Cardiac Magnetic Resonance Stress Perfusion Imaging for Evaluation of Patients With Chest Pain

Abstract

Background: Stress cardiac magnetic resonance imaging (CMR) has demonstrated excellent diagnostic and prognostic value in single-center studies.

Objectives: This study sought to investigate the prognostic value of stress CMR and downstream costs from subsequent cardiac testing in a retrospective multicenter study in the United States.

Methods: In this retrospective study, consecutive patients from 13 centers across 11 states who presented with a chest pain syndrome and were referred for stress CMR were followed for a target period of 4 years. The authors associated CMR findings with a primary outcome of cardiovascular death or nonfatal myocardial infarction using competing risk-adjusted regression models and downstream costs of ischemia testing using published Medicare national payment rates.

Results: In this study, 2,349 patients (63 ± 11 years of age, 47% female) were followed for a median of 5.4 years. Patients with no ischemia or late gadolinium enhancement (LGE) by CMR, observed in 1,583 patients (67%), experienced low annualized rates of primary outcome (<1%) and coronary revascularization (1% to 3%), across all years of study follow-up. In contrast, patients with ischemia+/LGE+ experienced a >4-fold higher annual primary outcome rate and a >10-fold higher rate of coronary revascularization during the first year after CMR. Patients with ischemia and LGE both negative had low average annual cost spent on ischemia testing across all years of follow-up, and this pattern was similar across the 4 practice environments of the participating centers.

Conclusions: In a multicenter U.S. cohort with stable chest pain syndromes, stress CMR performed at experienced centers offers effective cardiac prognostication. Patients without CMR ischemia or LGE experienced a low incidence of cardiac events, little need for coronary revascularization, and low spending on subsequent ischemia testing. (Stress CMR Perfusion Imaging in the United States [SPINS]: A Society for Cardiovascular Resonance Registry Study; NCT03192891).

Keywords: cost of care; prognosis; stress cardiac magnetic resonance imaging.

Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.

Figures

FIGURE 1. Primary and Secondary Outcome Event Rates

Annualized rates of primary and secondary outcomes, stratified by presence and/or absence of ischemia and left gadolinium enhancement (LGE) (left) and extent of ischemia (right).

FIGURE 2. Primary Outcome Over Years of Follow-Up

Occurrence of primary outcome across different years of study follow-up, stratified by presence and/or absence of ischemia and left gadolinium enhancement (LGE).

FIGURE 3. Need for Coronary Revascularization

Occurrence of coronary revascularization across different years of study follow-up, stratified by presence and/or absence of ischemia and left gadolinium enhancement (LGE).

FIGURE 4. Invasive XCA and Revascularization at 90 Days

Referral to invasive coronary angiography (XCA) at 90-day post-stress cardiac magnetic resonance imaging with corresponding proportion of patients undergoing revascularization (Revasc), stratified by presence and/or absence of ischemia and left gadolinium enhancement (LGE) (left) and extent of ischemia (right).

FIGURE 5. Costs of Ischemia Testing

Costs of downstream cardiac tests incurred during follow-up, stratified by stress cardiac magnetic resonance imaging (CMR) findings with breakdown by modality. Costs are in U.S. dollars spent per patient. CTA = computed tomography angiography; LGE = late gadolinium enhancement.

FIGURE 6. Invasive XCA at 90 Days, Stratified by Practice Types

Referral to invasive XCA at 90-day post stress CMR, stratified by presence and/or absence of ischemia and LGE, according to practice environment. Abbreviations as in Figures 1, 4, and 5.

CENTRAL ILLUSTRATION. Stress Cardiac Magnetic Resonance Imaging Registry for Prognosis and Costs in the United States

Cumulative incidence functions for primary and secondary outcomes derived from a Fine and Gray competing risk model accounting for noncardiovascular death as a competing risk event. The top panels were stratified by presence and/or absence of ischemia and late gadolinium enhancement, and the bottom panels were stratified by the extent of ischemia.