Diagnostic and prognostic value of stress CMR imaging to evaluate stable chest pain: a twenty-year meta-analysis

Abstract

Abstract Funding Acknowledgements Type of funding sources: None. Background Assessment of inducible ischemia with stress cardiovascular magnetic resonance (CMR) is recommended in patients with chest pain and intermediate or high pre-test probability of coronary artery disease (CAD). We aimed to provide a contemporary quantitative data synthesis on diagnostic accuracy and prognostic value of stress CMR in patients with stable chest pain syndromes. Methods We performed a prespecified systematic review and meta-analysis of studies published over the last twenty years on the diagnostic and prognostic value of stress CMR (PROSPERO: CRD42022299275). We measured pooled diagnostic indicators, including diagnostic odds ratio (DOR), sensitivity, specificity, area under the curve (AUC), and summary effect size indicators, including odds ratios (ORs) and cumulative annualized event rates (AERs) for all-cause death, cardiovascular death and major adverse cardiac events (MACE). Results We identified 33 diagnostic studies pooling 7,815 individuals (mean age, 62 years, 62% males) and 31 prognostic studies pooling 67,080 patients (mean age, 62 years; 57% males; mean follow-up 3.5 years for a total of 381,357 person-years). Stress CMR yielded a pooled DOR of 26.4 (95%CI:10.6–65.9), a sensitivity of 81% (95%CI:68–89%), a specificity of 86% (95%CI:75–93%), and an AUC of 0.84 (95%CI:0.77–0.89) for the detection of functionally obstructive CAD with fractional flow reserve as the reference test. In subgroup analysis, 3 Tesla imaging yielded higher diagnostic accuracy achieving a DOR of 33.2. Presence of stress-inducible ischemia was associated with higher all-cause mortality (OR:2.0; 95%CI:1.7–2.3), cardiovascular mortality (OR:6.4; 95%CI:4.5–9.1), and increased risk of MACE (OR:5.3; 95%CI:4.0–7.0). AERs for cardiovascular death and MACE were < 1% in patients without stress-inducible ischemia. Conclusion Stress CMR yields high diagnostic accuracy and delivers robust prognostication in patients with stable chest pain and known or suspected CAD, particularly with 3 Tesla imaging. While inducible ischemia portends excess mortality and increased risk of MACE, a negative stress CMR indicates a very low risk of future cardiovascular events, with a warranty period of at least 3.5 years.