Comparing prognostic significance of dual bolus and dual sequence quantitative stress perfusion cardiac magnetic resonance

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Abstract
Aims: Quantitative stress perfusion (QP) cardiac magnetic resonance (CMR) can be performed using the dual sequence (DS) or dual bolus (DB) technique. DS does not require additional contrast and image acquisition but needs a research sequence. DB can be performed on all magnetic resonance imaging (MRI) scanners with standard perfusion sequences but requires additional contrast injection and image acquisition. Our aim was to compare the prognostic significance of DB and DS. Methods and Results: DB and DS were performed on the same patient and the same examination. Analysts were blinded to clinical outcomes. Stress myocardial blood flow (MBF) and myocardial perfusion reserve (MPR) were quantified. The primary outcome was a composite of major adverse cardiovascular events (MACE) comprising acute coronary syndrome, stroke, heart failure (HF) hospitalization, late revascularization, and all-cause death. 570 patients (mean age: 63.2 ± 12.3 years; 61.2% male) were recruited. Median follow-up was 743 days; 54 events were documented. All QP CMR variables demonstrated significance in univariate Cox regression [DB stress MBF [HR = 0.53 (95%CI:0.35–0.78)], DB MPR [HR = 0.38 (95%CI:0.22–0.66)], DS stress MBF [HR = 0.27 (95%CI:0.18–0.40)] and DS MPR [HR = 0.19 (95%CI:0.13–0.29)]]. On multivariable Cox regression models, only DB MPR, DS MBF, and DS MPR remained significant for MACE (HR = 0.50 (95%CI:0.28–0.89), HR = 0.35 (95%CI:0.23–0.53); HR = 0.23 (95%CI 0.15–0.36), respectively). Harrell’s C-index of DS MPR and DS stress MBF showed significantly better prognostication than their DB counterparts (P < 0.001 and P = 0.012, respectively). Conclusion: In this blinded comparison, DS stress MBF and MPR demonstrated better prognostication than DB stress MBF and MPR. Our findings support DS as the preferred approach where available.

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