University of Leicester
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Comparison of exercise testing and CMR measured myocardial perfusion reserve for predicting outcome in asymptomatic aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) Study.

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journal contribution
posted on 2017-03-22, 16:01 authored by Anvesha Singh, John P. Greenwood, Colin Berry, Dana K. Dawson, Kai Hogrefe, Damian J. Kelly, Vijay Dhakshinamurthy, Chim C. Lang, Jeffrey P. Khoo, David Sprigings, Richard P. Steeds, Michael Jerosch-Herold, Stefan Neubauer, Bernard Prendergast, Bryan Williams, Ruiqi Zhang, Ian Hudson, Iain B. Squire, Ian Ford, Nilesh J. Samani, Gerry P. McCann
Aims To assess cardiovascular magnetic resonance (CMR) measured myocardial perfusion reserve (MPR) and exercise testing in asymptomatic patients with moderate-severe AS. Methods and results Multi-centre, prospective, observational study, with blinded analysis of CMR data. Patients underwent adenosine stress CMR, symptom-limited exercise testing (ETT) and echocardiography and were followed up for 12–30 months. The primary outcome was a composite of: typical AS symptoms necessitating referral for AVR, cardiovascular death and major adverse cardiovascular events. 174 patients were recruited: mean age 66.2 ± 13.34 years, 76% male, peak velocity 3.86 ± 0.56 m/s and aortic valve area index 0.57 ± 0.14 cm2/m2. A primary outcome occurred in 47 (27%) patients over a median follow-up of 374 (IQR 351–498) days. The mean MPR in those with and without a primary outcome was 2.06 ± 0.65 and 2.34 ± 0.70 (P = 0.022), while the incidence of a symptom-limited ETT was 45.7% and 27.0% (P = 0.020), respectively. MPR showed moderate association with outcome area under curve (AUC) = 0.61 (0.52–0.71, P = 0.020), as did exercise testing (AUC = 0.59 (0.51–0.68, P = 0.027), with no significant difference between the two. Conclusions MPR was associated with symptom-onset in initially asymptomatic patients with AS, but with moderate accuracy and was not superior to symptom-limited exercise testing. (NCT01658345).


This report is independent research arising from a Post-Doctoral Fellowship supported by the National Institute for Health Research (NIHR-PDF 2011-04-51 Gerald P McCann). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health. Support was also recieved from NIHR Leicester Cardiovascular Biomedical Research Unit, the NIHR Comprehensive Local Research Networks and the Leeds and Leicester NIHR Clinical Research Facilities. BW is supported by the NIHR UCL Hospitals Biomedical Research Centre.



European Heart Journal, 2017, 0, 1–8

Author affiliation

/Organisation/COLLEGE OF MEDICINE, BIOLOGICAL SCIENCES AND PSYCHOLOGY/School of Medicine/Department of Cardiovascular Sciences


  • AM (Accepted Manuscript)

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European Heart Journal


Oxford University Press (OUP) for European Society of Cardiology





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Supplementary material is available at European Heart Journal online.



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