State-of-the-Art Paper
Comparative Definitions for Moderate-Severe Ischemia in Stress Nuclear, Echocardiography, and Magnetic Resonance Imaging

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The lack of standardized reporting of the magnitude of ischemia on noninvasive imaging contributes to variability in translating the severity of ischemia across stress imaging modalities. We identified the risk of coronary artery disease (CAD) death or myocardial infarction (MI) associated with ≥10% ischemic myocardium on stress nuclear imaging as the risk threshold for stress echocardiography and cardiac magnetic resonance. A narrative review revealed that ≥10% ischemic myocardium on stress nuclear imaging was associated with a median rate of CAD death or MI of 4.9%/year (interquartile range: 3.75% to 5.3%). For stress echocardiography, ≥3 newly dysfunctional segments portend a median rate of CAD death or MI of 4.5%/year (interquartile range: 3.8% to 5.9%). Although imprecisely delineated, moderate-severe ischemia on cardiac magnetic resonance may be indicated by ≥4 of 32 stress perfusion defects or ≥3 dobutamine-induced dysfunctional segments. Risk-based thresholds can define equivalent amounts of ischemia across the stress imaging modalities, which will help to translate a common understanding of patient risk on which to guide subsequent management decisions.

Key Words

cardiac imaging
ischemia
prognosis

Abbreviations and Acronyms

CAD
coronary artery disease
CMR
cardiac magnetic resonance
MI
myocardial infarction
NHLBI
National Heart, Lung, and Blood Institute
NIH
National Institutes of Health
OMT
optimal medical therapy
PCI
percutaneous coronary intervention
SIHD
stable ischemic heart disease

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Dr. Shaw has received research support from Astellas and Bracco Diagnostics Inc. Dr. Friedrich is a board member, advisor, and shareholder for Circle Cardiovascular Imaging. Dr. Senior is a member of the speaker's bureau for and has received honoraria from Bracco Diagnostics Inc. and Philips Healthcare. Dr. Min is a member of the medical advisory board and speaker's bureau for and has received research support from GE Healthcare; is a member of the medical advisory board for Arineta Ltd.; has received research support from Philips Healthcare; and holds equity interest in TC3 and MDDX. Dr. Arai has received research support from Siemens. Dr. Iskandrian is a member of the advisory committee for Rapidscan Pharma. Dr. Bateman is a member of the advisory committee for and receives research support from Astellas, Lantheus Medical Imaging, GE Healthcare, and Spectrum Dynamics. Dr. Miller is a consultant for Astellas. Dr. Nagel has received research support from Philips Healthcare and Bayer HealthCare. Dr. Borges-Neto is a member of the speaker's bureau and advisory board for and has received grant support from Astellas and is a member of the advisory board for and has received grant support from GE Healthcare. Dr. Hochman has received a consulting fee and modest honoraria from GlaxoSmithKline. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.