While the benefit of coronary revascularization in patients with stable CAD is debated, data assessing the potential interest of stress CMR to guide coronary revascularization are limited.

To assess the long-term prognostic value of stress CMR-related coronary revascularization in consecutive patients from a large registry.

Between 2008 and 2018, a retrospective cohort study with a median follow-up of 6.0years (IQR: 5.0–8.0) included all consecutive patients referred for stress CMR. Stress CMR-related coronary revascularization was defined by any coronary revascularization performed within 90 days after CMR with presence of inducible ischemia. The primary outcome was all-cause death based on the National Death Registry.

Among the 31,752 consecutive patients (mean age 63.7±12.1years and 65.7% males), 2679 (8.4%) died at 206,453 patient-years of follow-up. In the overall population, CMR-related coronary revascularization was an independent predictor of greater survival (HR: 0.58; 99.5% CI: 0.46–0.74; P<0.001). In 1680, 1:1 matched patients using a limited number of variables (840 revascularized, 840 non-revascularized), CMR-related revascularization was associated with a lower incidence of death only in patients with severe inducible ischemia (>5 segments, P<0.001), but showed no benefit in patients with mild or moderate ischemia (≤5 segments, P=0.109). Using multivariable analysis in the propensity-matched population, CMR-related revascularization remained an independent predictor of a lower incidence of all-cause mortality (HR=0.66; 99.5% CI: 0.54–0.80, P<0.001) (Fig. 1).

In this large observational series of consecutive patients, stress CMR-related revascularization guided by the presence of inducible ischemia was associated with a lower incidence of death in patients with severe ischemia.