Use of Myocardial Perfusion Imaging to Guide Prognosis and Management in Older Adults: Is There an Age Limit?
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Patel Krishna K, Miller Robert J H, Lemley Mark, Shanbhag Aakash, Ramirez Giselle, Liang Joanna X, Acampa Wanda, Bateman Timothy M, Dorbala Sharmila, Einstein Andrew J, Hauser M Timothy, Kaufmann Philipp A, Feher Attila, Miller Edward J, Ruddy Terrence D, Sharir Tali, Halcox Julian, Martins Monica, Chareonthaitawee Panithaya, Wopperer Samuel, Rosamond Thomas L, Packard Rene R S, Al-Mallah Mouaz, Carvajal-Juarez Isabel, Alexanderson Erick, Knight Stacey, Buechel Ronny R, Slipczuk Leandro, Dey Damini, Berman Daniel S, Di Carli Marcelo, Slomka Piotr J
Аннотация
METHODS: We included 73 038 patients who underwent single photon emission computed tomography (n=45 252) or positron emission tomography (n=27 786) myocardial perfusion imaging across 20 sites from 2009 to 2024. ER was defined as revascularization within 90 days post-myocardial perfusion imaging. Propensity score-adjusted Cox models evaluated the interaction between age, ischemic burden (myocardial flow reserve for positron emission tomography), and ER for the primary outcome of all-cause death or nonfatal myocardial infarction.
RESULTS: Median age was 66 years; 45.3% were <65, 31.5% were 65 to 74, 19.1% were 75 to 84, and 4.2% were ≥85. ER was performed in 6.1%, rising to 7.0% in those aged 75 to 84 years and decreasing to 6.5% in those aged ≥85 years. During a median follow-up of 3.7 years, 10 757 deaths/myocardial infarctions occurred. Increasing ischemia was associated with lower event rates after ER versus medical therapy across most age groups, with no significant continuous age-ischemia-ER interaction (P=0.748). In an exploratory analysis of 3031 patients aged ≥85 years, this association appeared attenuated (hazard ratio for ischemia >10%: 0.90 [0.64-1.26]), although precision was limited, likely reflecting, in part, the small number of patients undergoing ER (n=198). Among positron emission tomography patients, the myocardial flow reserve×ER association did not vary with age (3-way interaction P=0.689). In analyses excluding patients with ER, ischemia remained prognostic in all age groups, though its associated risk declined with advancing age.
CONCLUSIONS: Ischemia remains prognostic across all ages and may help identify candidates who have improved outcomes with ER. In an exploratory analysis, this association appeared attenuated in patients aged ≥85 years, a hypothesis-generating observation. Positron emission tomography-derived myocardial flow reserve may provide complementary physiological information for treatment selection in older adults.