title: Stress Perfusion Cardiac Magnetic Resonance Imaging Effectively Risk Stratifies Diabetic Patients With Suspected Myocardial Ischemia.
abstract: BACKGROUND
  Diabetics remain at high risk of cardiovascular disease and mortality despite advancements in medical therapy. Noninvasive cardiac risk profiling is often more difficult in diabetics owing to the prevalence of silent ischemia with unrecognized myocardial infarction, reduced exercise capacity, nondiagnostic electrocardiographic changes, and balanced ischemia from diffuse epicardial coronary atherosclerosis and microvascular dysfunction.
  
  
  RESULTS
  A consecutive cohort of 173 patients with diabetes mellitus (mean age, 61.7±11.9 years; 37% women) with suspected myocardial ischemia underwent stress perfusion cardiac magnetic resonance imaging. Patients were evaluated for adverse cardiac events after cardiac magnetic resonance imaging with mean follow-up time of 2.9±2.5 years. Mean hemoglobin A1c for the population was 7.9±1.8%. Primary end point was a composite of cardiac death and nonfatal myocardial infarction. Diabetics with no inducible ischemia (n=94) experienced an annualized event rate of 1.4% compared with 8.2% (P=0.0003) in those with inducible ischemia (n=79). Diabetics without late gadolinium enhancement or inducible ischemia had a low annual cardiac event rate (0.5% per year). The presence of inducible ischemia was the strongest unadjusted predictor (hazard ratio, 4.86; P<0.01) for cardiac death and nonfatal myocardial infarction. This association remained robust in adjusted stepwise multivariable Cox regression analysis (hazard ratio, 4.28; P=0.02). In addition, categorical net reclassification index using 5-year risk cutoffs of 5% and 10% resulted in reclassification of 43.4% of the diabetic cohort with net reclassification index of 0.38 (95% confidence interval, 0.20-0.56; P<0.0001).
  
  
  CONCLUSIONS
  Stress perfusion cardiac magnetic resonance imaging provided independent prognostic utility and effectively reclassified risk in patients with diabetes mellitus referred for ischemic assessment. Further evaluation is required to determine whether a noninvasive imaging strategy with cardiac magnetic resonance imaging can favorably affect downstream outcomes and improve cost-effectiveness of care in diabetics.
authors.affiliation: From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.).
authors.forename: Bobak
authors.initials: B
authors.lastname: Heydari
authors.affiliation: From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.).
authors.forename: Yu-Hsiang
authors.initials: YH
authors.lastname: Juan
authors.affiliation: From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.).
authors.forename: Hui
authors.initials: H
authors.lastname: Liu
authors.affiliation: From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.).
authors.forename: Siddique
authors.initials: S
authors.lastname: Abbasi
authors.affiliation: From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.).
authors.forename: Ravi
authors.initials: R
authors.lastname: Shah
authors.affiliation: From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.).
authors.forename: Ron
authors.initials: R
authors.lastname: Blankstein
authors.affiliation: From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.).
authors.forename: Michael
authors.initials: M
authors.lastname: Steigner
authors.affiliation: From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.).
authors.forename: Michael
authors.initials: M
authors.lastname: Jerosch-Herold
authors.affiliation: From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.). rykwong@partners.org.
authors.forename: Raymond Y
authors.initials: RY
authors.lastname: Kwong
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003287:Contrast Media; D003920:Diabetes Mellitus; D005260:Female; D019786:Gadolinium DTPA; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000175:diagnosis*; D011379:Prognosis; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors
chemical_list: D003287:Contrast Media; D019786:Gadolinium DTPA
keywords: death; diabetes mellitus; ischemia; magnetic resonance imaging; myocardial infarction; perfusion