While current guidelines recommend noninvasive testing to detect coronary artery disease, stress tests are deemed inconclusive in a quarter of cases. The strategy for risk stratification after inconclusive stress testing is not well standardized. To assess the prognostic value of vasodilator stress cardiovascular magnetic resonance (CMR) parameters and CMR-based coronary revascularization in patients after inconclusive stress testing. Between 2008 and 2020, consecutive patients with a first non-CMR inconclusive stress test referred for vasodilator stress perfusion CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. CMR-related coronary revascularization was defined as any revascularisation occurring within 90 days after CMR. Univariable and multivariable Cox regressions were performed to determine the prognostic value of each parameter. Of 1563 patients who completed the CMR protocol, 1402 patients (66.7% male, 69.5 ± 11.0 years) completed the follow-up (median [interquartile range], 6.5 [5.6–7.5] years); 197 experienced a MACE (14.1%). Vasodilator 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: 2.88 [95% CI 2.18–3.81]; and HR: 1.46 [95% CI 1.16–1.89], both p < 0.001; respectively). In multivariable Cox regression, the presence and extent of inducible ischemia were independent predictors of a higher incidence of MACE (HR: 2.53 [95% CI 1.89–3.40]; and HR: 1.58 [95% CI 1.47–1.71]; both p < 0.001; respectively). After adjustment, the extent of inducible ischemia showed the best improvement in model discrimination above traditional risk factors (C-statistic 0.75 [95% CI 0.69–0.81] with C-statistic improvement: 0.12). The study suggested no benefit of CMR-related coronary revascularization in reducing MACE. In patients with a first non-CMR inconclusive stress test, vasodilator stress CMR has good prognostic value to predict MACE offering an incremental prognostic value over traditional risk factors.

中文翻译：

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负荷试验不确定后血管扩张剂负荷灌注心血管磁共振的预后价值

虽然目前的指南建议采用无创测试来检测冠状动脉疾病，但在四分之一的病例中，压力测试被认为是不确定的。不确定压力测试后的风险分层策略没有很好地标准化。评估血管扩张剂应激心血管磁共振 (CMR) 参数和基于 CMR 的冠状动脉血运重建在不确定的压力测试后患者的预后价值。在 2008 年至 2020 年期间，连续进行了第一次非 CMR 不确定性压力测试并转诊进行血管扩张剂负荷灌注 CMR 的患者，随后对主要不良心血管事件 (MACE) 的发生情况进行了跟踪，这些事件定义为心血管死亡或非致命性心肌梗塞。CMR 相关冠状动脉血运重建定义为 CMR 后 90 天内发生的任何血运重建。进行单变量和多变量 Cox 回归以确定每个参数的预后值。在完成 CMR 方案的 1563 名患者中，1402 名患者（66.7% 男性，69.5 ± 11.0 岁）完成了随访（中位数 [四分位距]，6.5 [5.6-7.5] 年）；197 人经历了 MACE（14.1%）。血管扩张剂应激 CMR 的耐受性良好，没有严重的不良事件。使用 Kaplan-Meier 分析，诱导性缺血和迟发钆增强 (LGE) 与 MACE 的发生显着相关（风险比，HR：2.88 [95% CI 2.18-3.81]；HR：1.46 [95% CI 1.16-1.89] ]，两者 p < 0.001；分别）。在多变量 Cox 回归中，诱导性缺血的存在和程度是 MACE 发生率较高的独立预测因子（HR：2.53 [95% CI 1.89-3.40]；HR：1.58 [95% CI 1.47-1.71]；两者 p < 0.001; 分别）。调整后，诱导性缺血的程度在模型区分方面显示出优于传统风险因素的最佳改善（C 统计量 0.75 [95% CI 0.69–0.81]，C 统计量改善：0.12）。该研究表明，CMR 相关的冠状动脉血运重建术在降低 MACE 方面没有益处。在第一次非 CMR 压力测试不确定的患者中，血管扩张剂压力 CMR 具有良好的预后价值，可以预测 MACE，提供比传统风险因素更高的预后价值。