Stress Cardiac MRI in Modern Cardiology: EU vs USA
By Chiara Bucciarelli-Ducci,
Chief Executive Officer, Society Cardiovascular Magnetic Resonance (SCMR) and Co-Director, Clinical Research and Imaging Centre, University of Bristol, U.K
Imaging cardiologist Bucciarelli-Ducci is the Academic lead for imaging at the Bristol NIHR Biomedical Research Centre, Co-Director of the Clinical Research and Imaging Centre (CRIC) Bristol, UK and also the Chair of the CMR Section.
Currently, she is the Chief Executive officer of the Society for Cardiovascular Magnetic Resonance, global international society based in the United States.
She was earlier the Vice-President of EACVI (European Association of Cardiovascular Imaging) (2016-2018) and EACVI secretary (2018-2019).
Bucciarelli-Ducci holds a PhD in cardiovascular magnetic resonance (CMR) from National Heart and Lung Institute (NHLI), Imperial College London.
She is passionate about cardiac imaging research & education, and training & mentors the young generation of imagers. She has a deep commitment to advance the field of how imaging can guide and improve patients' care.
Chiara Bucciarelli-Ducci, MD, PhD
Chief Executive Officer, Society Cardiovascular Magnetic Resonance (SCMR) and
Co-Director, Clinical Research and Imaging Centre, University of Bristol, U.K
Cardiac MRI, including stress Cardiac MRI is underutilized in the United States despite the increasing evidence that is changing clinical practice in Europe.
Stress Cardiac MRI has been indicated in Class IA for the investigation of chest pain in the European Society of Cardiology (ESC) guidelines since 2014 (2014 ESC/EACTS Guidelines on myocardial revascularization), similarly to other stress tests such as SPECT, PET and stress echocardiography. The new 2019 “ESC Guidelines for the diagnosis and management of chronic coronary syndromes” maintained the approach of using non-invasive functional imaging for myocardial ischemia (including stress Cardiac MRI) or coronary cardiac CT (newly introduced) as the initial test to diagnose coronary artery disease in symptomatic patients.
There 3 major randomised trails in the most prestigious international medical journals establishing that stress Cardiac MRI has a good diagnostic yield in patients with suspected coronary artery disease reducing unnecessary coronary angiography.
The CE-MARC study (Lancet 2012) demonstrated that in patients with suspected coronary artery disease stress Cardiac MRI has high diagnostic accuracy (sensitivity 86·5%, specificity 83·4%, positive predictive value 77·2%, and negative predictive value 90·5% ) in coronary heart disease with a superior diagnostic performance compared to SPECT. The CE-MARC 2 study (JAMA 2016) showed that in patients with suspected angina, investigation by CMR resulted in a lower probability of unnecessary angiography within 12 months than NICE guideline–directed care.
The recent MR-INFORM trial published in the New England Journal of Medicine 2019 has recently shown that adenosine stress cardiac MRI is non-inferior to FFR in the detection of hemodynamically significant coronary stenosis. The study recruited 918 patients with stable angina and risk factors for coronary artery disease who were randomized to 2 management strategies: invasive angiography or a 40-minute cardiac MRI stress perfusion test. A total of 184 of 454 patients (40.5%) in the cardiac-MRI group and 213 of 464 patients (45.9%) in the FFR group met criteria to recommend revascularization (P=0.11). Fewer patients in the cardiac-MRI group than in the FFR group underwent index revascularization (162 [35.7%] vs. 209 [45.0%], P=0.005). In patients with stable angina and risk factors for coronary artery disease, myocardial-perfusion cardiovascular MRI was associated with a lower incidence of coronary revascularization than FFR; also, Cardiac MRI was noninferior to FFR with respect to major adverse cardiac events.
Finally, the Stress CMR Perfusion Imaging in the United States (SPINS) study (JACC 2019) demonstrated in a multicenter U.S. cohort with stable chest pain syndromes stress Cardiac MRI offers effective cardiac prognostication. Moreover, patients without inducible ischemia on stress Cardiac MRI or late myocardial enhancement (myocardial scarring) experienced a low incidence of cardiac events, little need for coronary revascularization, and low spending on subsequent ischemia testing.
As healthcare is moving toward value-based rather than volume-based imaging, Cardiac MRI will play a more prominent role in evaluating and treating patients with ischemic heart disease thanks to its impressive diagnostic and prognostic capabilities, along with its increasingly proven cost-effectiveness.
Cardiac MRI is underutilized in the United States despite the increasing evidence that is changing clinical practice in Europe.
Chiara Bucciarelli-Ducci, MD, PhD