J Cardiovasc Magn Reson. 2025 Nov 27:101993. doi: 10.1016/j.jocmr.2025.101993. Online ahead of print.
ABSTRACT
OBJECTIVE: Phosphorus-31 magnetic resonance spectroscopy (³¹P MRS) is the only non-invasive imaging modality that directly quantifies myocardial energy metabolism in vivo. While extensively studied, its readiness for clinical application in heart failure remains uncertain. This meta-analysis aimed to evaluate the association between myocardial phosphocreatine-to-ATP (PCr/ATP) ratio, measured by ³¹P MRS, and heart failure, as a step toward assessing its translational potential as a clinical biomarker.
METHODS: We systematically reviewed studies published from Jan 1, 1990, to Dec 31, 2024, using PubMed, Embase, and Web of Science. Eligible studies included cohort studies and randomised controlled trials reporting PCr/ATP ratios in heart failure patients and healthy controls. A random-effects model was used to estimate pooled odds ratios. Risk of bias was assessed using the ROBINS-E tool.
FINDINGS: Twenty-six observational studies met inclusion criteria; no randomised trials were identified. Meta-analysis showed a directionally consistent and substantial association between reduced PCr/ATP ratio and heart failure (odds ratio 7.62, 95% CI 4.90-11.85), with moderate between-study heterogeneity (I²=60% and the prediction interval is (1.35-42.92)). Studies at field strengths >1.5T showed reduced heterogeneity (I²=18.8%) with a comparable effect size (odds ratio 7.69, 95% CI 5.17-11.43). Pre-specified meta-regression did not identify significant moderators (age, female proportion, ejection fraction, NYHA class, field strength, or blood-pool correction; all p≥0.18).
INTERPRETATION: These findings support a clinically sizable but heterogeneous association between impaired myocardial energy metabolism-measured by reduced PCr/ATP ratio using ³¹P MRS-and heart failure. The consistency across subgroups, including HFpEF, suggests potential utility in early-stage or diagnostically challenging heart failure. The results support inclusion of PCr/ATP in prospective studies aimed at validating its clinical utility and advancing metabolic imaging toward routine cardiovascular care.
PMID:41318032 | DOI:10.1016/j.jocmr.2025.101993