CLINICAL STUDY: EXERCISE TESTING
When to stress patients after coronary artery bypass surgery?
Risk stratification in patients early and late post-CABG using stress myocardial perfusion SPECT: implications of apppropriate clinical strategies
Michael J. Zellweger, MD*,
Howard C. Lewin, MD*,
Shenghan Lai, MD, PhD ,
Eric A. Dubois, MD, PhD*,
John D. Friedman, MD, FACC*,
Guido Germano, PhD, FACC*,
Xingping Kang, MD*,
Tali Sharir, MD* and
Daniel S. Berman, MD, FACC*
* Department of Imaging (Division of Nuclear Medicine), Medicine (Division of Cardiology), and Artificial Intelligence in Medicine Program, Cedars–Sinai Medical Center; the CSMC Burns and Allen Research Institute, and the Department of Medicine, University of California Los Angeles, School of Medicine, Los Angeles, California, USA
University of Miami, Miami, Florida, USA
Manuscript received July 30, 1999;
revised manuscript received August 14, 2000,
accepted September 27, 2000.
Reprint requests and correspondence: Dr. Daniel S. Berman, Cedars–Sinai Medical Center, 8700 Beverly Boulevard, Room A-041, Los Angeles, California 90048
bermand{at}cshs.org
OBJECTIVES
The study compared the prognostic significance of myocardial perfusion single-photon emission computed tomography (SPECT) (MPS) in patients early and late after coronary artery bypass graft surgery (CABG).
BACKGROUND
The long-term effectiveness of CABG is limited by graft stenosis. The greatest incidence of graft occlusion occurs between five and eight years after surgery. However, little is known regarding the appropriate time to stress patients post-CABG with respect to risk stratification.
METHODS
We identified 1,765 patients, who underwent MPS 7.1 ± 5.0 years post-CABG. All patients underwent rest Tl-201/stress Tc-99m sestamibi MPS and were followed up  1 year after testing. Patients with early CABG or PTCA (<60 days after MPS) were censored. The prognostic population consisted of 1,544 patients. A semiquantitative visual analysis employing a 20-segment model was used to define summed stress score (SSS), summed rest score (SRS), summed difference score (SDS), and the number of nonreversible segments (NRS).
RESULTS
During follow-up, 53 cardiac deaths (CD) occurred. There was a significant increase in annual CD rates as a function of SSS. A multivariate analysis identified age, ischemia (SDS), and infarct size (NRS) as independent predictors of CD. Nuclear variables added incremental value to prescan information. The annual CD rate was relatively low (1.3%) in patients  5 years post-CABG. In this subgroup only age and infarct size (NRS) were predictive of CD.
CONCLUSION
MPS is strongly predictive of subsequent CD in post-CABG patients and adds incremental value over clinical and treadmill test information. Our data suggest that symptomatic patients 5 years and all patients >5 years post-CABG may benefit from testing.
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Abbreviations and Acronyms
| | CABG | = coronary artery bypass graft surgery | | CAD | = coronary artery disease | | CD | = cardiac death | | LVEF | = left ventricular ejection fraction | | MPS | = myocardial perfusion SPECT | | NRS | = nonreversible segments | | PTCA | = percutaneous transluminal coronary angioplasty | | SDS | = summed difference score | | SPECT | = single-photon emission computed tomography | | SRS | = summed rest score | | SSS | = summed stress score |
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