Incremental value of adenosine stress cardiac magnetic resonance in coronary artery disease detection ☆ Eulália Pereira a, ⁎ ,1 , Nuno Bettencourt a,b,c,1 , Nuno Ferreira a , Andreas Schuster b,d , Amedeo Chiribiri b , João Primo a , Madalena Teixeira a , Lino Simões a , Adelino Leite-Moreira c , José Silva-Cardoso c , Vasco Gama a , Eike Nagel b a Cardiology Department, Centro Hospitalar de Gaia/Espinho, Portugal b Kings College London, United Kingdom c Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal d Department of Cardiology and Pneumology, Heart Research Centre, Georg-August-University, Göttingen, Germany abstract article info Article history: Received 12 December 2012 Received in revised form 31 May 2013 Accepted 13 July 2013 Available online 12 August 2013 Keywords: Adenosine stress cardiac magnetic resonance Exercise treadmill test Coronary artery disease Invasive fractional flow reserve X-ray coronary angiography Pretest probability of coronary artery disease Introduction: Cardiac magnetic resonance myocardial perfusion imaging (CMR-MPI) is considered a state- of-the-art non-invasive modality for ischemia detection but its additive value in a multiple-test strategy in patients with suspected coronary artery disease (CAD) is not fully validated. We aimed to evaluate CMR-MPI integration with exercise treadmill test (ETT) for the diagnostic workup of patients with suspected CAD, having invasive fractional flow reserve (FFR) as reference standard. Methods: In this prospective single-center study, patients with suspected CAD underwent sequential ETT, CMR-MPI and X-ray invasive coronary angiography (XA). Significant CAD was defined by the presence of stenosis N 40% with FFR ≤ 0.8 in vessels N 2 mm or ≥ 90% stenosis/occlusion. Results: 80 symptomatic patients (68% male, 61 ± 8 years) were enrolled. Compared to ETT, CMR-MPI showed similar sensitivity (81%) and higher specificity (93 vs. 58%, p b 0.001) for CAD detection (prevalence = 46%) translating into better diagnostic performance (AUC 0.87 vs. 0.70; p = 0.002). CMR-MPI improved accuracy in- dependently of ETT in all patients with high pre-test probability and in intermediate-probability patients but those with a clearly positive-ETT (symptoms + ST-shift), in whom ETT correctly identified CAD. In the low- probability group CMR-MPI was useful as a gatekeeper for XA after a positive-ETT. The best integrating protocol achieved a global accuracy of 89% (AUC 0.88) and was clearly superior to an approach based solely in ETT (AUC 0.70, p b 0.001), yet similar to isolated CMR-MPI (AUC 0.87, p = ns). Conclusions: CMR-MPI has high sensitivity and specificity for CAD detection and may be combined with ETT in a diagnostic workflow aiming to increase accuracy and reduce the number of unnecessary catheterizations. © 2013 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Coronary artery disease (CAD) remains one of the leading causes of morbidity and mortality [1]. Clinical suspicion of CAD is a common cause to refer patients to cardiology and medical history and physical examinations alone may not be sufficient to detect or exclude CAD with a high certainty. Subsidiary tests are often needed to confirm the diagnosis of CAD and assess its functional consequences and the most appropriate treatment option. Choosing the best diagnostic test should be driven by patient's pretest probability of CAD (based on age, gender and typicality of symptoms) and the accuracy, risks, limitations and costs of available techniques [3]. Patients deemed to have a high likelihood of CAD can be directly referred to X-ray invasive coronary angiography (XA) if symptomatic despite maximal medical therapy, but otherwise benefit from non-invasive risk stratification mainly for prognostic information. For patients with low likelihood of CAD, the most appropriate non- invasive diagnostic strategy remains uncertain. The intermediate pretest population is the group most commonly encountered in the outpatient clinical setting and most likely to benefit from non-invasive diagnostic and prognostic testing [3]. A multiple-test strategy has several advantages over direct referral to catheterization, namely: lower exposure to ionizing radiation; identification of patients who will actually benefit from revascularization, avoiding decision based International Journal of Cardiology 168 (2013) 4160–4167 ☆ Each of all the authors takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. ⁎ Corresponding author at: Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, EPE, Rua Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal. Tel.: +351 934318023. E-mail address: eulaliaalvespereira@gmail.com (E. Pereira). 1 Both authors contributed equally to this work. 0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.07.114 Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard