Comparison of exercise testing and CMR measured myocardial perfusion reserve for predicting outcome in asymptomatic aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) study

Anvesha  Singh; John P. Greenwood; Colin Berry; Dana K. Dawson; Kai Hogrefe; Damian J. Kelly; Vijay Dhakshinamurthy; Chim C. Lang; Jeffrey P. Khoo; David Sprigings; Richard P. Steeds; Michael Jerosch-Herold; Stefan Neubauer; Bernard Prendergast; Brian Williams; Ruiqi Zhang; Ian Hudson; Iain B. Squire; Ian Ford; Nilesh J. Samani; Gerry P. McCann

doi:10.1093/eurheartj/ehx001

Comparison of exercise testing and CMR measured myocardial perfusion reserve for predicting outcome in asymptomatic aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) study

Anvesha Singh, John P. Greenwood, Colin Berry, Dana K. Dawson, Kai Hogrefe, Damian J. Kelly, Vijay Dhakshinamurthy, Chim C. Lang, Jeffrey P. Khoo, David Sprigings, Richard P. Steeds, Michael Jerosch-Herold, Stefan Neubauer, Bernard Prendergast, Brian Williams, Ruiqi Zhang, Ian Hudson, Iain B. Squire, Ian Ford, Nilesh J. SamaniGerry P. McCann (Lead / Corresponding author)

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Abstract

Aims

To assess cardiovascular magnetic resonance (CMR) measured myocardial perfusion reserve (MPR) and exercise testing in asymptomatic patients with moderate-severe AS.
Methods and results

Multi-centre, prospective, observational study, with blinded analysis of CMR data. Patients underwent adenosine stress CMR, symptom-limited exercise testing (ETT) and echocardiography and were followed up for 12–30 months. The primary outcome was a composite of: typical AS symptoms necessitating referral for AVR, cardiovascular death and major adverse cardiovascular events. 174 patients were recruited: mean age 66.2 ± 13.34 years, 76% male, peak velocity 3.86 ± 0.56 m/s and aortic valve area index 0.57 ± 0.14 cm2/m2. A primary outcome occurred in 47 (27%) patients over a median follow-up of 374 (IQR 351–498) days. The mean MPR in those with and without a primary outcome was 2.06 ± 0.65 and 2.34 ± 0.70 (P = 0.022), while the incidence of a symptom-limited ETT was 45.7% and 27.0% (P = 0.020), respectively. MPR showed moderate association with outcome area under curve (AUC) = 0.61 (0.52–0.71, P = 0.020), as did exercise testing (AUC = 0.59 (0.51–0.68, P = 0.027), with no significant difference between the two.
Conclusions

MPR was associated with symptom-onset in initially asymptomatic patients with AS, but with moderate accuracy and was not superior to symptom-limited exercise testing. ClinicalTrials.gov (NCT01658345).

Original language	English
Pages (from-to)	1222-1229
Number of pages	8
Journal	European Heart Journal
Volume	38
Issue number	16
Early online date	13 Feb 2017
DOIs	https://doi.org/10.1093/eurheartj/ehx001
Publication status	Published - 21 Apr 2017

Keywords

Aortic stenosis
exercise testing
magnetic resonance imaging
myocardial perfusion reserve

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Author accepted manuscript
This is a pre-copyedited, author-produced version of an article accepted for publication in European Heart Journal following peer review. The version of record 'Comparison of exercise testing and CMR measured myocardial perfusion reserve for prediciting outcome in asympotmatic aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) study', is available online at: https://doi.org/10.1093/eurheartj/ehx001
Accepted author manuscript, 1.06 MB

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Lang, Chim
- Cardiovascular Research - Clinical Professor (Teaching and Research)
Person: Academic

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Singh, A., Greenwood, J. P., Berry, C., Dawson, D. K., Hogrefe, K., Kelly, D. J., Dhakshinamurthy, V., Lang, C. C., Khoo, J. P., Sprigings, D., Steeds, R. P., Jerosch-Herold, M., Neubauer, S., Prendergast, B., Williams, B., Zhang, R., Hudson, I., Squire, I. B., Ford, I., ... McCann, G. P. (2017). Comparison of exercise testing and CMR measured myocardial perfusion reserve for predicting outcome in asymptomatic aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) study. European Heart Journal, 38(16), 1222-1229. https://doi.org/10.1093/eurheartj/ehx001

@article{34cc35c28d4644aa957dfdac82e021e9,

title = "Comparison of exercise testing and CMR measured myocardial perfusion reserve for predicting outcome in asymptomatic aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) study",

abstract = "AimsTo assess cardiovascular magnetic resonance (CMR) measured myocardial perfusion reserve (MPR) and exercise testing in asymptomatic patients with moderate-severe AS.Methods and resultsMulti-centre, prospective, observational study, with blinded analysis of CMR data. Patients underwent adenosine stress CMR, symptom-limited exercise testing (ETT) and echocardiography and were followed up for 12–30 months. The primary outcome was a composite of: typical AS symptoms necessitating referral for AVR, cardiovascular death and major adverse cardiovascular events. 174 patients were recruited: mean age 66.2 ± 13.34 years, 76% male, peak velocity 3.86 ± 0.56 m/s and aortic valve area index 0.57 ± 0.14 cm2/m2. A primary outcome occurred in 47 (27%) patients over a median follow-up of 374 (IQR 351–498) days. The mean MPR in those with and without a primary outcome was 2.06 ± 0.65 and 2.34 ± 0.70 (P = 0.022), while the incidence of a symptom-limited ETT was 45.7% and 27.0% (P = 0.020), respectively. MPR showed moderate association with outcome area under curve (AUC) = 0.61 (0.52–0.71, P = 0.020), as did exercise testing (AUC = 0.59 (0.51–0.68, P = 0.027), with no significant difference between the two.ConclusionsMPR was associated with symptom-onset in initially asymptomatic patients with AS, but with moderate accuracy and was not superior to symptom-limited exercise testing. ClinicalTrials.gov (NCT01658345).",

keywords = "Aortic stenosis, exercise testing, magnetic resonance imaging, myocardial perfusion reserve",

author = "Anvesha Singh and Greenwood, {John P.} and Colin Berry and Dawson, {Dana K.} and Kai Hogrefe and Kelly, {Damian J.} and Vijay Dhakshinamurthy and Lang, {Chim C.} and Khoo, {Jeffrey P.} and David Sprigings and Steeds, {Richard P.} and Michael Jerosch-Herold and Stefan Neubauer and Bernard Prendergast and Brian Williams and Ruiqi Zhang and Ian Hudson and Squire, {Iain B.} and Ian Ford and Samani, {Nilesh J.} and McCann, {Gerry P.}",

note = "The study was supported by a grant from the National Institute of Health Research (NIHRPDF 2011-04-51 Gerald P McCann) and the NIHR Leicester Cardiovascular Biomedical Research Unit, the NIHR Comprehensive Local Research Networks and the Leeds & Leicester NIHR Clinical Research Facilities. BW is supported by the NIHR UCL Hospitals Biomedical Research Centre. The views expressed are those of the author(s) and not necessarily those of the NHS, NIHR or the Department of Health.",

year = "2017",

month = apr,

day = "21",

doi = "10.1093/eurheartj/ehx001",

language = "English",

volume = "38",

pages = "1222--1229",

journal = "European Heart Journal",

issn = "0195-668X",

publisher = "Oxford University Press",

number = "16",

}

Singh, A, Greenwood, JP, Berry, C, Dawson, DK, Hogrefe, K, Kelly, DJ, Dhakshinamurthy, V, Lang, CC, Khoo, JP, Sprigings, D, Steeds, RP, Jerosch-Herold, M, Neubauer, S, Prendergast, B, Williams, B, Zhang, R, Hudson, I, Squire, IB, Ford, I, Samani, NJ & McCann, GP 2017, 'Comparison of exercise testing and CMR measured myocardial perfusion reserve for predicting outcome in asymptomatic aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) study', European Heart Journal, vol. 38, no. 16, pp. 1222-1229. https://doi.org/10.1093/eurheartj/ehx001

Comparison of exercise testing and CMR measured myocardial perfusion reserve for predicting outcome in asymptomatic aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) study. / Singh, Anvesha ; Greenwood, John P.; Berry, Colin et al.
In: European Heart Journal, Vol. 38, No. 16, 21.04.2017, p. 1222-1229.

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

TY - JOUR

T1 - Comparison of exercise testing and CMR measured myocardial perfusion reserve for predicting outcome in asymptomatic aortic stenosis

T2 - the PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) study

AU - Singh, Anvesha

AU - Greenwood, John P.

AU - Berry, Colin

AU - Dawson, Dana K.

AU - Hogrefe, Kai

AU - Kelly, Damian J.

AU - Dhakshinamurthy, Vijay

AU - Lang, Chim C.

AU - Khoo, Jeffrey P.

AU - Sprigings, David

AU - Steeds, Richard P.

AU - Jerosch-Herold, Michael

AU - Neubauer, Stefan

AU - Prendergast, Bernard

AU - Williams, Brian

AU - Zhang, Ruiqi

AU - Hudson, Ian

AU - Squire, Iain B.

AU - Ford, Ian

AU - Samani, Nilesh J.

AU - McCann, Gerry P.

N1 - The study was supported by a grant from the National Institute of Health Research (NIHRPDF 2011-04-51 Gerald P McCann) and the NIHR Leicester Cardiovascular Biomedical Research Unit, the NIHR Comprehensive Local Research Networks and the Leeds & Leicester NIHR Clinical Research Facilities. BW is supported by the NIHR UCL Hospitals Biomedical Research Centre. The views expressed are those of the author(s) and not necessarily those of the NHS, NIHR or the Department of Health.

PY - 2017/4/21

Y1 - 2017/4/21

N2 - AimsTo assess cardiovascular magnetic resonance (CMR) measured myocardial perfusion reserve (MPR) and exercise testing in asymptomatic patients with moderate-severe AS.Methods and resultsMulti-centre, prospective, observational study, with blinded analysis of CMR data. Patients underwent adenosine stress CMR, symptom-limited exercise testing (ETT) and echocardiography and were followed up for 12–30 months. The primary outcome was a composite of: typical AS symptoms necessitating referral for AVR, cardiovascular death and major adverse cardiovascular events. 174 patients were recruited: mean age 66.2 ± 13.34 years, 76% male, peak velocity 3.86 ± 0.56 m/s and aortic valve area index 0.57 ± 0.14 cm2/m2. A primary outcome occurred in 47 (27%) patients over a median follow-up of 374 (IQR 351–498) days. The mean MPR in those with and without a primary outcome was 2.06 ± 0.65 and 2.34 ± 0.70 (P = 0.022), while the incidence of a symptom-limited ETT was 45.7% and 27.0% (P = 0.020), respectively. MPR showed moderate association with outcome area under curve (AUC) = 0.61 (0.52–0.71, P = 0.020), as did exercise testing (AUC = 0.59 (0.51–0.68, P = 0.027), with no significant difference between the two.ConclusionsMPR was associated with symptom-onset in initially asymptomatic patients with AS, but with moderate accuracy and was not superior to symptom-limited exercise testing. ClinicalTrials.gov (NCT01658345).

AB - AimsTo assess cardiovascular magnetic resonance (CMR) measured myocardial perfusion reserve (MPR) and exercise testing in asymptomatic patients with moderate-severe AS.Methods and resultsMulti-centre, prospective, observational study, with blinded analysis of CMR data. Patients underwent adenosine stress CMR, symptom-limited exercise testing (ETT) and echocardiography and were followed up for 12–30 months. The primary outcome was a composite of: typical AS symptoms necessitating referral for AVR, cardiovascular death and major adverse cardiovascular events. 174 patients were recruited: mean age 66.2 ± 13.34 years, 76% male, peak velocity 3.86 ± 0.56 m/s and aortic valve area index 0.57 ± 0.14 cm2/m2. A primary outcome occurred in 47 (27%) patients over a median follow-up of 374 (IQR 351–498) days. The mean MPR in those with and without a primary outcome was 2.06 ± 0.65 and 2.34 ± 0.70 (P = 0.022), while the incidence of a symptom-limited ETT was 45.7% and 27.0% (P = 0.020), respectively. MPR showed moderate association with outcome area under curve (AUC) = 0.61 (0.52–0.71, P = 0.020), as did exercise testing (AUC = 0.59 (0.51–0.68, P = 0.027), with no significant difference between the two.ConclusionsMPR was associated with symptom-onset in initially asymptomatic patients with AS, but with moderate accuracy and was not superior to symptom-limited exercise testing. ClinicalTrials.gov (NCT01658345).

KW - Aortic stenosis

KW - exercise testing

KW - magnetic resonance imaging

KW - myocardial perfusion reserve

U2 - 10.1093/eurheartj/ehx001

DO - 10.1093/eurheartj/ehx001

M3 - Article

C2 - 28204448

SN - 0195-668X

VL - 38

SP - 1222

EP - 1229

JO - European Heart Journal

JF - European Heart Journal

IS - 16

ER -

Singh A, Greenwood JP, Berry C, Dawson DK, Hogrefe K, Kelly DJ et al. Comparison of exercise testing and CMR measured myocardial perfusion reserve for predicting outcome in asymptomatic aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) study. European Heart Journal. 2017 Apr 21;38(16):1222-1229. Epub 2017 Feb 13. doi: 10.1093/eurheartj/ehx001

Comparison of exercise testing and CMR measured myocardial perfusion reserve for predicting outcome in asymptomatic aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) study

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Lang, Chim

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