title: Does stress perfusion imaging improve the diagnostic accuracy of late gadolinium enhanced cardiac magnetic resonance for establishing the etiology of heart failure?
abstract: Late gadolinium enhanced cardiovascular magnetic resonance (LGE-CMR) has excellent specificity, sensitivity and diagnostic accuracy for differentiating between ischemic cardiomyopathy (ICM) and non-ischemic dilated cardiomyopathy (NICM). CMR first-pass myocardial perfusion imaging (perfusion-CMR) may also play role in distinguishing heart failure of ischemic and non-ischemic origins, although the utility of additional of stress perfusion imaging in such patients is unclear. The aim of this retrospective study was to assess whether the addition of adenosine stress perfusion imaging to LGE-CMR is of incremental value for differentiating ICM and NICM in patients with severe left ventricular systolic dysfunction (LVSD) of uncertain etiology.
  
  
  
  We retrospectively identified 100 consecutive adult patients (median age 69 years (IQR 59-73)) with severe LVSD (mean LV EF 26.6 ± 7.0%) referred for perfusion-CMR to establish the underlying etiology of heart failure. The cause of heart failure was first determined on examination of CMR cine and LGE images in isolation. Subsequent examination of complete adenosine stress perfusion-CMR studies (cine, LGE and perfusion images) was performed to identify whether this altered the initial diagnosis.
  
  
  
  On LGE-CMR, 38 patients were diagnosed with ICM, 46 with NICM and 16 with dual pathology. With perfusion-CMR, there were 39 ICM, 44 NICM and 17 dual pathology diagnoses. There was excellent agreement in diagnoses between LGE-CMR and perfusion-CMR (κ 0.968, p<0.001). The addition of adenosine stress perfusion images to LGE-CMR altered the diagnosis in only two of the 100 patients.
  
  
  
  The addition of adenosine stress perfusion-CMR to cine and LGE-CMR provides minimal incremental diagnostic yield for determining the etiology of heart failure in patients with severe LVSD.
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK. gg149@leicester.ac.uk.|The NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK. gg149@leicester.ac.uk.
authors.forename: Gaurav S
authors.initials: GS
authors.lastname: Gulsin
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK.|The NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK.
authors.forename: Abishek
authors.initials: A
authors.lastname: Shetye
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK.|The NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Khoo
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK.|The NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Swarbrick
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK.|The NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK.
authors.forename: Eylem
authors.initials: E
authors.lastname: Levelt
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK.|The NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK.
authors.forename: Florence Y
authors.initials: FY
authors.lastname: Lai
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK.|The NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK.
authors.forename: Iain B
authors.initials: IB
authors.lastname: Squire
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK.|The NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK.
authors.forename: Jayanth R
authors.initials: JR
authors.lastname: Arnold
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK.|The NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK.
authors.forename: Gerry P
authors.initials: GP
authors.lastname: McCann
mesh_terms: D000241:Adenosine / Q000008:administration & dosage*; D000368:Aged; D000369:Aged, 80 and over; D009202:Cardiomyopathies / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology; D003287:Contrast Media / Q000008:administration & dosage*; D017023:Coronary Angiography; D003937:Diagnosis, Differential; D005260:Female; D006333:Heart Failure / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology; D006801:Humans; D019028:Magnetic Resonance Imaging, Cine / Q000379:methods*; D008297:Male; D008536:Meglumine / Q000008:administration & dosage*; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000150:complications / Q000000981:diagnostic imaging* / Q000503:physiopathology; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D009942:Organometallic Compounds / Q000008:administration & dosage*; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D014665:Vasodilator Agents / Q000008:administration & dosage*; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology; D016277:Ventricular Function, Left
chemical_list: D003287:Contrast Media; D009942:Organometallic Compounds; D014665:Vasodilator Agents; D008536:Meglumine; D000241:Adenosine; C072417:gadoterate meglumine
keywords: Adenosine stress perfusion; Cardiovascular magnetic resonance; Heart failure; Late gadolinium enhancement; Non-ischemic cardiomyopathy