Imaging of Clinically Unrecognized Myocardial Fibrosis in Patients With Suspected Coronary Artery Disease

SPINS Study Investigators

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Background: Stress cardiac magnetic resonance (CMR) provides accurate assessment of both myocardial infarction (MI) and ischemia. Objectives: This study aimed to evaluate the incremental prognostic value of unrecognized myocardial infarction (UMI), detected during assessment of coronary artery disease (CAD) by stress CMR, beyond cardiac function and ischemia. Methods: In the multicenter SPINS (Stress CMR Perfusion Imaging in the United States) study, 2,349 consecutive patients (63 ± 11 years of age, 53% were male) with suspected CAD were assessed by stress CMR and followed over a median of 5.4 years. UMI was defined as the presence of late gadolinium enhancement consistent with MI in the absence of medical history of MI. This study investigated the association of UMI with all-cause mortality and nonfatal MI (death and/or MI), and major adverse cardiac events (MACE). Results: UMI was detected in 347 patients (14.8%) and clinically recognized myocardial infarction (RMI) in 358 patients (15.2%). Compared with patients with RMI, patients with UMI had a similar burden of cardiovascular risk factors, but significantly lower left ventricular ejection fraction (p < 0.001) and lower rates of guideline-directed medical therapies, including aspirin (p < 0.001), statin (p < 0.001), and beta-blockers (p = 0.002). During follow-up, 328 deaths and/or MIs and 528 MACE occurred. In univariate analysis, UMI and RMI were strongly associated with death and/or MI (UMI: hazard ratio [HR]: 2.15; 95% confidence interval [CI]: 1.63 to 2.83; p < 0.001; RMI: HR: 2.45; 95% CI: 1.89 to 3.18) and MACE. Compared with patients with RMI, patients with UMI presented an increased risk for heart failure hospitalization (UMI vs. RMI: HR: 2.60; 95% CI: 1.48 to 4.58; p < 0.001). In a multivariate model including ischemia and left ventricular ejection fraction, UMI and RMI maintained robust prognostic association with death and/or MI (UMI: HR: 1.82; 95% CI: 1.37 to 2.42; p < 0.001; RMI: HR: 1.54; 95% CI: 1.14 to 2.09) and MACE. Conclusions: In a multicenter cohort of patients with suspected CAD, presence of UMI or RMI portended an equally significant risk for death and/or MI, independently of the presence of ischemia. Compared with RMI patients, those with UMI were less likely to receive guideline-directed medical therapies and presented an increased risk for heart failure hospitalization that warrants further study. (Stress CMR Perfusion Imaging in the United States [SPINS]; NCT03192891)

Original languageEnglish (US)
Pages (from-to)945-957
Number of pages13
JournalJournal of the American College of Cardiology
Issue number8
StatePublished - Aug 25 2020

Bibliographical note

Funding Information:
The SPINS (Stress CMR Perfusion Imaging in the United States) study of the SCMR (Society for Cardiovascular Magnetic Resonance) registry was funded by the SCMR, using a research grant jointly sponsored by Siemens Healthineers (Erlangen, Germany) and Bayer AG (Leverkusen, Germany). These sponsors to SCMR provided financial support for the study but did not play a role in study design, data collection, analysis, interpretation, or manuscript drafting. Dr. Antiochos has received research funding from the Swiss National Science Foundation (grant P2LAP3_184037), the Novartis Foundation for Medical-Biological Research, the Bangerter-Rhyner Foundation, and the SICPA Foundation. Dr. Shenoy has received support from a National Institutes of Health grant (K23HL132011). Dr. Arai has research agreements with Siemens, Bayer, and Circle Cardiovascular Imaging. Dr. Bandettini is the principal investigator of one of the Bayer-sponsored GadaCAD2 (Gadavist-Enhanced Cardiac Magnetic Resonance Imaging to Detect Coronary Artery Disease) sites. Dr. Patel has received a research grant from and served on the Speakers Bureau of Astellas. Dr. Schulz-Menger has research agreements with Siemens; and serves on the Advisory Board of Bayer. Dr. Stuber has received nonmonetary research support form Siemens Healthineers. Drs. Raman and Simonetti receive institutional research support from Siemens. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.


  • coronary artery disease
  • secondary prevention
  • silent myocardial infarction
  • stress cardiac magnetic resonance
  • unrecognized myocardial infarction

PubMed: MeSH publication types

  • Journal Article
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

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