Long-Term Prognostic Value of Stress Perfusion Cardiovascular Magnetic Resonance Imaging

  • Peter D. Filev
  • Arthur E. StillmanEmail author
Imaging (Q Truong, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Imaging


Purpose of review

The purpose of this review is to analyze the long-term prognostic value of stress perfusion cardiovascular magnetic resonance (CMR) in patients with suspected or known coronary artery disease (CAD).

Recent findings

Stress perfusion CMR provides high diagnostic accuracy for detection of CAD, with high sensitivity and relatively lower specificity. A normal stress perfusion CMR examination is highly predictive of overall low patient risk. Conversely, abnormal stress perfusion CMR results are associated with mortality and increased risk for adverse cardiac-related events. Stress perfusion CMR is a useful and robust tool for risk reclassification across different CAD risk categories, and most significant for patients of intermediate risk. Stress CMR is reliable for excluding clinically significant coronary artery disease in patients presenting with low-risk acute chest pain. An ischemic burden threshold of less than 1.5 cardiac segments has been found to be most appropriate for safe deferral from revascularization therapy. A stress perfusion CMR-guided strategy has been shown to be noninferior compared to fractional flow reserve (FFR) for revascularization in patients with stable CAD. In clinical practice, CMR offers a multiplicity of useful techniques besides stress perfusion which may add significant prognostic value when combined with the findings of the stress test itself.


Stress perfusion CMR is an accurate noninvasive diagnostic test for patients with suspected CAD and provides strong prognostic value across different risk categories.


Cardiovascular magnetic resonance Imaging Stress perfusion Coronary artery disease 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Torpy JM, Burke AE, Glass RM. JAMA patient page. Coronary heart disease risk factors. JAMA. 2009;302(7):2388.CrossRefGoogle Scholar
  2. 2.
    Cassar A, Holmes DR Jr, Rihal CS, Gersh BJ. Chronic coronary artery disease: diagnosis and management. Mayo Clin Proc. 2009;84(12):1130–46.CrossRefGoogle Scholar
  3. 3.
    Ford TJ, Corcoran D, Berry C. Stable coronary syndromes: pathophysiology, diagnostic advances and therapeutic need. Heart. 2018;104(4):284–92.PubMedGoogle Scholar
  4. 4.
    Grizzard JD, Judd RM, Kim RJ. Cardiovascular MRI in practice: a teaching file approach. London: Springer; 2008. xv, 299p. p.Google Scholar
  5. 5.
    Klem I, Heitner JF, Shah DJ, Sketch MH Jr, Behar V, Weinsaft J, et al. Improved detection of coronary artery disease by stress perfusion cardiovascular magnetic resonance with the use of delayed enhancement infarction imaging. J Am Coll Cardiol. 2006;47(8):1630–8.CrossRefGoogle Scholar
  6. 6.
    Gerber BL, Raman SV, Nayak K, Epstein FH, Ferreira P, Axel L, et al. Myocardial first-pass perfusion cardiovascular magnetic resonance: history, theory, and current state of the art. J Cardiovasc Magn Reson. 2008;10:18.CrossRefGoogle Scholar
  7. 7.
    Biglands JD, Ibraheem M, Magee DR, Radjenovic A, Plein S, Greenwood JP. Quantitative myocardial perfusion imaging versus visual analysis in diagnosing myocardial ischemia: A CE-MARC Substudy. JACC Cardiovasc Imaging. 2018;11(5):711–8.CrossRefGoogle Scholar
  8. 8.
    Schwitter J, Wacker CM, van Rossum AC, Lombardi M, Al-Saadi N, Ahlstrom H, et al. MR-IMPACT: comparison of perfusion-cardiac magnetic resonance with single-photon emission computed tomography for the detection of coronary artery disease in a multicentre, multivendor, randomized trial. Eur Heart J. 2008;29(4):480–9.CrossRefGoogle Scholar
  9. 9.
    Nandalur KR, Dwamena BA, Choudhri AF, Nandalur MR, Carlos RC. Diagnostic performance of stress cardiac magnetic resonance imaging in the detection of coronary artery disease: a meta-analysis. J Am Coll Cardiol. 2007;50(14):1343–53.CrossRefGoogle Scholar
  10. 10.
    •• Heitner JF, Kim RJ, Kim HW, Klem I, Shah DJ, Debs D, et al. Prognostic value of vasodilator stress cardiac magnetic resonance imaging: a multicenter study with 48000 patient-years of follow-up. JAMA Cardiol. 2019; A powerful multicenter study with over 9000 patients evaluating the prognostic value of stress perfusion CMR.Google Scholar
  11. 11.
    Gargiulo P, Dellegrottaglie S, Bruzzese D, Savarese G, Scala O, Ruggiero D, et al. The prognostic value of normal stress cardiac magnetic resonance in patients with known or suspected coronary artery disease: a meta-analysis. Circ Cardiovasc Imaging. 2013;6(4):574–82.Google Scholar
  12. 12.
    Wilson PW, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97(18):1837–47.CrossRefGoogle Scholar
  13. 13.
    Steel K, Broderick R, Gandla V, Larose E, Resnic F, Jerosch-Herold M, et al. Complementary prognostic values of stress myocardial perfusion and late gadolinium enhancement imaging by cardiac magnetic resonance in patients with known or suspected coronary artery disease. Circulation. 2009;120(14):1390–400.CrossRefGoogle Scholar
  14. 14.
    Hartlage G, Janik M, Anadiotis A, Veledar E, Oshinski J, Kremastinos D, et al. Prognostic value of adenosine stress cardiovascular magnetic resonance and dobutamine stress echocardiography in patients with low-risk chest pain. Int J Cardiovasc Imaging. 2012;28(4):803–12.CrossRefGoogle Scholar
  15. 15.
    Shah R, Heydari B, Coelho-Filho O, Murthy VL, Abbasi S, Feng JH, et al. Stress cardiac magnetic resonance imaging provides effective cardiac risk reclassification in patients with known or suspected stable coronary artery disease. Circulation. 2013;128(6):605–14.CrossRefGoogle Scholar
  16. 16.
    Coelho-Filho OR, Seabra LF, Mongeon FP, Abdullah SM, Francis SA, Blankstein R, et al. Stress myocardial perfusion imaging by CMR provides strong prognostic value to cardiac events regardless of patient’s sex. JACC Cardiovasc Imaging. 2011;4(8):850–61.PubMedGoogle Scholar
  17. 17.
    Vincenti G, Masci PG, Monney P, Rutz T, Hugelshofer S, Gaxherri M, et al. Stress perfusion CMR in patients with known and suspected CAD: prognostic value and optimal ischemic threshold for revascularization. JACC Cardiovasc Imaging. 2017;10(5):526–37.PubMedGoogle Scholar
  18. 18.
    Cremer P, Hachamovitch R, Tamarappoo B. Clinical decision making with myocardial perfusion imaging in patients with known or suspected coronary artery disease. Semin Nucl Med. 2014;44(4):320–9.CrossRefGoogle Scholar
  19. 19.
    Greenwood JP, Maredia N, Younger JF, Brown JM, Nixon J, Everett CC, et al. Cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary heart disease (CE-MARC): a prospective trial. Lancet. 2012;379(9814):453–60.CrossRefGoogle Scholar
  20. 20.
    Greenwood JP, Herzog BA, Brown JM, Everett CC, Nixon J, Bijsterveld P, et al. Prognostic value of cardiovascular magnetic resonance and single-photon emission computed tomography in suspected coronary heart disease: long-term follow-up of a prospective, diagnostic accuracy cohort study. Ann Intern Med. 2016.Google Scholar
  21. 21.
    •• Nagel E, Greenwood JP, McCann GP, Bettencourt N, Shah AM, Hussain ST, et al. Magnetic resonance perfusion or fractional flow reserve in coronary disease. N Engl J Med. 2019;380(25):2418–28 A significant study which establishes a noninvasive management strategy guided by stress perfusion CMR as noninferior to the invasive FFR-guided approach.CrossRefGoogle Scholar
  22. 22.
    De Bruyne B, Pijls NH, Kalesan B, Barbato E, Tonino PA, Piroth Z, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med. 2012;367(11):991–1001.CrossRefGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Cardiothoracic Imaging, Department of Radiology and Imaging SciencesEmory University School of MedicineAtlantaUSA

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