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Stress CMR Perfusion Imaging in the Medicare-Eligible Population: Insights From the SPINS Study
Yin Ge1, Panagiotis Antiochos2, Benedikt Bernhard3
1Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Cardiology, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Insights
Stress cardiac magnetic resonance (CMR) effectively risk-stratifies older patients for cardiovascular events. Findings of inducible ischemia or late gadolinium enhancement on stress CMR predict adverse outcomes in this population.
Area of Science:
- Cardiology
- Medical Imaging
- Geriatrics
Background:
- Older adults (≥65 years) experience a high burden of cardiovascular (CV) events.
- Noninvasive detection of coronary artery disease in this demographic presents significant challenges.
- Medicare-eligible patients represent a key population for CV risk assessment.
Purpose of the Study:
- To evaluate the prognostic capability of stress cardiac magnetic resonance (CMR) in Medicare-eligible patients.
- To assess the value of stress CMR in a multicenter U.S. setting.
- To determine the association of stress CMR findings with CV outcomes and healthcare costs.
Main Methods:
- A multicenter U.S. registry identified patients aged ≥65 years referred for stress CMR.
- The primary outcome was defined as CV death or nonfatal myocardial infarction.
- Secondary outcomes included major adverse CV events, hospitalizations, and unplanned revascularization.
Main Results:
- Among 1,780 patients, 144 primary and 323 secondary events occurred over 4.8 years.
- Inducible ischemia and late gadolinium enhancement (LGE) on stress CMR were linked to increased event rates.
- Patients without inducible ischemia or LGE had <1% annualized primary outcome rate, with low revascularization and healthcare costs.
Conclusions:
- Stress CMR provides effective risk stratification for older, Medicare-eligible patients.
- The presence of inducible ischemia and LGE independently predicts adverse CV outcomes.
- Stress CMR aids in identifying patients who may benefit from further intervention while sparing low-risk individuals.
Background:
Patients aged ≥65 years account for a disproportionately large portion of cardiovascular (CV) events and pose a challenge for noninvasive detection of coronary artery disease.
Objectives:
This study sought to determine the prognostic value of stress cardiac magnetic resonance (CMR) in a Medicare-eligible group of patients in a multicenter setting in the United States.
Methods:
From a multicenter U.S. registry, the study identified patients aged ≥65 years who were referred for stress CMR for evaluation of myocardial inducible ischemia. The primary outcome was defined as CV death or nonfatal myocardial infarction, whereas the secondary outcome was defined as any primary outcome, hospitalization for unstable angina, hospitalization for congestive heart failure, and unplanned late coronary artery bypass grafting. The associations of CMR findings with CV outcomes adjusted to clinical risk markers and health care cost spending were determined.
Results:
Among 1,780 patients (aged 73 ± 5.7 years; 46% female), study investigators observed 144 primary events and 323 secondary events, over a median follow-up of 4.8 years. The presence of inducible ischemia and late gadolinium enhancement (LGE) was associated with incrementally higher event rates. Patients with neither inducible ischemia nor LGE experienced a <1% annualized rate of primary outcome. In a multivariable model adjusted for CV risk factors, inducible ischemia and LGE maintained an independent association with primary (HR: 2.80 [95% CI: 1.93-4.05]; P < 0.001; and HR: 1.85 [95% CI: 1.21-2.82]; P = 0.004, respectively) and secondary (HR: 2.46 [95% CI: 1.90-3.19]; P < 0.001; and HR: 1.72 [95% CI: 1.30-2.27]; P < 0.001, respectively) outcomes. Rates of revascularization, as well as downstream costs for patients without CMR-detected inducible ischemia, remained low throughout the follow-up period.
Conclusions:
In a multicenter cohort of Medicare-eligible older patients, stress CMR was effective in providing risk stratification. (Stress CMR Perfusion Imaging in the United States [SPINS] study; NCT03192891).
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