Background
Over the past decade, cardiovascular magnetic resonance (CMR) has become a key clinical imaging method for the evaluation of a wide range of heart and vascular diseases. A registry that fosters multicenter participation will gather evidence of the real-world diagnostic and therapeutic impact of CMR on patient care, key issues guiding future technical development, clinical adaptation, regulatory approval, and financial reimbursement. The European CMR Registry (EuroCMR) with now over 37,000 patients from 57 European centers has demonstrated CMR’s impact on clinical diagnosis and management in Europe [
1,
2]. Given the worldwide clinical adaptation of CMR in the past decade, the Society for Cardiovascular Magnetic Resonance (SCMR) in 2013 initiated and has since continued to support the development of a global registry. The Global CMR Registry (GCMR) aims to promote evidence-based adoption of CMR into patient management by facilitating standardized data collection across many centers of diverse patient demographics and clinical outcomes, qualitative and quantitative CMR results, determination of the downstream impact of CMR on diagnostic and therapeutic thinking, and its cost-effectiveness.
Discussion
The current project represents the first registry with the goal of integrating data from CMR programs globally, independent of clinical practice setting and level of experience of the participating program. The GCMR has developed a HIPAA-compatible, nonprofit, web-based database structure to allow integrated data collection across CMR centers around the globe. Depending on the clinical or research needs of a given site, PHI is either removed or encrypted and stored in regional servers. Analytical and reporting components of our database are designed to meet the standards of current practice guidelines supported by the SCMR [
5,
6]. This infrastructure allows data entry as a part of the clinical workflow with the goals of reducing the burden of redundant or onerous data entry. Given the complexity of CMR technology, multifaceted pulse sequence descriptions, and the wide range of clinical questions that CMR assesses, it is our opinion that this registry infrastructure will pave the path towards the growth of an integrated and a consistent body of evidence reflecting real-world data on CMR utilization and adoption. GCMR is the first of its kind to bring world-wide CMR practice patterns and clinical associations together in one unified database for purpose of evaluating the diagnostic impact and therapeutic guidance relevant to patient care.
While large-scale randomized prospective clinical trials will continue to provide the most robust evidence in guiding patient care, they can introduce selection bias, are costly, and in many clinical situations are impractical to conduct. Retrospective and prospective patient registries collecting real-world evidence can provide an alternative, complementary, and practical assessment for those conditions that are difficult to study in randomized trial settings. GCMR was designed to store a comprehensive range of data, which will enable researchers to evaluate various clinical outcome variables such as hospitalization, death, heart failure, arrhythmia and intervention as well as their relationship with commonly assessed clinical parameters, including cardiac function, chamber quantification, and myocardial perfusion. In contrast with clinical trials, which demand controlled conditions and tasks that are not usually reflective of daily clinical practice, patient registries provide a venue for collecting and storing data that correspond to parameters that are often routinely recorded. As such, patient registries are advantageous in that they are more amenable to mass-scale observational research and less prone to increasing the burden on participating CMR centers.
The EuroCMR Registry has prospectively enrolled over 37,000 patients from 57 centers in 15 European countries. Over the past decade, the EuroCMR Registry has led to new knowledge that is important to the clinical adoption of CMR: management changes were observed in approximately two-thirds of patients following a CMR scan [
1]; the safety profile of pharmacological vasodilatation for stress CMR was demonstrated, as was the safety of GBCM at dosage appropriate for CMR [
7]; and the prognostic implications of late gadolinium enhancement in hypertrophic cardiomyopathy patients [
8] was investigated. More recently, a health economics study used the EuroCMR Registry data to demonstrate that a strategy of CMR as gatekeeper for invasive coronary angiograms can save costs when compared with a direct invasive strategy including fractional flow reserve measurements in patients with low to intermediate pre-test probability for obstructive coronary artery disease [
9]. GCMR aims to learn from the successes of the EuroCMR Registry. While currently substantially less-developed than the EuroCMR Registry, GCMR is expected to continue to grow in CMR case volumes, geographic distribution and number of participating sites, and diversity of sites’ CMR experience.
Challenges ahead
The GCMR faces several key challenges. First, retrospective data has a high proportion of missing entries as a portion of the data were collected prior to the establishment of a data variable list and variable formats. However, we observed substantially higher adherence rates of data entry amongst sites that had adopted the use of the GCMR endorsed database. Nonetheless, given that key variables such as major demographic factors, CMR indications, and contrast use are available in most of the sites, we believe that the current retrospective cohort represents a unique resource to assess CMR utilization patterns in the past and inform directions for growth in the future. Going forward, it is expected that participating sites will converge in their data collection methods prospectively, regardless of methods of data collection, and the quality of the data collected will improve. Second, the use of native languages in CMR reporting from various geographic regions poses an expected challenge as GCMR expands. An effort from an international panel of CMR experts is currently underway in translating the web based data structures into various languages.
Conclusion
It is believed that the advantages of GCMR will be realized through its visions - becoming a universally representative CMR registry globally backed by the SCMR and a supportive and unifying data policy, user-friendly web data structures that are conducive to clinical workflow, and a goal of making a positive impact on patient care. GCMR provides the chance to acquire real-world, multi-dimensional evidence that can be used in many ways. Examples include a) to compare the clinical effectiveness of CMR with other imaging modalities, b) to conduct quality control of CMR images and data, which can be used to narrow the performance gap between nascent and experienced programs; c) to determine the cost-effectiveness of CMR when applied in important and common clinical scenarios; d) to study the impact on patient outcomes as compared to other imaging modalities. As an international registry, GCMR will offer opportunities to study variations across geographic regions, types of CMR center and CMR expertise in use of CMR protocols, performance, and clinical applications. Ultimately, the primary philosophy and goal of SCMR’s GCMR is to improve life expectancy and quality of life of patients with cardiovascular diseases.
Acknowledgements
We would like to sincerely thank the collaboration from David J. Hautemann MSc and Johan H. C. Reiber PhD of Medis Cardiovascular Imaging; Gregory Ogrodnick, Philipp Barckow, and Kelly Cherniwchan of Circles Cardiovascular Imaging; and Robert Judd, PhD of Heart Imaging Technology.
Authors’ contributions
RYK is the current Chair of the GCMR steering committee. He made substantial contributions to the design of the GMCR data infrastructure, acquisition of data, drafting and editing the manuscript, and analyzing and interpreting data.
AEA, SEB, YC, VMF, SDF, WPB, ETM, LN, SN, SVR, JJC, NR, and OPS made substantial contributions to the acquisition of data and were involved in drafting and editing the manuscript.
KS made substantial contributions to the acquisition of data and to drafting and editing the manuscript.
SEP, JS-M, RCC, and AAY made substantial contributions to the conception and design of the study and were involved in drafting and editing the manuscript.
EBS, USV, and VAF made substantial contributions to the conception and design of the study.
YLC made substantial contributions to analyzing data and was involved in drafting and editing portions of the manuscript.
LF and MP made substantial contributions to drafting portions of the manuscript.
All authors read and approved the manuscript.
Ethics approval and consent to participate
1. Participating sites have obtained either an approval or waiver from an ethics or regulatory board prior to submitting data to the GCMR.
2. Given the retrospective nature of the current data spanning the past decade, obtaining informed consent from each patient was not logistically feasible, and a waiver for signing informed consent was obtained from the IRB of each participating site.
IRBs of sites that have contributed data:
Brigham and Women’s Hospital: Partners Human Research Committee
Central Utah Clinic: Review of this project has been waived by the regulatory bodies of Revere Health, Provo, Utah, as only non-identifiable information was shared.
National Institutes of Health: The IRB of the National Heart, Lung, and Blood Institute, Division of Intramural Research
Ohio State University: OSU Human Subjects Review Committee
Oklahoma Heart Institute: Hillcrest Medical Center IRB
University of Oxford: The UK’s Health Research Authority states that research involving previously collected non-identifiable information does not require research ethics committee review.
St. Francis Hospital: The St. Francis Hospital Institutional Review Board
University of South Florida: Tampa General Hospital Institutional Review Board
West China Hospital: Ethics Committee at West China Hospital
Wilford Hall Medical Center: San Antonio Military Medical Center Institutional Review Board