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Diagnostic Performance of Treadmill Exercise Cardiac Magnetic Resonance: The Prospective, Multicenter Exercise CMR's Accuracy for Cardiovascular Stress Testing ( EXACT ) Trial

View Article: PubMed Central - PubMed

ABSTRACT

Background: Stress cardiac magnetic resonance (CMR) has typically involved pharmacologic agents. Treadmill CMR has shown utility in single‐center studies but has not undergone multicenter evaluation.

Methods and results: Patients referred for treadmill stress nuclear imaging (SPECT) were prospectively enrolled across 4 centers. After rest 99mTc SPECT, patients underwent resting cine CMR. In‐room stress was then performed using an MR‐compatible treadmill with continuous 12‐lead electrocardiogram monitoring. At peak stress, 99mTc was injected, and patients rapidly returned to the MR scanner isocenter for real‐time, free‐breathing stress cine and perfusion imaging. After recovery, cine and rest perfusion followed by late gadolinium enhancement acquisitions concluded CMR imaging. Stress SPECT was then acquired in adjacent nuclear laboratories. A subset of patients not referred for invasive coronary angiography within 2 weeks of stress underwent coronary computed tomography angiography. Angiographic data available in 94 patients showed sensitivity of 79%, specificity of 99% for exercise CMR with positive predictive value of 92% and negative predictive value of 96%. Agreement between treadmill stress CMR and angiography was strong (κ=0.82), and moderate between SPECT and angiography (κ=0.46) and CMR versus SPECT (κ=0.48).

Conclusions: The multicenter EXACT trial indicates excellent diagnostic value of treadmill stress CMR in typical patients referred for exercise SPECT.

No MeSH data available.


Related in: MedlinePlus

Exercise‐induced ST depression without wall motion or perfusion abnormalities. A 62‐year‐old male with exertional dyspnea in the setting of hypertension and a family history of coronary artery disease was referred for stress imaging. Exercise was terminated at 7.5 minutes due to fatigue, the patient having reached 108% of his age‐predicted maximum heart rate. Although ST depression developed with exercise, no appreciable wall motion or perfusion abnormalities were seen by either CMR or SPECT. Clinically directed invasive angiography demonstrated an anatomic stenosis in the proximal left anterior descending coronary angiography prompting subsequent percutaneous revascularization. Of note, fractional flow reserve was not measured prior to PCI. CMR indicates cardiac magnetic resonance; ECG; electrocardiogram; SPECT, single photon emission computed tomography; PCI, percutaneous coronary intervention.
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jah31672-fig-0003: Exercise‐induced ST depression without wall motion or perfusion abnormalities. A 62‐year‐old male with exertional dyspnea in the setting of hypertension and a family history of coronary artery disease was referred for stress imaging. Exercise was terminated at 7.5 minutes due to fatigue, the patient having reached 108% of his age‐predicted maximum heart rate. Although ST depression developed with exercise, no appreciable wall motion or perfusion abnormalities were seen by either CMR or SPECT. Clinically directed invasive angiography demonstrated an anatomic stenosis in the proximal left anterior descending coronary angiography prompting subsequent percutaneous revascularization. Of note, fractional flow reserve was not measured prior to PCI. CMR indicates cardiac magnetic resonance; ECG; electrocardiogram; SPECT, single photon emission computed tomography; PCI, percutaneous coronary intervention.

Mentions: Agreement between CMR and SPECT was moderate (Figures 2 and 3), indicated by a κ statistic of 0.42 (0.23–0.60) (P<0.0001). LGE‐CMR demonstrated subendocardial infarct scar in 8 patients with normal SPECT images (Figure 4), whereas SPECT demonstrated a fixed defect in 9 patients without LGE abnormality by LGE‐CMR. Additionally, 6 patients had midwall fibrosis by LGE, indicating nonischemic myocardial disease. CMR identified additional abnormalities not evident by SPECT, including LV thrombus in 1 subject and apical hypertrophic cardiomyopathy in 2 subjects (Figure 5).


Diagnostic Performance of Treadmill Exercise Cardiac Magnetic Resonance: The Prospective, Multicenter Exercise CMR's Accuracy for Cardiovascular Stress Testing ( EXACT ) Trial
Exercise‐induced ST depression without wall motion or perfusion abnormalities. A 62‐year‐old male with exertional dyspnea in the setting of hypertension and a family history of coronary artery disease was referred for stress imaging. Exercise was terminated at 7.5 minutes due to fatigue, the patient having reached 108% of his age‐predicted maximum heart rate. Although ST depression developed with exercise, no appreciable wall motion or perfusion abnormalities were seen by either CMR or SPECT. Clinically directed invasive angiography demonstrated an anatomic stenosis in the proximal left anterior descending coronary angiography prompting subsequent percutaneous revascularization. Of note, fractional flow reserve was not measured prior to PCI. CMR indicates cardiac magnetic resonance; ECG; electrocardiogram; SPECT, single photon emission computed tomography; PCI, percutaneous coronary intervention.
© Copyright Policy - creativeCommonsBy-nc-nd
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5015300&req=5

jah31672-fig-0003: Exercise‐induced ST depression without wall motion or perfusion abnormalities. A 62‐year‐old male with exertional dyspnea in the setting of hypertension and a family history of coronary artery disease was referred for stress imaging. Exercise was terminated at 7.5 minutes due to fatigue, the patient having reached 108% of his age‐predicted maximum heart rate. Although ST depression developed with exercise, no appreciable wall motion or perfusion abnormalities were seen by either CMR or SPECT. Clinically directed invasive angiography demonstrated an anatomic stenosis in the proximal left anterior descending coronary angiography prompting subsequent percutaneous revascularization. Of note, fractional flow reserve was not measured prior to PCI. CMR indicates cardiac magnetic resonance; ECG; electrocardiogram; SPECT, single photon emission computed tomography; PCI, percutaneous coronary intervention.
Mentions: Agreement between CMR and SPECT was moderate (Figures 2 and 3), indicated by a κ statistic of 0.42 (0.23–0.60) (P<0.0001). LGE‐CMR demonstrated subendocardial infarct scar in 8 patients with normal SPECT images (Figure 4), whereas SPECT demonstrated a fixed defect in 9 patients without LGE abnormality by LGE‐CMR. Additionally, 6 patients had midwall fibrosis by LGE, indicating nonischemic myocardial disease. CMR identified additional abnormalities not evident by SPECT, including LV thrombus in 1 subject and apical hypertrophic cardiomyopathy in 2 subjects (Figure 5).

View Article: PubMed Central - PubMed

ABSTRACT

Background: Stress cardiac magnetic resonance (CMR) has typically involved pharmacologic agents. Treadmill CMR has shown utility in single&#8208;center studies but has not undergone multicenter evaluation.

Methods and results: Patients referred for treadmill stress nuclear imaging (SPECT) were prospectively enrolled across 4 centers. After rest 99mTc SPECT, patients underwent resting cine CMR. In&#8208;room stress was then performed using an MR&#8208;compatible treadmill with continuous 12&#8208;lead electrocardiogram monitoring. At peak stress, 99mTc was injected, and patients rapidly returned to the MR scanner isocenter for real&#8208;time, free&#8208;breathing stress cine and perfusion imaging. After recovery, cine and rest perfusion followed by late gadolinium enhancement acquisitions concluded CMR imaging. Stress SPECT was then acquired in adjacent nuclear laboratories. A subset of patients not referred for invasive coronary angiography within 2&nbsp;weeks of stress underwent coronary computed tomography angiography. Angiographic data available in 94 patients showed sensitivity of 79%, specificity of 99% for exercise CMR with positive predictive value of 92% and negative predictive value of 96%. Agreement between treadmill stress CMR and angiography was strong (&kappa;=0.82), and moderate between SPECT and angiography (&kappa;=0.46) and CMR versus SPECT (&kappa;=0.48).

Conclusions: The multicenter EXACT trial indicates excellent diagnostic value of treadmill stress CMR in typical patients referred for exercise SPECT.

No MeSH data available.


Related in: MedlinePlus