Stress-induced ischemia by CMR is a strong prognostic marker for event-free survival, independent of sex, in patients with suspected chronic coronary syndrome

Thursday, February 5, 2026

8:20 AM - 8:30 AM

Location: Asia IV and Hall 8 (3rd Floor)

Presenting Author(s)

SA

Shahnaz Akil, MSc

Technologist, PhD
Lund university and Skåne University Hospital, Lund
Lund, Skane Lan, Sweden

Primary Author(s)

SA

Shahnaz Akil, MSc

Technologist, PhD
Lund university and Skåne University Hospital, Lund
Lund, Skane Lan, Sweden

Co-Author(s)

MK

Morten Kraen, MD, PhD

Senior consultant, PhD
Skåne University Hospital, Lund, Sweden
BK

Barbro Kjellström, PhD

PhD
Lund University and Skåne University Hospital, Lund, Sweden, Sweden
Ellen Ostenfeld, MD, PhD

MD, PhD, Associate professor
Lund University and Skåne University Hospital, Lund, Sweden
Lund, Skane Lan, Sweden
Peter Kellman, PhD

Senior Scientist
National Institutes of Health
Bethesda, Maryland, United States
HA

Håkan Arheden, MD, PhD

MD, PhD, Professor
Lund University and Skåne University Hospital, Lund, Sweden
Lund, Sweden
HE

Henrik Engblom, MD, PhD

Professor, MD
Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
Lund, Skane Lan, Sweden

Background: There are known sex-differences in normal coronary physiology and myocardial perfusion. Females develop coronary artery disease > 10 years later than males, often with a different clinical presentation. This constitutes both diagnostic and patient management challenges. To what extent sex-differences affect outcome in the presence of stress-induced ischemia and/or infarction by CMR is not completely understood. Therefore, the aim of this study was to assess sex-differences in outcome after stress imaging by CMR in patients with suspected chronic coronary syndrome (CCS).

Methods: This single-centre study included patients from the CMR arm of the CHOICE registry. All patients were referred for adenosine stress CMR at Skane University hospital in Lund, Sweden, during 2019-2022 due to suspected CCS. CMR findings of ischemia and/or infarction by late gadolinium enhancement were related to major adverse cardiac events (MACE), obtained from the Swedish National Board of Health and Welfare Registry. MACE was defined as a composite of cardiovascular death, acute myocardial infarction or revascularisation (CABG/PCI) during the follow-up period. Kaplan Meier curves for event-free survival analysis were used. Multivariable Cox regression analysis, including known risk factors as well as CMR findings, was performed to assess risk of MACE.

Results: In total 2 159 patients (947 females) were included in the analyses. Patient characteristics are shown in Table 1. Females had 56 composite events and males 139 during the follow-up period, with a mean time to event of 2.6±0.9 years and 2.4±1.0 years in females and males, respectively. There was no statistically significant sex-difference in event-free survival in patients exhibiting ischemia or infarction (Figure 1). Presence of ischemia was associated with risk of MACE (hazard ratio =4.1, p< 0.001) with no additional risk for male sex (hazard ratio =1.2, p=0.36; Table 2).

Conclusion: Stress-induced ischemia by CMR is a strong prognostic marker, independent of sex. Thus, despite known sex differences in the development of coronary artery disease, CMR may have the potential to guide coronary care to equalize patient outcome between sexes.

Table 1. Population characteristics and CMR findings

	Females (n=947)	Males (n=1212)	P-value
*Age (years±SD)*	66±12	65±12	0.5
*Body surface area (m²± SD)*	1.83±0.21	2.09±0.21	0.5
*Diabetes*	88 (9%)	169 (16%)	< 0.001
*Hypertension*	258 (27%)	430 (35%)	< 0.001
*Prior* *IHD*	148 (16%)	346 (29%)	< 0.001
*CMR findings:*
LVEF (%±SD)	59±10	53±12	< 0.001
*No infarct or ischemia*	764 (81%)	736 (61%)	< 0.001
*Ischemia only*	77 (8%)	150 (12%)	< 0.001
*Infarct only*	66 (7%)	168 (14%)	< 0.001
*Both infarct and ischemia*	40 (4%)	158 (13%)	< 0.001

IHD=Ischemic heart disease, LVEF= Left ventricular ejection fractionTable 2. Multivariate Cox-regression analysis

Variables	Hazard ratio (95% CI)	P-value
*Sex*	1.16 (0.84-1.61)	0.36
*Age*	1.02 (1.0-1.04)	0.007
LVEF	0.98 (0.97-0.99)	< 0.001
*Diabetes*	1.31 (0.93-1.84)	0.13
*Hypertension*	1.18 (0.86-1.60)	0.31
*Prior* *IHD*	1.51 (1.08-2.12)	0.02
*Ischemia by CMR*	4.1 (2.99-5.60)	< 0.001
*Infarct by CMR*	1.69 (1.18-2.43)	0.004

IHD=Ischemic heart disease, LVEF= Left ventricular ejection fractionFigure 1. Probability of event- free survival after stress CMR in relation to CMR findings in males (blue) and females (red).