Author + information
- Received January 9, 2020
- Revision received February 19, 2020
- Accepted February 25, 2020
- Published online July 6, 2020.
- Yin Ge, MDa,
- Ankur Pandya, PhDb,
- Kevin Steel, DOc,
- Scott Bingham, MDd,
- Michael Jerosch-Herold, PhDa,
- Yi-Yun Chen, MD, MPHa,
- J. Ronald Mikolich, MDe,
- Andrew E. Arai, MDf,
- W. Patricia Bandettini, MDf,
- Amit R. Patel, MDg,
- Afshin Farzaneh-Far, MD, PhDh,
- John F. Heitner, MDi,
- Chetan Shenoy, MDj,
- Steve W. Leung, MDk,
- Jorge A. Gonzalez, MDl,
- Dipan J. Shah, MDm,
- Subha V. Raman, MDn,
- Victor A. Ferrari, MDo,
- Jeanette Schulz-Menger, MDp,
- Rory Hachamovitch, MD, PhDq,
- Matthias Stuber, PhDr,
- Orlando P. Simonetti, PhDn and
- Raymond Y. Kwong, MD, MPHa,∗ ()
- aNoninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts
- bDepartment of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- cCardiology Division, San Antonio Military Medical Center, San Antonio, Texas
- dRevere Health, Provo, Utah
- eDepartment of Cardiovascular Medicine, Sharon Regional Health System, Sharon, Pennsylvania
- fNational Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
- gSection of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
- hDivision of Cardiology, University of Illinois at Chicago, Chicago, Illinois
- iDivision of Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York
- jCardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
- kGill Heart and Vascular Institute, Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
- lDivision of Cardiology and Radiology, Scripps Clinic, La Jolla, California
- mHouston Methodist DeBakey Heart and Vascular Center, Houston, Texas
- nDivision of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
- oCardiovascular Division, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- pWorking Group on Cardiovascular Magnetic Resonance at ECRC, Charité, Medical Faculty of the Humboldt-University Berlin and Helios Clinics, Berlin, Germany, Partner Site DZHK
- qDivision of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
- rDepartment of Radiology, University Hospital and University of Lausanne, Lausanne, Switzerland
- ↵∗Address for correspondence:
Dr. Raymond Y. Kwong, Brigham and Women’s Hospital, Cardiovascular Division, Department of Medicine, Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115.
Objectives The aim of this study was to compare, using results from the multicenter SPINS (Stress CMR Perfusion Imaging in the United States) study, the incremental cost-effectiveness of a stress cardiovascular magnetic resonance (CMR)–first strategy against 4 other clinical strategies for patients with stable symptoms suspicious for myocardial ischemia: 1) immediate x-ray coronary angiography (XCA) with selective fractional flow reserve for all patients; 2) single-photon emission computed tomography; 3) coronary computed tomographic angiography with selective computed tomographic fractional flow reserve; and 4) no imaging.
Background Stress CMR perfusion imaging has established excellent diagnostic utility and prognostic value in coronary artery disease (CAD), but its cost-effectiveness in current clinical practice has not been well studied in the United States.
Methods A decision analytic model was developed to project health care costs and lifetime quality-adjusted life years (QALYs) for symptomatic patients at presentation with a 32.4% prevalence of obstructive CAD. Rates of clinical events, costs, and quality-of-life values were estimated from SPINS and other published research. The analysis was conducted from a U.S. health care system perspective, with health and cost outcomes discounted annually at 3%.
Results Using hard cardiovascular events (cardiovascular death or acute myocardial infarction) as the endpoint, total costs per person were lowest for the no-imaging strategy ($16,936) and highest for the immediate XCA strategy ($20,929). Lifetime QALYs were lowest for the no-imaging strategy (12.72050) and highest for the immediate XCA strategy (12.76535). The incremental cost-effectiveness ratio for the CMR-based strategy compared with the no-imaging strategy was $52,000/QALY, whereas the incremental cost-effectiveness ratio for the immediate XCA strategy was $12 million/QALY compared with CMR. Results were sensitive to variations in model inputs for prevalence of disease, hazard rate ratio for treatment of CAD, and annual discount rate.
Conclusions Prior to invasive XCA, stress CMR can be a cost-effective gatekeeping tool in patients at risk for obstructive CAD in the United States. (Stress CMR Perfusion Imaging in the United States [SPINS] Study; NCT03192891
The SPINS registry was funded by the Society for Cardiovascular Magnetic Resonance, using a research grant jointly sponsored by Siemens Healthineers and Bayer. These sponsors to the Society for Cardiovascular Magnetic Resonance provided financial support for the study but did not play a role in study design, data collection, analysis, interpretation, or manuscript drafting. Dr. Arai has research agreements with Siemens, Bayer, and Circle Cardiovascular Imaging. Dr. Bandettini is the principal investigator of one of the Bayer-sponsored GadaCAD2 (Gadavist-Enhanced Cardiac Magnetic Resonance Imaging to Detect Coronary Artery Disease) sites. Dr. Patel has received a research grant from and served on the Speakers Bureau of Astellas. Drs. Raman and Simonetti both receive institutional research support from Siemens. Dr. Schulz-Menger has research agreements with Siemens; and serves on the Advisory Board of Bayer. Dr. Stuber has received nonmonetary research support form Siemens Healthineers. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Cardiovascular Imaging author instructions page.
- Received January 9, 2020.
- Revision received February 19, 2020.
- Accepted February 25, 2020.
- 2020 American College of Cardiology Foundation
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