The Role of Stress Cardiac Magnetic Resonance in Women Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology The Role of Stress Cardiac Magnetic Resonance in Women Andrea Cardona, MD1,2, Karolina M. Zareba, MD1, Subha V. Raman, MD1 1-Ohio State University, Division of Cardiovascular Medicine. Columbus - USA 2- University of Perugia, Division of Cardiology, Perugia - Italy Head shot ofauthor required Institution Picture/Logo Optional (opt-out) Copyright American Society of Nuclear Cardiology

Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology BACKGROUND Ischemic heart disease (IHD) is the leading cause of death in women. An overwhelming body of evidence indicates under-diagnosis and under-treatment of women for suspected or known ischemic heart disease (IHD), incurring preventable IHD events and adverse outcomes. Appropriate evaluation of IHD in women requires recognition of the range of myocardial sequelae to upstream abnormalities in epicardial coronaries and microcirculation. Copyright American Society of Nuclear Cardiology

Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology Stress CMR - Why Several aspects of CMR make it an appealing and useful stress imaging modality for women with known or suspected IHD: No ionizing radiation, especially important in pre-menopausal women and those with genetic susceptibility to breast cancer. Image formation is not affected by soft tissue attenuation or acoustic window, which prevents body habitus from reducing diagnostic accuracy. High spatial resolution images afford reliable visualization of subendocardial ischemia and non-transmural infarct scar. Standard CMR exam provides comprehensive information on ischemia, myocardial scar and tissue characteristics and ventricular function which can explain symptoms in the absence of ischemia. Copyright American Society of Nuclear Cardiology

Two main classes of pharmacologic agents are used for stress CMR: Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology Stress CMR - How Two main classes of pharmacologic agents are used for stress CMR: Vasodilators Vasodilator stress myocardial perfusion imaging with CMR employs rapid dynamic imaging during the first pass of a gadolinium-based contrast agent. Stress perfusion CMR performs well in detecting ischemia in patients with known or suspected IHD due to epicardial coronary artery stenosis. Beyond epicardial CAD, perfusion CMR has established value in diagnosing microvascular disease that is all too common in women. Inotropes Dobutamine stress CMR can be performed without contrast, though addition of contrast can delineate extent of myocardial fibrosis. Perfusion image acquisition at peak dobutamine stress provides complementary information to regional wall motion assessment. Dobutamine CMR can be used in high dose to detect stress-induced ischemia and in low dose to identify contractile reserve. Copyright American Society of Nuclear Cardiology

Stress CMR – Diagnostic and Prognostic Value Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology Stress CMR – Diagnostic and Prognostic Value Overall Women Diagnostic Accuracy ⃰ Sensitivity Specificity Vasodilators 90% 81% Dobutamine 83% 86% In the CE-MARC study ⃰ analysis by gender showed that CMR offers women referred for stress perfusion imaging both higher sensitivity (88.7% vs. 50.9%, p<0.0001) and diagnostic accuracy compared to SPECT (AUC, 0.90 vs. 0.67; p<0.0001) Prognostic Value ⃰ In a meta-analysis with > 11,000 patients with known or suspected IHD, positive stress CMR was strongly associated with the outcome (CV death and non-fatal MI): OR: 6.47; 95% CI 4.42-9.46 (perfusion) OR: 6.20; 95% CI 2.61-14.73 (dobutamine) In a study of gender-related prognostic value of either adenosine perfusion or dobutamine CMR with a median follow-up of 5.3 years, multivariate analysis revealed the presence of inducible perfusion defects or WMA as independent predictors of hard cardiac events. In women, a negative stress CMR demonstrated an event-free survival of 100%. ⃰ see main text for references Copyright American Society of Nuclear Cardiology

Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology CONCLUSIONS Stress CMR has several decades of evidence supporting its diagnostic accuracy, prognostic value, safety and utility. Considerable growth and education of providers over just the past few years is helping to ensure widespread availability. Superior diagnostic accuracy and lack of exposure to ionizing radiation, plus the unique ability to characterize both epicardial coronary as well as microvascular disease make stress CMR an appealing imaging modality for the assessment of IHD in women. Copyright American Society of Nuclear Cardiology