Prognostic value of stress perfusion cardiac magnetic resonance in patients with known or suspected coronary artery disease and supranormal left ventricular ejection fraction.
Pakdeesrisakda K & Kaolawanich Y • Open heart • 2026
In patients undergoing stress perfusion CMR with supranormal LVEF, myocardial ischaemia detected by CMR provided significant prognostic value for predicting a composite of all-cause death, ACS or hospitalisation for heart failure.
Key Findings
Results
Myocardial ischaemia detected by stress perfusion CMR was associated with a significantly higher rate of MACE in patients with supranormal LVEF.
MACE rate was 3.71 per 100 patient-years in patients with ischaemia vs 1.74 per 100 patient-years in those without ischaemia
Unadjusted HR 2.13 (95% CI 1.28 to 3.54; p=0.004)
63 MACE occurred during a median follow-up of 5.4 years (IQR 2.1–9.5)
MACE was defined as a composite of all-cause death, acute coronary syndrome, or hospitalisation for heart failure
124 of 531 patients had myocardial ischaemia detected on CMR
Results
Myocardial ischaemia remained an independent predictor of MACE after multivariable adjustment.
Adjusted HR 1.81 (95% CI 1.08 to 3.05; p=0.02) in multivariable Cox regression analysis
Multivariable model also included age, history of heart failure, and LV mass index as covariates
This confirms that ischaemia on CMR has independent prognostic value beyond clinical risk factors
Results
The prognostic value of myocardial ischaemia was consistent across all three LVEF tertiles within the supranormal range.
p for interaction = 0.79, indicating no significant interaction between ischaemia and LVEF tertile
All patients had LVEF ≥65%; mean LVEF was 75.1% ± 6.2%
This suggests the prognostic significance of ischaemia does not vary by degree of supranormal LVEF
Results
Age, history of heart failure, and LV mass index were additional independent predictors of MACE in multivariable analysis.
Age: HR 1.03 (95% CI 1.001 to 1.05; p=0.03)
History of heart failure: HR 2.65 (95% CI 1.57 to 4.46; p<0.001)
LV mass index: HR 1.03 (95% CI 1.02 to 1.04; p<0.001)
Methods
The study cohort consisted of patients with known or suspected coronary artery disease and supranormal LVEF who underwent clinical stress perfusion CMR at an academic hospital in Thailand.
531 patients were included, mean age 68.7 ± 11.0 years, 42.6% male
Study period was 2011 to 2022
Inclusion criterion was LVEF ≥65% on CMR
Patients were divided into two groups based on presence or absence of myocardial ischaemia on CMR
Background
Prior studies have shown that a supranormal range of LVEF is associated with adverse cardiovascular outcomes, but the prognostic value of stress perfusion CMR in this population had not been well defined.
The study aimed to fill this specific knowledge gap
Supranormal LVEF was defined as LVEF ≥65%
The study is described as a cohort study conducted at an academic hospital in Thailand
What This Means
This research suggests that a heart imaging test called stress perfusion cardiac magnetic resonance (CMR) can predict the risk of serious heart events in a specific group of patients — those whose hearts appear to pump very strongly (with a so-called 'supranormal' ejection fraction of 65% or higher). While a strong pumping heart might seem protective, previous research has shown that an unusually high ejection fraction can actually be associated with worse outcomes. This study followed 531 patients in Thailand for a median of about 5.4 years and found that those whose CMR scan revealed reduced blood flow to parts of the heart muscle (myocardial ischaemia) were more than twice as likely to experience a major adverse cardiovascular event — including death, heart attack, or hospitalization for heart failure — compared to those with normal blood flow.
The association between detected ischaemia and worse outcomes remained even after accounting for other risk factors like age, history of heart failure, and heart muscle mass. Notably, the predictive value of ischaemia was consistent regardless of how high the ejection fraction was within the supranormal range, suggesting the finding is robust across this patient group.
This research suggests that stress perfusion CMR provides meaningful risk information even in patients who appear to have strongly functioning hearts. Identifying ischaemia in this population — who might otherwise be considered lower-risk due to their high ejection fraction — could help clinicians better stratify risk and potentially guide management decisions. The findings highlight that a seemingly 'normal' or even 'supranormal' pumping function does not rule out important underlying coronary artery disease with prognostic consequences.
Pakdeesrisakda K, Kaolawanich Y. (2026). Prognostic value of stress perfusion cardiac magnetic resonance in patients with known or suspected coronary artery disease and supranormal left ventricular ejection fraction.. Open heart. https://doi.org/10.1136/openhrt-2026-004086