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Stress CMR in Suspected Ischemic Heart Disease in Women
Quick Takes
- Stress CMR has excellent prognostic performance with lower rates of invasive coronary angiography (ICA) referral in women.
- The study underscores the prognostic utility of stress CMR in women, which may be performed without ionizing radiation and may significantly reduce rates of ICA and health care costs.
- Additional prospective clinical trials are needed to evaluate the optimal approach in the evaluation and management for patients presenting with suspected ischemic heart disease and to further define the role of stress CMR.
Study Questions:
What is the effect of sex on the prognostic utility and downstream invasive revascularization and costs of stress perfusion cardiac magnetic resonance (CMR) for suspected cardiovascular disease (CVD)?
Methods:
The investigators evaluated sex-specific prognostic performance in a 2,349-patient multicenter SPINS (Stress CMR Perfusion Imaging in the United States [SPINS] Study) registry. The primary outcome measure was a composite of cardiovascular death and nonfatal myocardial infarction; secondary outcomes were hospitalization for unstable angina or heart failure, and late unplanned coronary artery bypass grafting. Cumulative incidence curves were generated by plotting cumulative incidence of primary or secondary outcome by time of follow-up, stratified by sex and stress CMR results. Significance was compared by means of the log-rank test.
Results:
SPINS included 1,104 women (47% of cohort); women had higher prevalence of chest pain (62% vs. 50%; p < 0.0001) but lower use of medical therapies. At the 5.4-year median follow-up, women with normal stress CMR had a low annualized rate of the primary composite outcome similar to men (0.54%/y vs. 0.75%/y, respectively; p = NS). In contrast, women with abnormal CMR were at higher risk for both primary (3.74%/y vs. 0.54%/y; p < 0.0001) and secondary (9.8%/y vs. 1.6%/y; p < 0.0001) outcomes compared with women with normal CMR. Abnormal stress CMR was an independent predictor for the primary (hazard ratio [HR], 2.64; 95% confidence interval [CI], 1.20-5.90; p = 0.02) and secondary (HR, 2.09; 95% CI, 1.43-3.08; p < 0.0001) outcome measures. There was no effect modification for sex. Women had lower rates of invasive coronary angiography (ICA; 3.6% vs. 7.3%; p = 0.0001) and downstream costs ($114 vs. $171; p = 0.001) at 90 days following CMR. There was no effect of sex on diagnostic image quality.
Conclusions:
The authors report that stress CMR demonstrated excellent prognostic performance with lower rates of ICA referral in women.
Perspective:
This post hoc analysis of the SPINS Registry reports that stress CMR has excellent prognostic performance with lower rates of ICA referral in women. These data support functional evaluation with stress perfusion CMR in symptomatic women at intermediate to high pretest risk of CVD. Furthermore, the study underscores the prognostic utility of stress CMR in women, which may be performed without ionizing radiation and may significantly reduce rates of ICA and health care costs. Given the retrospective, post hoc nature of the current study, prospective clinical trials are needed to evaluate the optimal approach in the evaluation and management for patients presenting with suspected ischemic heart disease and to further define the role of stress CMR.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Angina, Unstable, Chest Pain, Coronary Angiography, Coronary Artery Bypass, Cost-Benefit Analysis, Diagnostic Imaging, Heart Failure, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Outcome Assessment, Health Care, Perfusion, Perfusion Imaging, Radiation, Ionizing, Women
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