Magnetic resonance perfusion or fractional flow reserve in coronary disease

Eike Nagel; John P. Greenwood; Gerry P. McCann; Nuno Bettencourt; Ajay M. Shah; Shazia T. Hussain; Divaka Perera; Sven Plein; Chiara Bucciarelli-Ducci; Matthias Paul; Mark A. Westwood; Wolf-Stefan Richter; Michael Marber; Valentina O. Puntmann; Carsten Schwenke; Jeanette Schulz-Menger; Rajiv Das; Joyce Wong; Derek J. Hausenloy; Henning Steen; Colin Berry; MR-INFORM Investigators; Joseph Brindaban Selvanayagam

doi:10.1056/NEJMoa1716734

Magnetic resonance perfusion or fractional flow reserve in coronary disease

Eike Nagel
, John P. Greenwood
, Gerry P. McCann
, Nuno Bettencourt
, Ajay M. Shah
, Shazia T. Hussain
, Divaka Perera
, Sven Plein
, Chiara Bucciarelli-Ducci
, Matthias Paul
, Mark A. Westwood
, Wolf-Stefan Richter
, Michael Marber
, Valentina O. Puntmann
, Carsten Schwenke
, Jeanette Schulz-Menger
, Rajiv Das
, Joyce Wong
, Derek J. Hausenloy
, Henning Steen

Colin Berry, MR-INFORM Investigators, Joseph Brindaban Selvanayagam

Research output: Contribution to journal › Article › peer-review

413 Citations (Scopus)

41 Downloads (Pure)

Abstract

BACKGROUND In patients with stable angina, two strategies are often used to guide revascularization: one involves myocardial-perfusion cardiovascular magnetic resonance imaging (MRI), and the other involves invasive angiography and measurement of fractional flow reserve (FFR). Whether a cardiovascular MRI-based strategy is noninferior to an FFR-based strategy with respect to major adverse cardiac events has not been established.

METHODS We performed an unblinded, multicenter, clinical-effectiveness trial by randomly assigning 918 patients with typical angina and either two or more cardiovascular risk factors or a positive exercise treadmill test to a cardiovascular MRI-based strategy or an FFR-based strategy. Revascularization was recommended for patients in the cardiovascular-MRI group with ischemia in at least 6% of the myocardium or in the FFR group with an FFR of 0.8 or less. The composite primary outcome was death, nonfatal myocardial infarction, or target-vessel revascularization within 1 year. The noninferiority margin was a risk difference of 6 percentage points.

RESULTS A total of 184 of 454 patients (40.5%) in the cardiovascular-MRI group and 213 of 464 patients (45.9%) in the FFR group met criteria to recommend revascularization (P=0.11). Fewer patients in the cardiovascular-MRI group than in the FFR group underwent index revascularization (162 [35.7%] vs. 209 [45.0%], P=0.005). The primary outcome occurred in 15 of 421 patients (3.6%) in the cardiovascular-MRI group and 16 of 430 patients (3.7%) in the FFR group (risk difference, −0.2 percentage points; 95% confidence interval, −2.7 to 2.4), findings that met the noninferiority threshold. The percentage of patients free from angina at 12 months did not differ significantly between the two groups (49.2% in the cardiovascular-MRI group and 43.8% in the FFR group, P=0.21).

CONCLUSIONS Among patients with stable angina and risk factors for coronary artery disease, myocardial-perfusion cardiovascular MRI was associated with a lower incidence of coronary revascularization than FFR and was noninferior to FFR with respect to major adverse cardiac events.

Original language	English
Pages (from-to)	2418-2428
Number of pages	11
Journal	New England Journal of Medicine
Volume	380
Issue number	25
DOIs	https://doi.org/10.1056/NEJMoa1716734
Publication status	Published - 20 Jun 2019
Externally published	Yes

Bibliographical note

From Nagel, E., Greenwood, J. P., McCann, G. P., Bettencourt, N., Shah, A. M., Hussain, S. T., … Berry, C. (2019). Magnetic Resonance Perfusion or Fractional Flow Reserve in Coronary Disease. New England Journal of Medicine, 380(25), 2418–2428. https://doi.org/10.1056/nejmoa1716734
© 2019 Massachusetts Medical Society. Reprinted with permission.

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Nagel, E., Greenwood, J. P., McCann, G. P., Bettencourt, N., Shah, A. M., Hussain, S. T., Perera, D., Plein, S., Bucciarelli-Ducci, C., Paul, M., Westwood, M. A., Richter, W.-S., Marber, M., Puntmann, V. O., Schwenke, C., Schulz-Menger, J., Das, R., Wong, J., Hausenloy, D. J., ... Selvanayagam, J. B. (2019). Magnetic resonance perfusion or fractional flow reserve in coronary disease. New England Journal of Medicine, 380(25), 2418-2428. https://doi.org/10.1056/NEJMoa1716734

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title = "Magnetic resonance perfusion or fractional flow reserve in coronary disease",

abstract = "BACKGROUND In patients with stable angina, two strategies are often used to guide revascularization: one involves myocardial-perfusion cardiovascular magnetic resonance imaging (MRI), and the other involves invasive angiography and measurement of fractional flow reserve (FFR). Whether a cardiovascular MRI-based strategy is noninferior to an FFR-based strategy with respect to major adverse cardiac events has not been established. METHODS We performed an unblinded, multicenter, clinical-effectiveness trial by randomly assigning 918 patients with typical angina and either two or more cardiovascular risk factors or a positive exercise treadmill test to a cardiovascular MRI-based strategy or an FFR-based strategy. Revascularization was recommended for patients in the cardiovascular-MRI group with ischemia in at least 6\% of the myocardium or in the FFR group with an FFR of 0.8 or less. The composite primary outcome was death, nonfatal myocardial infarction, or target-vessel revascularization within 1 year. The noninferiority margin was a risk difference of 6 percentage points. RESULTS A total of 184 of 454 patients (40.5\%) in the cardiovascular-MRI group and 213 of 464 patients (45.9\%) in the FFR group met criteria to recommend revascularization (P=0.11). Fewer patients in the cardiovascular-MRI group than in the FFR group underwent index revascularization (162 [35.7\%] vs. 209 [45.0\%], P=0.005). The primary outcome occurred in 15 of 421 patients (3.6\%) in the cardiovascular-MRI group and 16 of 430 patients (3.7\%) in the FFR group (risk difference, −0.2 percentage points; 95\% confidence interval, −2.7 to 2.4), findings that met the noninferiority threshold. The percentage of patients free from angina at 12 months did not differ significantly between the two groups (49.2\% in the cardiovascular-MRI group and 43.8\% in the FFR group, P=0.21). CONCLUSIONS Among patients with stable angina and risk factors for coronary artery disease, myocardial-perfusion cardiovascular MRI was associated with a lower incidence of coronary revascularization than FFR and was noninferior to FFR with respect to major adverse cardiac events.",

author = "Eike Nagel and Greenwood, \{John P.\} and McCann, \{Gerry P.\} and Nuno Bettencourt and Shah, \{Ajay M.\} and Hussain, \{Shazia T.\} and Divaka Perera and Sven Plein and Chiara Bucciarelli-Ducci and Matthias Paul and Westwood, \{Mark A.\} and Wolf-Stefan Richter and Michael Marber and Puntmann, \{Valentina O.\} and Carsten Schwenke and Jeanette Schulz-Menger and Rajiv Das and Joyce Wong and Hausenloy, \{Derek J.\} and Henning Steen and Colin Berry and \{MR-INFORM Investigators\} and Selvanayagam, \{Joseph Brindaban\}",

note = "From Nagel, E., Greenwood, J. P., McCann, G. P., Bettencourt, N., Shah, A. M., Hussain, S. T., … Berry, C. (2019). Magnetic Resonance Perfusion or Fractional Flow Reserve in Coronary Disease. New England Journal of Medicine, 380(25), 2418–2428. https://doi.org/10.1056/nejmoa1716734 {\textcopyright} 2019 Massachusetts Medical Society. Reprinted with permission. ",

year = "2019",

month = jun,

day = "20",

doi = "10.1056/NEJMoa1716734",

language = "English",

volume = "380",

pages = "2418--2428",

journal = "New England Journal of Medicine",

issn = "0028-4793",

publisher = "Massachussetts Medical Society",

number = "25",

}

Nagel, E, Greenwood, JP, McCann, GP, Bettencourt, N, Shah, AM, Hussain, ST, Perera, D, Plein, S, Bucciarelli-Ducci, C, Paul, M, Westwood, MA, Richter, W-S, Marber, M, Puntmann, VO, Schwenke, C, Schulz-Menger, J, Das, R, Wong, J, Hausenloy, DJ, Steen, H, Berry, C, MR-INFORM Investigators & Selvanayagam, JB 2019, 'Magnetic resonance perfusion or fractional flow reserve in coronary disease', New England Journal of Medicine, vol. 380, no. 25, pp. 2418-2428. https://doi.org/10.1056/NEJMoa1716734

TY - JOUR

T1 - Magnetic resonance perfusion or fractional flow reserve in coronary disease

AU - Nagel, Eike

AU - Greenwood, John P.

AU - McCann, Gerry P.

AU - Bettencourt, Nuno

AU - Shah, Ajay M.

AU - Hussain, Shazia T.

AU - Perera, Divaka

AU - Plein, Sven

AU - Bucciarelli-Ducci, Chiara

AU - Paul, Matthias

AU - Westwood, Mark A.

AU - Richter, Wolf-Stefan

AU - Marber, Michael

AU - Puntmann, Valentina O.

AU - Schwenke, Carsten

AU - Schulz-Menger, Jeanette

AU - Das, Rajiv

AU - Wong, Joyce

AU - Hausenloy, Derek J.

AU - Steen, Henning

AU - Berry, Colin

AU - MR-INFORM Investigators

AU - Selvanayagam, Joseph Brindaban

N1 - From Nagel, E., Greenwood, J. P., McCann, G. P., Bettencourt, N., Shah, A. M., Hussain, S. T., … Berry, C. (2019). Magnetic Resonance Perfusion or Fractional Flow Reserve in Coronary Disease. New England Journal of Medicine, 380(25), 2418–2428. https://doi.org/10.1056/nejmoa1716734 © 2019 Massachusetts Medical Society. Reprinted with permission.

PY - 2019/6/20

Y1 - 2019/6/20

N2 - BACKGROUND In patients with stable angina, two strategies are often used to guide revascularization: one involves myocardial-perfusion cardiovascular magnetic resonance imaging (MRI), and the other involves invasive angiography and measurement of fractional flow reserve (FFR). Whether a cardiovascular MRI-based strategy is noninferior to an FFR-based strategy with respect to major adverse cardiac events has not been established. METHODS We performed an unblinded, multicenter, clinical-effectiveness trial by randomly assigning 918 patients with typical angina and either two or more cardiovascular risk factors or a positive exercise treadmill test to a cardiovascular MRI-based strategy or an FFR-based strategy. Revascularization was recommended for patients in the cardiovascular-MRI group with ischemia in at least 6% of the myocardium or in the FFR group with an FFR of 0.8 or less. The composite primary outcome was death, nonfatal myocardial infarction, or target-vessel revascularization within 1 year. The noninferiority margin was a risk difference of 6 percentage points. RESULTS A total of 184 of 454 patients (40.5%) in the cardiovascular-MRI group and 213 of 464 patients (45.9%) in the FFR group met criteria to recommend revascularization (P=0.11). Fewer patients in the cardiovascular-MRI group than in the FFR group underwent index revascularization (162 [35.7%] vs. 209 [45.0%], P=0.005). The primary outcome occurred in 15 of 421 patients (3.6%) in the cardiovascular-MRI group and 16 of 430 patients (3.7%) in the FFR group (risk difference, −0.2 percentage points; 95% confidence interval, −2.7 to 2.4), findings that met the noninferiority threshold. The percentage of patients free from angina at 12 months did not differ significantly between the two groups (49.2% in the cardiovascular-MRI group and 43.8% in the FFR group, P=0.21). CONCLUSIONS Among patients with stable angina and risk factors for coronary artery disease, myocardial-perfusion cardiovascular MRI was associated with a lower incidence of coronary revascularization than FFR and was noninferior to FFR with respect to major adverse cardiac events.

AB - BACKGROUND In patients with stable angina, two strategies are often used to guide revascularization: one involves myocardial-perfusion cardiovascular magnetic resonance imaging (MRI), and the other involves invasive angiography and measurement of fractional flow reserve (FFR). Whether a cardiovascular MRI-based strategy is noninferior to an FFR-based strategy with respect to major adverse cardiac events has not been established. METHODS We performed an unblinded, multicenter, clinical-effectiveness trial by randomly assigning 918 patients with typical angina and either two or more cardiovascular risk factors or a positive exercise treadmill test to a cardiovascular MRI-based strategy or an FFR-based strategy. Revascularization was recommended for patients in the cardiovascular-MRI group with ischemia in at least 6% of the myocardium or in the FFR group with an FFR of 0.8 or less. The composite primary outcome was death, nonfatal myocardial infarction, or target-vessel revascularization within 1 year. The noninferiority margin was a risk difference of 6 percentage points. RESULTS A total of 184 of 454 patients (40.5%) in the cardiovascular-MRI group and 213 of 464 patients (45.9%) in the FFR group met criteria to recommend revascularization (P=0.11). Fewer patients in the cardiovascular-MRI group than in the FFR group underwent index revascularization (162 [35.7%] vs. 209 [45.0%], P=0.005). The primary outcome occurred in 15 of 421 patients (3.6%) in the cardiovascular-MRI group and 16 of 430 patients (3.7%) in the FFR group (risk difference, −0.2 percentage points; 95% confidence interval, −2.7 to 2.4), findings that met the noninferiority threshold. The percentage of patients free from angina at 12 months did not differ significantly between the two groups (49.2% in the cardiovascular-MRI group and 43.8% in the FFR group, P=0.21). CONCLUSIONS Among patients with stable angina and risk factors for coronary artery disease, myocardial-perfusion cardiovascular MRI was associated with a lower incidence of coronary revascularization than FFR and was noninferior to FFR with respect to major adverse cardiac events.

UR - https://www.scopus.com/pages/publications/85067793712

U2 - 10.1056/NEJMoa1716734

DO - 10.1056/NEJMoa1716734

M3 - Article

C2 - 31216398

AN - SCOPUS:85067793712

SN - 0028-4793

VL - 380

SP - 2418

EP - 2428

JO - New England Journal of Medicine

JF - New England Journal of Medicine

IS - 25

ER -

Magnetic resonance perfusion or fractional flow reserve in coronary disease

Abstract

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