Stress cardiac MR imaging compared with stress echocardiography in the early evaluation of patients who present to the emergency department with intermediate-risk chest pain.
OBJECTIVE
To compare the utility and efficacy of stress cardiac magnetic resonance (MR) imaging and stress echocardiography in an emergency setting in patients with acute chest pain (CP) and intermediate risk of coronary artery disease (CAD).


METHODS
Written informed consent was obtained from all patients. This HIPAA-compliant study was approved by the institutional review board for research ethics. Sixty patients without history of CAD presented to the emergency department with intermediate-risk acute CP and were prospectively enrolled. Patients underwent both stress cardiac MR imaging and stress echocardiography in random order within 12 hours of presentation. Stress imaging results were interpreted clinically immediately (blinded interpretation was performed months later), and coronary angiography was performed if either result was abnormal. CAD was considered significant if it was identified at angiography (narrowing >50% ) or if a cardiac event (death or myocardial infarction) occurred during follow-up (mean, 14 months ± 5 [standard deviation]). McNemar test was used to compare the diagnostic accuracy of techniques.


RESULTS
Stress cardiac MR imaging and stress echocardiography had similar specificity, accuracy, and positive and negative predictive values (92% vs 96%, 93% vs 88%, 67% vs 60%, and 100% vs 91%, respectively, for clinical interpretation; 90% vs 92%, 90% vs 88%, 58% vs 56%, and 98% vs 94%, respectively, for blinded interpretation). Stress cardiac MR imaging had higher sensitivity at clinical interpretation (100% vs 38%, P = .025), which did not reach significance at blinded interpretation (88% vs 63%, P = .31). However, multivariable logistic regression analysis showed stress cardiac MR imaging to be the strongest independent predictor of significant CAD (P = .002).


CONCLUSIONS
In patients presenting to the emergency department with intermediate-risk CP, adenosine stress cardiac MR imaging performed within 12 hours of presentation is safe and potentially has improved performance characteristics compared with stress echocardiography. Online supplemental material is available for this article.
From the Duke Cardiovascular Magnetic Resonance Center (J.F.H., I.K., H.W.K., L.M.R.V.A., M.P., R.M.J., R.J.K.) and Departments of Medicine (J.F.H., I.K., D.R., H.W.K., L.M.R.V.A., M.P., R.M.J., J.G.J., R.J.K.), Emergency Medicine (A.C.), and Radiology (R.M.J., R.J.K.), Duke University Medical Center, Box 3934, Durham, NC 27710.
John F
JF
Heitner
Igor
I
Klem
Derek
D
Rasheed
Abhinav
A
Chandra
Han W
HW
Kim
Lowie M R
LM
Van Assche
Michele
M
Parker
Robert M
RM
Judd
James G
JG
Jollis
Raymond J
RJ
Kim
D002637:Chest Pain / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000503:physiopathology; D003287:Contrast Media; D017023:Coronary Angiography; D003327:Coronary Disease / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000503:physiopathology; D025401:Echocardiography, Stress; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009942:Organometallic Compounds; D011237:Predictive Value of Tests; D018570:Risk Assessment; D012307:Risk Factors; D012680:Sensitivity and Specificity
D003287:Contrast Media; D009942:Organometallic Compounds; C112666:gadoversetamide