The World's ageing population with a life expectancy that is steadily increasing raises the question of the benefit of screening for coronary artery disease (CAD) in very old patients.

To assess the prognostic value of vasodilator stress perfusion Cardiac Magnetic Resonance (CMR) in elderly patients aged>75years without known CAD.

Consecutive elderly patients>75years without known CAD referred for vasodilator stress perfusion CMR were followed for major adverse cardiovascular events(MACE) defined as cardiac death, non-fatal myocardial infarction or stroke. Univariable and multivariable Cox regressions for MACE were performed to assess the prognostic value of inducible ischemia and late gadolinium enhancement (LGE).

Of 747 elderly high risk patients with CMR (82±4years, 48% men), 659 (88%) completed the follow-up (median follow-up 5.7±2.5years). Stress CMR was well tolerated without occurrence of severe disabling adverse event. Patients without inducible ischemia or LGE experienced a substantially lower annual rate of MACE (5.5% vs. 9.9% for those with ischemia and vs. 6.9% for those with ischemia and/or LGE). In multivariable analysis, the absence of inducible ischemia was an independent predictor of a lower incidence of MACE (HR 0.46; 95%CI: 0.34 to 0.62; P<0.001; Fig. 1A) and all-cause mortality (HR 0.67; 95%CI: 0.45 to 0.97; P=0.037). When patients with early coronary revascularization (within 30days) were censored on the day of revascularization, both presence of inducible ischemia and ischemia extent per segment maintained a strong association with MACE. Moreover, the absence of inducible ischemia was a predictor of a lower incidence of MACE less significant in men than in women (P<0.01; Fig. 1B).

Stress CMR is safe and has discriminative prognostic value in very elderly patients, with a very low negative event rate in patients without ischemia or infarction.