receiving medical therapy alone. A recent sub-study of ISCHEMIA in patients with heart failure or reduced left ventricular ejection fraction (LVEF <45%) indicated that revascularization improved clinical outcomes compared to medical therapy alone. Furthermore, other large observational studies have suggested a favorable prognostic impact of coronary revascularization in patients with severe inducible ischemia assessed by stress cardiovascular magnetic resonance (CMR). Indeed, some data suggest that stress CMR-guided revascularization assessing the extent of the ischemia could be useful in identifying patients who would most benefit from invasive procedures such as myocardial revascularization. Interestingly, the MR-INFORM trial has recently shown that a first-line stress CMR-based non-invasive assessment was non-inferior in terms of outcomes, with a lower incidence of coronary revascularization compared to an initial invasive approach guided by fractional flow reserve in patients with stable angina. In the present review, we will discuss the current state-of-the-art data on the prognostic value of stress CMR assessment of myocardial ischemia in light of the ISCHEMIA trial results, highlighting meaningful sub-analyses, and still unanswered opportunities of this pivotal study. We will also review the available evidence for the potential clinical application of quantifying the extent of ischemia to stratify cardiovascular risk and to best guide invasive and non-invasive treatment strategies.https://www.frontiersin.org/articles/10.3389/fcvm.2021.683434/fullcardiovascular magnetic resonancestress testingmyocardial ischemiacardiovascular eventscoronary revascularizationstable coronary disease |
collection |
DOAJ |
language |
English |
format |
Article |
sources |
DOAJ |
author |
Théo Pezel Théo Pezel Luis Miguel Silva Adriana Aparecia Bau Adherbal Teixiera Michael Jerosch-Herold Otávio R. Coelho-Filho |
spellingShingle |
Théo Pezel Théo Pezel Luis Miguel Silva Adriana Aparecia Bau Adherbal Teixiera Michael Jerosch-Herold Otávio R. Coelho-Filho What Is the Clinical Impact of Stress CMR After the ISCHEMIA Trial? Frontiers in Cardiovascular Medicine cardiovascular magnetic resonance stress testing myocardial ischemia cardiovascular events coronary revascularization stable coronary disease |
author_facet |
Théo Pezel Théo Pezel Luis Miguel Silva Adriana Aparecia Bau Adherbal Teixiera Michael Jerosch-Herold Otávio R. Coelho-Filho |
author_sort |
Théo Pezel |
title |
What Is the Clinical Impact of Stress CMR After the ISCHEMIA Trial? |
title_short |
What Is the Clinical Impact of Stress CMR After the ISCHEMIA Trial? |
title_full |
What Is the Clinical Impact of Stress CMR After the ISCHEMIA Trial? |
title_fullStr |
What Is the Clinical Impact of Stress CMR After the ISCHEMIA Trial? |
title_full_unstemmed |
What Is the Clinical Impact of Stress CMR After the ISCHEMIA Trial? |
title_sort |
what is the clinical impact of stress cmr after the ischemia trial? |
publisher |
Frontiers Media S.A. |
series |
Frontiers in Cardiovascular Medicine |
issn |
2297-055X |
publishDate |
2021-06-01 |
description |
After progressively receding for decades, cardiovascular mortality due to coronary artery disease has recently increased, and the associated healthcare costs are projected to double by 2030. While the 2019 European Society of Cardiology guidelines for chronic coronary syndromes recommend non-invasive cardiac imaging for patients with suspected coronary artery disease, the impact of non-invasive imaging strategies to guide initial coronary revascularization and improve long-term outcomes is still under debate. Recently, the ISCHEMIA trial has highlighted the fundamental role of optimized medical therapy and the lack of overall benefit of early invasive strategies at a median follow-up of 3.2 years. However, sub-group analyses excluding procedural infarctions with longer follow-ups of up to 5 years have suggested that patients undergoing revascularization had better outcomes than those receiving medical therapy alone. A recent sub-study of ISCHEMIA in patients with heart failure or reduced left ventricular ejection fraction (LVEF <45%) indicated that revascularization improved clinical outcomes compared to medical therapy alone. Furthermore, other large observational studies have suggested a favorable prognostic impact of coronary revascularization in patients with severe inducible ischemia assessed by stress cardiovascular magnetic resonance (CMR). Indeed, some data suggest that stress CMR-guided revascularization assessing the extent of the ischemia could be useful in identifying patients who would most benefit from invasive procedures such as myocardial revascularization. Interestingly, the MR-INFORM trial has recently shown that a first-line stress CMR-based non-invasive assessment was non-inferior in terms of outcomes, with a lower incidence of coronary revascularization compared to an initial invasive approach guided by fractional flow reserve in patients with stable angina. In the present review, we will discuss the current state-of-the-art data on the prognostic value of stress CMR assessment of myocardial ischemia in light of the ISCHEMIA trial results, highlighting meaningful sub-analyses, and still unanswered opportunities of this pivotal study. We will also review the available evidence for the potential clinical application of quantifying the extent of ischemia to stratify cardiovascular risk and to best guide invasive and non-invasive treatment strategies. |
topic |
cardiovascular magnetic resonance stress testing myocardial ischemia cardiovascular events coronary revascularization stable coronary disease |
url |
https://www.frontiersin.org/articles/10.3389/fcvm.2021.683434/full |
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