Stress CMR phenotyping across systemic diseases: ischemic burden and prognostic implications of late gadolinium enhancement
A Kante, T Goncalves, P Garot, S Toupin, F Sanguineti, T Hovasse, S Duhamel, S Champagne, T Unterseeh, M Akodad, A Neylon, S Houssany, P Henry, J Garot, T PezelAbstract
Background
Stress cardiovascular magnetic resonance (CMR) is widely used for the diagnosis and risk stratification of coronary artery diseases (CAD). Systemic diseases are immune-mediated conditions associated with a higher risk of cardiovascular events due to chronic inflammation. However, the prevalence of myocardial ischemia and the prognostic value of stress CMR findings remain unclear.
Objectives
To investigate the prevalence of myocardial ischemia and to evaluate the prognostic value of stress CMR findings in predicting all-cause mortality in patients with systemic diseases.
Methods
Between 2008 and 2023, all consecutive patients referred for stress CMR were prospectively enrolled in 3 French centres. The primary outcome was all-cause mortality. Patients with systemic diseases were matched 1:1 with controls using a propensity score. Cox proportional hazards regression analyses were performed to assess the association between stress CMR parameters and all-cause mortality.
Results
A total of 238 patients (median age of 65 [56–72] years, and 63% male) with systemic diseases were included. Among those, we included 104 patients with vasculitides (ANCA-associated vasculitis, Takayasu arteritis, giant cell arteritis, Behçet disease, Kawasaki disease, polyarteritis nodosa and cryoglobulinemia) (Figure 1), 50 patients with systemic sclerosis (SSc), 15 with systemic lupus erythematosus, and 68 with sarcoidosis. While myocardial ischemia was more prevalent in patients with systemic diseases (19% vs. 11%, p=0.011), revascularization rates were similar to matched controls (p=0.9). The prevalence of late gadolinium enhancement (LGE) did not differ significantly between patients with and without systemic disease (23% vs. 25%, p=0.6). Over a median follow-up of 8 [4–13] years, death occurred in 67 patients with systemic disease (28%). After multivariable adjustment, the presence of LGE was independently associated with all-cause mortality in patients with systemic diseases (hazard ratio 1.79 [1.03–3.10], p=0.037) (Figure 2A). Among disease subgroups, SSc patients with LGE had the highest annualized mortality rate (7.1%), followed by ANCA-associated vasculitis and lupus (6.8%), Behçet disease (5.3%), large-vessel vasculitides (4.5%), and sarcoidosis (3.4%), all exceeding rates observed in matched controls (Figure 2B).
Conclusions
In this large multicenter cohort of patients with systemic diseases, LGE on CMR independently predicted all-cause mortality beyond established risk factors. Although patients with systemic diseases exhibited a greater ischemic burden than matched controls, this did not translate into higher revascularization rates suggesting a possible predominance of non-obstructive microvascular dysfunction in this population.Graphical AbstractFigure 2