Paper of the Month

July 2019

Magnetic Resonance Perfusion or Fractional Flow Reserve in Coronary Disease. N Engl J Med. DZHK authors: Nagel, Puntmann, Schulz-Menger

Cardiovascular magnetic resonance perfusion imaging could replace invasive procedures for assessing patients with stable chest pain.

The decision for revascularization in patients with stable chest pain can be made by a 40 minute, non-invasive, perfusion cardiovascular magnetic resonance (CMR) scan rather than by invasive coronary angiogram including pressure measurements (fractional flow reserve).
The MR-INFORM study, led by Prof. Eike Nagel from University Hospital Frankfurt, and partially supported by funds from the German Centre for Cardiovascular Research (DZHK), tested 918 patients from four countries and discovered that guiding therapy by perfusion CMR is as effective as an invasive coronary angiogram plus fractional flow reserve.
Currently, patients with stable angina are frequently examined with invasive angiography to detect coronary artery stenosis. The use of fractional flow reserve to decide on the need for revascularization has improved outcome of patients with coronary artery disease and is considered the gold-standard.
The MR Perfusion Imaging to Guide Management of Patients with Stable Coronary Artery Disease (MR-INFORM) study randomly assigned 918 patients with stable angina to receive either a coronary angiogram or perfusion CMR to assess if they needed further treatment. All patients were monitored for one year and any major event, such as myocardial infarction, target vessel revascularization, or death was recorded.
In the CMR guided arm, only 40.5% of patients went to invasive angiography and 35.7% of patients were revascularized. This was significantly below the revascularization rate of the invasive arm (45%). There were no differences in angina status between groups after one year. Both treatment groups patients had low event rates of 3.9% in the angiography guided group and 3.3% in the perfusion CMR guided group resulting in non-inferiority of perfusion CMR to angiography to guide patient management.
The results demonstrate, that perfusion CMR can be safely used as a first line test in patients with stable chest pain, reducing the number of invasive angiographies and revascularizations, while providing identical outcomes on symptoms and event free survival. CMR is faster, does not require ionizing radiation and is non-invasive.


Press release Goethe University