Incremental value of prognostic testing in patients with known or suspected ischemic heart disease: a basis for optimal utilization of exercise technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography

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J Am Coll Cardiol, 1995; 26:639-647
© 1995 by the American College of Cardiology Foundation

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Incremental value of prognostic testing in patients with known or suspected ischemic heart disease: a basis for optimal utilization of exercise technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography

DS Berman, R Hachamovitch, H Kiat, I Cohen, JA Cabico, FP Wang, JD Friedman, G Germano, K Van Train, and GA Diamond

Department of Imaging (Division of Nuclear Medicine), Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.

OBJECTIVES. This study assessed the incremental prognostic implications of normal and equivocal exercise technetium-99m (Tc-99m) sestamibi single-photon emission computed tomography (SPECT) and sought to determine its incremental prognostic value, impact on patient management and cost implications. BACKGROUND. The prognostic implications of Tc-99m sestamibi SPECT are not well defined, and risk stratification using this test has not been explored. METHODS. We studied 1,702 patients referred for exercise Tc-99m sestamibi SPECT who were followed up for a mean (+/- SD) of 20 +/- 5 months. Patients with previous percutaneous transluminal coronary angioplasty or coronary artery bypass surgery were excluded. The SPECT studies were assessed using semiquantitative visual analysis. Cardiac death and myocardial infarction were considered "hard" events, and coronary angioplasty and bypass surgery > 60 days after testing were considered "soft" events. RESULTS. Of the 1,702 patients studied, 1,131 had normal or equivocal scan results. A total of 10 events occurred in this group (1 cardiac death and 1 myocardial infarction [0.2% hard events]; 4 coronary angioplasty and 4 bypass surgery procedures [0.7% soft events]). The rates of hard events and referral to catheterization after SPECT were similarly low in patients with a low (< 0.15), intermediate (0.15 to 0.85) and high (> 0.85) post-exercise treadmill test (ETT) likelihood of coronary artery disease. With respect to scan type, patients with normal, probably normal or equivocal scan results had similarly low hard event rates. In the 571 patients with abnormal scan results, there were 43 hard events (7.5%) and 42 soft events (7.4%) (p < 0.001 vs. 1,131 patients with normal scan results for both). When the complete spectrum of scan responses was considered, SPECT provided incremental prognostic value in all patient subgroups analyzed. However, the nuclear scan was cost-effective only in patients with interpretable exercise ECG responses and an intermediate to high post-ETT likelihood of coronary artery disease and in those with uninterpretable exercise ECG responses and an intermediate to high pre-ETT likelihood of coronary artery disease. CONCLUSIONS. Normal or equivocal exercise Tc-99m sestamibi study results are associated with a benign prognosis, even in patients with a high likelihood of coronary artery disease. Although incremental prognostic value is added by nuclear testing in all patient subgroups, a testing strategy incorporating nuclear testing proved to be cost-effective only in the groups with an intermediate to high likelihood of coronary artery disease before scanning.

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				D. G. Katritsis, J. P.A. Ioannidis, T. P. Wharton Jr., V. A. Umans, H. O. Peels, A. P. Shah, D. M. Shavelle, W. J. French, S. De Servi, H. Kiat, et al. PCI for Stable Coronary Disease N. Engl. J. Med., July 26, 2007; 357(4): 414 - 418. [Full Text] [PDF]

				A. Rozanski, H. Gransar, N. D. Wong, L. J. Shaw, R. Miranda-Peats, D. Polk, S. W. Hayes, J. D. Friedman, and D. S. Berman Clinical Outcomes After Both Coronary Calcium Scanning and Exercise Myocardial Perfusion Scintigraphy J. Am. Coll. Cardiol., March 27, 2007; 49(12): 1352 - 1361. [Abstract] [Full Text] [PDF]

				J. A. Goldstein, M. J. Gallagher, W. W. O'Neill, M. A. Ross, B. J. O'Neil, and G. L. Raff A Randomized Controlled Trial of Multi-Slice Coronary Computed Tomography for Evaluation of Acute Chest Pain J. Am. Coll. Cardiol., February 27, 2007; 49(8): 863 - 871. [Abstract] [Full Text] [PDF]

				L. D. Metz, M. Beattie, R. Hom, R. F. Redberg, D. Grady, and K. E. Fleischmann The Prognostic Value of Normal Exercise Myocardial Perfusion Imaging and Exercise Echocardiography: A Meta-Analysis J. Am. Coll. Cardiol., January 16, 2007; 49(2): 227 - 237. [Abstract] [Full Text] [PDF]

				K. Yoshinaga, B. J.W. Chow, K. Williams, L. Chen, R. A. deKemp, L. Garrard, A. Lok-Tin Szeto, M. Aung, R. A. Davies, T. D. Ruddy, et al. What is the Prognostic Value of Myocardial Perfusion Imaging Using Rubidium-82 Positron Emission Tomography? J. Am. Coll. Cardiol., September 5, 2006; 48(5): 1029 - 1039. [Abstract] [Full Text] [PDF]

				D. S. Berman, R. Hachamovitch, L. J. Shaw, J. D. Friedman, S. W. Hayes, L. E.J. Thomson, D. S. Fieno, G. Germano, N. D. Wong, X. Kang, et al. Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Noninvasive Risk Stratification and a Conceptual Framework for the Selection of Noninvasive Imaging Tests in Patients with Known or Suspected Coronary Artery Disease J. Nucl. Med., July 1, 2006; 47(7): 1107 - 1118. [Abstract] [Full Text] [PDF]

				X. Kang, L. J. Shaw, S. W. Hayes, R. Hachamovitch, A. Abidov, I. Cohen, J. D. Friedman, L. E.J. Thomson, D. Polk, G. Germano, et al. Impact of Body Mass Index on Cardiac Mortality in Patients With Known or Suspected Coronary Artery Disease Undergoing Myocardial Perfusion Single-Photon Emission Computed Tomography J. Am. Coll. Cardiol., April 4, 2006; 47(7): 1418 - 1426. [Abstract] [Full Text] [PDF]

				P. Sorajja, P. Chareonthaitawee, N. Rajagopalan, T. D. Miller, R. L. Frye, D. O. Hodge, and R. J. Gibbons Improved Survival in Asymptomatic Diabetic Patients With High-Risk Spect Imaging Treated With Coronary Artery Bypass Grafting Circulation, August 30, 2005; 112(9_suppl): I-311 - I-316. [Abstract] [Full Text] [PDF]

				T. H. Marwick Can we Justify the Cost of Echocardiography? Lessons from Outcomes Research Eur J Echocardiogr, June 1, 2005; 6(3): 155 - 163. [Abstract] [Full Text] [PDF]

				L. J. Shaw, R. C. Hendel, M. Cerquiera, J. H. Mieres, N. Alazraki, E. Krawczynska, S. Borges-Neto, J. Maddahi, and C. N. Bairey Merz Ethnic Differences in the Prognostic Value of Stress Technetium-99m Tetrofosmin Gated Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging J. Am. Coll. Cardiol., May 3, 2005; 45(9): 1494 - 1504. [Abstract] [Full Text] [PDF]

				U. S. Valeti, T. D. Miller, D. O. Hodge, and R. J. Gibbons Exercise Single-Photon Emission Computed Tomography Provides Effective Risk Stratification of Elderly Men and Elderly Women Circulation, April 12, 2005; 111(14): 1771 - 1776. [Abstract] [Full Text] [PDF]

				R. Hachamovitch, S. W. Hayes, J. D. Friedman, I. Cohen, and D. S. Berman A prognostic score for prediction of cardiac mortality risk after adenosine stress myocardial perfusion scintigraphy J. Am. Coll. Cardiol., March 1, 2005; 45(5): 722 - 729. [Abstract] [Full Text] [PDF]

				R. Hachamovitch and M. F. Di Carli Are Human Readers Needed for Prognostication from Stress Myocardial Perfusion SPECT? Using Outcomes Research to Validate Medical Technology J. Nucl. Med., February 1, 2005; 46(2): 194 - 197. [Full Text] [PDF]

				W. D. Leslie, S. A. Tully, M. S. Yogendran, L. M. Ward, K. A. Nour, and C. J. Metge Prognostic Value of Automated Quantification of 99mTc-Sestamibi Myocardial Perfusion Imaging J. Nucl. Med., February 1, 2005; 46(2): 204 - 211. [Abstract] [Full Text] [PDF]

				M. F. Di Carli and R. Hachamovitch Should we screen for occult coronary artery disease among asymptomatic patients with diabetes? J. Am. Coll. Cardiol., January 4, 2005; 45(1): 50 - 53. [Abstract] [Full Text] [PDF]

				L. Liao, W. T. Smith IV, R. H. Tuttle, L. K. Shaw, R. E. Coleman, and S. Borges-Neto Prediction of Death and Nonfatal Myocardial Infarction in High-Risk Patients: A Comparison Between the Duke Treadmill Score, Peak Exercise Radionuclide Angiography, and SPECT Perfusion Imaging J. Nucl. Med., January 1, 2005; 46(1): 5 - 11. [Abstract] [Full Text] [PDF]

				T. J. Meine, M. W. Hanson, and S. Borges-Neto The Additive Value of Combined Assessment of Myocardial Perfusion and Ventricular Function Studies J. Nucl. Med., October 1, 2004; 45(10): 1721 - 1724. [Abstract] [Full Text] [PDF]

				A. Abidov, R. Hachamovitch, A. Rozanski, S. W. Hayes, M. M. Santos, M. G. Sciammarella, I. Cohen, J. Gerlach, J. D. Friedman, G. Germano, et al. Prognostic implications of atrial fibrillation in patients undergoing myocardial perfusion single-photon emission computed tomography J. Am. Coll. Cardiol., September 1, 2004; 44(5): 1062 - 1070. [Abstract] [Full Text] [PDF]

				S. Borges-Neto, R. H. Tuttle, L. K. Shaw, W. T. Smith IV, D. Jain, R. E. Coleman, and D. Whellan Outcome Prediction in Patients at High Risk for Coronary Artery Disease: Comparison between 99mTc Tetrofosmin and 99mTc Sestamibi Radiology, July 1, 2004; 232(1): 58 - 65. [Abstract] [Full Text] [PDF]

				F. Aboul-Enein, S. Kar, S. W. Hayes, M. Sciammarella, A. Abidov, R. Makkar, J. D. Friedman, N. Eigler, and D. S. Berman Influence of Angiographic Collateral Circulation on Myocardial Perfusion in Patients with Chronic Total Occlusion of a Single Coronary Artery and No Prior Myocardial Infarction J. Nucl. Med., June 1, 2004; 45(6): 950 - 955. [Abstract] [Full Text] [PDF]

				M. J Zellweger, R. Hachamovitch, X. Kang, S. W Hayes, J. D Friedman, G. Germano, M. E Pfisterer, and D. S Berman Prognostic relevance of symptoms versus objective evidence of coronary artery disease in diabetic patients Eur. Heart J., April 1, 2004; 25(7): 543 - 550. [Abstract] [Full Text] [PDF]

				P. J. Slomka, H. Nishina, D. S. Berman, X. Kang, J. D. Friedman, S. W. Hayes, U. E. Aladl, and G. Germano Automatic Quantification of Myocardial Perfusion Stress-Rest Change: A New Measure of Ischemia J. Nucl. Med., February 1, 2004; 45(2): 183 - 191. [Abstract] [Full Text] [PDF]

				G. A. Beller and D. D. Watson Risk stratification using stress myocardial perfusion imaging: don't neglect the value of clinical variables J. Am. Coll. Cardiol., January 21, 2004; 43(2): 209 - 212. [Full Text] [PDF]

				A. Abidov, J. J. Bax, S. W. Hayes, R. Hachamovitch, I. Cohen, J. Gerlach, X. Kang, J. D. Friedman, G. Germano, and D. S. Berman Transient ischemic dilation ratio of the left ventricle is a significant predictor of future cardiac events in patients with otherwise normal myocardial perfusion SPECT J. Am. Coll. Cardiol., November 19, 2003; 42(10): 1818 - 1825. [Abstract] [Full Text] [PDF]

				S. Isobe, H. Izawa, Y. Takeichi, M. Nonokawa, M. Nanasato, A. Ando, K. Kato, M. Ikeda, T. Murohara, and M. Yokota Relationship Between Exercise-Induced Myocardial Ischemia and Reduced Left Ventricular Distensibility in Patients with Nonobstructive Hypertrophic Cardiomyopathy J. Nucl. Med., November 1, 2003; 44(11): 1717 - 1724. [Abstract] [Full Text] [PDF]

				W. J. Kang, D. S. Lee, J. C. Paeng, K.-B. Kim, J.-K. Chung, and M. C. Lee Prognostic Value of Rest 201Tl-Dipyridamole Stress 99mTc-Sestamibi Gated SPECT for Predicting Patient-Based Clinical Outcomes After Bypass Surgery in Patients with Ischemic Left Ventricular Dysfunction J. Nucl. Med., November 1, 2003; 44(11): 1735 - 1740. [Abstract] [Full Text] [PDF]

				C. L. Grines, M. W. Watkins, J. J. Mahmarian, A. E. Iskandrian, J. J. Rade, P. Marrott, C. Pratt, N. Kleiman, and for the Angiogenic GENe Therapy (AGENT-2) Study Gr A randomized, double-blind, placebo-controlled trial of Ad5FGF-4 gene therapy and its effect on myocardial perfusion in patients with stable angina J. Am. Coll. Cardiol., October 15, 2003; 42(8): 1339 - 1347. [Abstract] [Full Text] [PDF]

				S. W. Hayes, A. De Lorenzo, R. Hachamovitch, S. C. Dhar, P. Hsu, I. Cohen, J. D. Friedman, X. Kang, and D. S. Berman Prognostic Implications of Combined Prone and Supine Acquisitions in Patients with Equivocal or Abnormal Supine Myocardial Perfusion SPECT J. Nucl. Med., October 1, 2003; 44(10): 1633 - 1640. [Abstract] [Full Text] [PDF]

				D. S. Lee, J. C. Paeng, and M. C. Lee Implication of Prognostically Significant Negative Results on Prone SPECT J. Nucl. Med., October 1, 2003; 44(10): 1641 - 1643. [Full Text] [PDF]

				M. J. Zellweger, M. Weinbacher, A. W. Zutter, R. V. Jeger, J. Mueller-Brand, C. Kaiser, P. T. Buser, and M. E. Pfisterer Long-term outcome of patients with silent versus symptomatic ischemia six months after percutaneous coronary intervention and stenting J. Am. Coll. Cardiol., July 2, 2003; 42(1): 33 - 40. [Abstract] [Full Text] [PDF]