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CLINICAL STUDIES

Comparative prognostic value of automatic quantitative analysis versus semiquantitative visual analysis of exercise myocardial perfusion single-photon emission computed tomography

Daniel S. Berman, MD, FACC^*, Xingping Kang, MD^b, Kenneth F. Van Train, MS^b, Howard C. Lewin, MD^b, Ishac Cohen, PhD^b, Joseph Areeda^b, John D. Friedman, MD, FACC^b, Guido Germano, PhD, FACC^b, Leslee J. Shaw, PhD and Rory Hachamovitch, MD

^* Department of Imaging (Division of Nuclear Medicine), Department of Medicine (Division of Cardiology), and CSMC Burns & Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
^b Department of Medicine, University of California Los Angeles, School of Medicine, Los Angeles, California, USA
Department of Medicine (Division of Cardiology), New York Hospital-Cornell Medical Center, New York, New York, USA
Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA

Manuscript received March 17, 1998; revised manuscript received July 21, 1998, accepted August 6, 1998.

Address for correspondence: Daniel S. Berman, MD, Department of Imaging, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Room A042, Los Angeles, California 90048
bermand{at}cshs.org

Objectives. The purpose of this study was to determine the prognostic value of automatic quantitative analysis in exercise dual-isotope myocardial perfusion single-photon emission computed tomography (SPECT) and to compare the prognostic value of quantitative analysis to semiquantitative visual SPECT analysis.

Background. Extent, severity and reversibility of exercise myocardial perfusion defects have been shown to correlate with prognosis. However, most studies examining the prognostic value of SPECT in chronic coronary artery disease (CAD) have been based on visual analysis by experts.

Methods. We studied 1,043 consecutive patients with known or suspected CAD who underwent rest Tl-201/exercise Tc-99m sestamibi dual-isotope myocardial perfusion SPECT and were followed up for at least 1 year (mean 20.0 ± 3.7 months). After censoring 59 patients with early coronary artery bypass grafting or percutaneous transluminal coronary angioplasty, <60 days after nuclear testing, the final population consisted of 984 patients (36% women, mean age 63 ± 12 years).

Results. During the follow-up period, 28 hard events (14 cardiac deaths, 14 nonfatal myocardial infarctions) occurred. Patients with higher defect extent (>10%), severity (>150) and reversibility (>5%) by quantitative SPECT defect analysis, as well as those with an abnormal scan (>2 abnormal segments, summed stress score >4 and summed difference score >2) by semiquantitative visual SPECT analysis, had a significantly higher hard event rate compared to patients with a normal scan (p < 0.001). With both visual and quantitative analyses, hard event rates of approximately 1% with normal scans and 5% with abnormal scans (p > 0.05) were observed over the 20-month follow-up period. A Cox proportional hazards regression model showed that chi-square increased similarly with the addition of quantitative defect extent and visual summed stress score variables after considering both clinical and exercise variables (improvement chi-square = 11 for both, p < 0.0007). There were no significant differences in the areas under receiver operating characteristic curves between quantitative and visual analysis (p > 0.70). Linear regression analysis also indicated that quantitative assessments correlated well with visual semiquantitative assessments.

Conclusions. The findings of this study indicate that automatic quantitative analysis of exercise stress myocardial perfusion SPECT is similar to semiquantitative expert visual analysis for prognostic stratification. These findings may be of particular clinical importance in laboratories with less experienced visual interpreters.

Abbreviations and Acronyms   CAD = coronary artery disease   CEqual = Cedars-Emory quantitative analysis software   ECG = electrocardiographic   ETT = exercise treadmill test   LV = left ventricle   ROC = receiver operating characteristic   SDS = summed difference score   SPECT = single-photon emission computed tomography   SRS = summed rest score   SSS = summed stress score   TID = transient ischemic dilation

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