CMR feature-tracking-derived GLS is a powerful independent predictor of mortality in a multicenter population of patients with ischemic or nonischemic dilated cardiomyopathy, incremental to common clinical and CMR risk factors including EF and LGE.

BACKGROUND Stress cardiac magnetic resonance imaging (CMR) has demonstrated excellent diagnostic and prognostic value in single-center studies. OBJECTIVES This study sought to investigate the prognostic value of stress CMR and downstream costs from subsequent cardiac testing in a retrospective multicenter study in the United States. METHODS In this retrospective study, consecutive patients from 13 centers across 11 states who presented with a chest pain syndrome and were referred for stress CMR were followed for a target period of 4 years. The authors associated CMR findings with a primary outcome of cardiovascular death or nonfatal myocardial infarction using competing risk-adjusted regression models and downstream costs of ischemia testing using published Medicare national payment rates. RESULTS In this study, 2,349 patients (63 ± 11 years of age, 47% female) were followed for a median of 5.4 years. Patients with no ischemia or late gadolinium enhancement (LGE) by CMR, observed in 1,583 patients (67%), experienced low annualized rates of primary outcome (<1%) and coronary revascularization (1% to 3%), across all years of study follow-up. In contrast, patients with ischemia+/LGE+ experienced a >4-fold higher annual primary outcome rate and a >10-fold higher rate of coronary revascularization during the first year after CMR. Patients with ischemia and LGE both negative had low average annual cost spent on ischemia testing across all years of follow-up, and this pattern was similar across the 4 practice environments of the participating centers. CONCLUSIONS In a multicenter U.S. cohort with stable chest pain syndromes, stress CMR performed at experienced centers offers effective cardiac prognostication. Patients without CMR ischemia or LGE experienced a low incidence of cardiac events, little need for coronary revascularization, and low spending on subsequent ischemia testing. (Stress CMR Perfusion Imaging in the United States [SPINS]: A Society for Cardiovascular Resonance Registry Study; NCT03192891 )

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IMPORTANCE Stress cardiac magnetic resonance imaging (CMR) is not widely used in current clinical practice, and its ability to predict patient mortality is unknown. OBJECTIVE To determine whether stress CMR is associated with patient mortality. DESIGN, SETTING, AND PARTICIPANTS Real-world evidence from consecutive clinically ordered CMR examinations. Multicenter study of patients undergoing clinical evaluation of myocardial ischemia. Patients with known or suspected coronary artery disease (CAD) underwent clinical vasodilator stress CMR at 7 different hospitals. An automated process collected data from the finalized clinical reports, deidentified and aggregated the data, and assessed mortality using the US Social Security Death Index. MAIN OUTCOMES AND MEASURES All-cause patient mortality. RESULTS Of the 9151 patients, the median (interquartile range) patient age was 63 (51-70) years, 55% were men, and the median (interquartile range) body mass index was 29 (25-33) (calculated as weight in kilograms divided by height in meters squared). The multicenter automated process yielded 9151 consecutive patients undergoing stress CMR, with 48 615 patient-years of follow-up. Of these patients, 4408 had a normal stress CMR examination, 4743 had an abnormal examination, and 1517 died during a median follow-up time of 5.0 years. Using multivariable analysis, addition of stress CMR improved prediction of mortality in 2 different risk models (model 1 hazard ratio [HR], 1.83; 95% CI, 1.63-2.06; P < .001; model 2: HR, 1.80; 95% CI, 1.60-2.03; P < .001) and also improved risk reclassification (net improvement: 11.4%; 95% CI, 7.3-13.6; P < .001). After adjustment for patient age, sex, and cardiac risk factors, Kaplan-Meier survival analysis showed a strong association between an abnormal stress CMR and mortality in all patients (

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Despite the many advances in cardiovascular medicine, decisions concerning the diagnosis, prevention, and treatment of left ventricular (LV) thrombus often remain challenging. There are only limited organizational guideline recommendations with regard to LV thrombus. Furthermore, management issues in current practice are increasingly complex, including concerns about adding oral anticoagulant therapy to dual antiplatelet therapy, the availability of direct oral anticoagulants as a potential alternative option to traditional vitamin K antagonists, and the use of diagnostic modalities such as cardiac magnetic resonance imaging, which has greater sensitivity for LV thrombus detection than echocardiography. Therefore, this American Heart Association scientific statement was commissioned with the goals of addressing 8 key clinical management questions related to LV thrombus, including the prevention and treatment after myocardial infarction, prevention and treatment in dilated cardiomyopathy, management of mural (laminated) thrombus, imaging of LV thrombus, direct oral anticoagulants as an alternative to warfarin, treatments other than oral anticoagulants for LV thrombus (eg, dual antiplatelet therapy, fibrinolysis, surgical excision), and the approach to persistent LV thrombus despite anticoagulation therapy. Practical management suggestions in the form of text, tables, and flow diagrams based on careful and critical review of actual study data as formulated by this multidisciplinary writing committee are given.

Objectives To evaluate performance characteristics of routine echo for LV thrombus (LVT). Background While the utility of dedicated echocardiography (echo) for LVT is established, echo is widely used as a general test for which LVT is rarely the primary indication. We used delayed enhancement cardiac magnetic resonance (DE-CMR) as a reference to evaluate LVT detection by routine echo. Methods Dedicated LVT assessment using DE-CMR was prospectively performed in patients with LV systolic dysfunction. Echoes were done as part of routine clinical care. Echo and CMR were independently read for LVT and related indices of LVT size, shape, and image quality/diagnostic confidence. Follow-up was done for embolic events and pathology validation of LVT. Results 243 patients had routine clinical echo and dedicated CMR within 1 week without intervening events. Follow-up supported DE-CMR as a reference standard, with >5-fold difference in endpoints between patients with vs. without LVT by DE-CMR (p=0.02). LVT prevalence was 10% by DE-CMR. Echo contrast was used in 4% of patients. Echo sensitivity and specificity were 33% and 91%, with positive and negative predictive values of 29% and 93%. Among patients with possible LVT as the clinical indication for echo, sensitivity and positive predictive value were markedly higher (60%, 75%). Regarding sensitivity, echo performance related to LVT morphology and mirrored cine-CMR, with protuberant thrombus typically missed when small (p≤0.02). There was also a strong trend to miss mural thrombus irrespective of size (p=0.06). Concerning positive predictive value, echo performance related to image quality, with lower diagnostic confidence scores for echoes read positive for LVT in discordance with DE-CMR compared to echoes concordant with DE-CMR (p<0.02). Conclusions Routine echo with rare contrast use can yield misleading results concerning LVT. Echo performance is improved when large protuberant thrombus is present and when the clinical indication is specifically for LVT assessment.

The proposed sequence allows cardiac phase-resolved T mapping with integrated B1+ assessment at a temporal resolution of 40 ms. Magn Reson Med 79:2087-2100, 2018. © 2017 International Society for Magnetic Resonance in Medicine.