Recent data suggest that patients with HFrEF [heart failure with reduced left ventricular ejection fraction (LVEF)<40%] referred for stress cardiovascular magnetic resonance (CMR) may have a less optimal hemodynamic response to intravenous vasodilator. The prognostic value of stress CMR has been poorly investigated in this population.

To assess the safety and the prognostic value of vasodilator stress perfusion CMR in patients with HFrEF.

Between 2008 and 2018, we prospectively included consecutive patients with HFrEF defined by LVEF<40% referred for vasodilator stress perfusion CMR with dipyridamole. They were followed for the occurrence of major adverse cardiovascular events (MACE) defined by cardiovascular death or non-fatal myocardial infarction (MI). The secondary endpoint was a composite outcome of cardiovascular death or rehospitalisation for acute HF. Univariable and multivariable Cox regressions were performed to determine the prognostic association of inducible ischemia or late gadolinium enhancement (LGE).

Of 1084 patients with HFrEF (65±11 years, median LVEF 34.6±4.9%), 1049 (97%) completed the CMR protocol and among those 952 (91%) completed the follow-up (median 5.6±2.4 years). Stress CMR was well tolerated without severe adverse event. Using Kaplan–Meier analysis, the presence of inducible ischemia and LGE were significantly associated with the occurrence of MACE (hazard ratio [HR]: 2.46 [95% CI: 1.69–3.59]; P<0.001) (Fig. 1). In multivariable stepwise Cox regression including clinical characteristics and CMR, the inducible ischemia was an independent predictor of a higher incidence of MACE at follow-up (adjusted HR: 2.26 [95% CI: 1.52–3.35]; P<0.001). However, there was no significant difference between patients with or without ischemia for the secondary outcome (P=0.28).

Stress CMR is safe and has a good discriminative prognostic value to predict the occurrence of MACE in patients with HFrEF.