Several studies have shown the excellent prognostic value of stress cardiovascular magnetic resonance (CMR). However, its prognostic value in patients with pacemaker (PM) remains unknown because most studies excluded PM patients. This study aimed to assess the prognostic value of vasodilator stress perfusion CMR in patients with PM.

Consecutive patients with MR-conditional pacemakers referred for stress perfusion CMR at 1.5T were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. Cox regressions analyses were performed to determine the prognostic value of CMR-parameters. The quality of CMR was rated by two observers blinded to clinical details. Data on pacemaker and leads were collected pre- and post-CMR.

Of 224 patients who completed the stress CMR protocol, 2 patients had inconclusive stress CMR due to artefact and 203 patients (72.9% male, mean age 71.4±8.7 years) completed the follow-up [median (interquartile range), 7.0 (5.2–7.3) years]. Among those, 23 experienced a MACE (11.3%). Stress CMR was well tolerated with no major adverse events. Overall, the image quality was rated good or excellent in 84.1% of segments. Using Kaplan–Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (HR: 11.80 [95%CI, 4.63–30.30]; and HR: 6.74 [95%CI, 2.47–18.40], both P<0.001; respectively). In multivariable Cox regression, inducible ischemia and LGE were independent predictors of a higher incidence of MACE [HR: 5.24 (95%CI, 2.61–14.40); and HR: 2.98 (95%CI, 2.25–4.02); both P<0.001; respectively]. In patients with ischemia, CMR-related coronary revascularization showed no benefit in reducing MACE (P=0.25) (Fig. 1).

Stress CMR is safe, feasible and has a good discriminative prognostic value in consecutive patients with PM.