CLINICAL STUDY: CARDIAC IMAGING
Determinants of risk and its temporal variation in patients with normal stress myocardial perfusion scans
What is the warranty period of a normal scan?
Rory Hachamovitch, MD, MSc, FACC*,
Sean Hayes, MD ,
John D. Friedman, MD, FACC,
Ishac Cohen, PhD,
Leslee J. Shaw, PhD ,
Guido Germano, PhD, MBA, FACC and
Daniel S. Berman, MD, FACC,*
* Division of Cardiovascular Medicine, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
Departments of Imaging (Division of Nuclear Medicine) and Medicine (Division of Cardiology), Cedars-Sinai Medical Center Burns and Allen Research Institute, Department of Medicine, UCLA School of Medicine, Los Angeles, California, USA
Atlanta Cardiovascular Research Institute, Atlanta, Georgia, USA
Manuscript received July 5, 2002;
revised manuscript received October 22, 2002,
accepted November 11, 2002.
* Reprint requests and correspondence: Dr. Daniel S. Berman, Cedars-Sinai Medical Center, Room A042, 8700 Beverly Boulevard, Los Angeles, California 90048, USA.
Daniel.berman{at}cshs.org
OBJECTIVES: The aim of this study was to determine the predictors of risk and the temporal characteristics of risk associated with normal myocardial perfusion single photon emission computed tomography (MPS).
BACKGROUND: No empiric data exist regarding predictors of risk after normal MPS and their temporal characteristics.
METHODS: Follow-up (mean: 665 ± 200 days, 96% complete) of 7,376 consecutive patients with normal exercise or adenosine MPS identified 78 hard events (HE) (45 cardiac deaths, 33 non-fatal myocardial infarction; 1.1% cumulative HE rate, 0.6%/year). Cox proportional hazards analysis was used to identify predictors of HE. Parametric survival analysis was used to model predicted time to HE.
RESULTS: The HE rates were greater in patients with versus without previous coronary artery disease (CAD). The Cox proportional hazards model identified pharmacologic stress, known CAD, diabetes mellitus (DM), male gender, and increasing age, with interactions between stress type and previous CAD (lower risk in patients without previous CAD undergoing exercise stress vs. all others) and between DM and gender (higher risk in DM females vs. all others) as the model most predictive of HE. The highest risk subgroups had a maximal event rate of 1.4% to 1.8%/year. Parametric survival models revealed that in patients without previous CAD the level of risk was uniform with time, but in patients with known CAD, risk increased with time (e.g., risk in the first year was less than in the second year, hence, a dynamic temporal component of risk was present).
CONCLUSIONS: Multiple clinical factors add incremental prognostic value in patients with normal MPS, affecting their risk and its temporal pattern, and may alter the appropriate timing of repeat testing, hence establishing the existence of a "warranty" period for normal MPS studies.
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Abbreviations and Acronyms
| | CAD | | coronary artery disease | | ECG | | electrocardiogram | | ETT | | exercise tolerance test | | HE | | hard event | | MI | | myocardial infarction | | MPHR | | maximal predicted heart rate | | MPS | | myocardial perfusion single photon emission computed tomography | | PTCA | | percutaneous transluminal coronary angioplasty | | SPECT | | single photon emission computed tomography | | Tc | | technetium | | Tl | | thallium |
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(2009)
j.jacc.2009.09.022v1.
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|
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54(20):
1872 - 1882.
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|
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2(6):
429 - 436.
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|
|
|
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|
J. M. Bourque, B. H. Holland, D. D. Watson, and G. A. Beller
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J. Am. Coll. Cardiol.,
August 4, 2009;
54(6):
538 - 545.
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|
|
|
|
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|
M. Hadamitzky, B. Freissmuth, T. Meyer, F. Hein, A. Kastrati, S. Martinoff, A. Schomig, and J. Hausleiter
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J. Am. Coll. Cardiol. Img.,
April 1, 2009;
2(4):
404 - 411.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Stirrup, K. Wechalekar, A. Maenhout, and C. Anagnostopoulos
Cardiac radionuclide imaging in stable coronary artery disease and acute coronary syndromes
Br. Med. Bull.,
March 1, 2009;
89(1):
63 - 78.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. M. van Werkhoven, J. D. Schuijf, O. Gaemperli, J. W. Jukema, E. Boersma, W. Wijns, P. Stolzmann, H. Alkadhi, I. Valenta, M. P.M. Stokkel, et al.
Prognostic value of multislice computed tomography and gated single-photon emission computed tomography in patients with suspected coronary artery disease.
J. Am. Coll. Cardiol.,
February 17, 2009;
53(7):
623 - 632.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Hakeem, S. Bhatti, K. S. Dillie, J. R. Cook, Z. Samad, M. D. Roth-Cline, and S. M. Chang
Predictive Value of Myocardial Perfusion Single-Photon Emission Computed Tomography and the Impact of Renal Function on Cardiac Death
Circulation,
December 9, 2008;
118(24):
2540 - 2549.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. Acampa, M. Petretta, L. Evangelista, G. Nappi, L. Luongo, M. P. Petretta, and A. Cuocolo
Stress cardiac single-photon emission computed tomographic imaging late after coronary artery bypass surgery for risk stratification and estimation of time to cardiac events
J. Thorac. Cardiovasc. Surg.,
July 1, 2008;
136(1):
46 - 51.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. P. Schenker, S. Dorbala, E. C. T. Hong, F. J. Rybicki, R. Hachamovitch, R. Y. Kwong, and M. F. Di Carli
Interrelation of Coronary Calcification, Myocardial Ischemia, and Outcomes in Patients With Intermediate Likelihood of Coronary Artery Disease: A Combined Positron Emission Tomography/Computed Tomography Study
Circulation,
April 1, 2008;
117(13):
1693 - 1700.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. Marcassa, J. J. Bax, F. Bengel, B. Hesse, C. L. Petersen, E. Reyes, R. Underwood, and on behalf of the European Council of Nuclear Cardi
Clinical value, cost-effectiveness, and safety of myocardial perfusion scintigraphy: a position statement
Eur. Heart J.,
February 2, 2008;
29(4):
557 - 563.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. J. Bax and J. D. Schuijf
Can Coronary Calcification Define the Warranty Period of a Normal Myocardial Perfusion Study?
Mayo Clin. Proc.,
January 1, 2008;
83(1):
10 - 12.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. W. Askew, T. D. Miller, P. A. Araoz, J. F. Breen, D. O. Hodge, and R. J. Gibbons
Abnormal Electron Beam Computed Tomography Results: The Value of Repeating Myocardial Perfusion Single-Photon Emission Computed Tomography in the Ongoing Assessment of Coronary Artery Disease
Mayo Clin. Proc.,
January 1, 2008;
83(1):
17 - 22.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. J. Bax, L. H. Young, R. L. Frye, R. O. Bonow, H. O. Steinberg, and E. J. Barrett
Screening for Coronary Artery Disease in Patients With Diabetes
Diabetes Care,
October 1, 2007;
30(10):
2729 - 2736.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Boyar
Cardiovascular Prevention in Asymptomatic Diabetic Patients
J. Am. Coll. Cardiol.,
September 18, 2007;
50(12):
1203 - 1203.
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Pundziute, J. D. Schuijf, J. W. Jukema, E. Boersma, A. J.H.A. Scholte, L. J.M. Kroft, E. E. van der Wall, and J. J. Bax
Noninvasive Assessment of Plaque Characteristics With Multislice Computed Tomography Coronary Angiography in Symptomatic Diabetic Patients
Diabetes Care,
May 1, 2007;
30(5):
1113 - 1119.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. J. Bax, S. E. Inzucchi, R. O. Bonow, J. D. Schuijf, M. R. Freeman, E. J. Barrett, and on behalf of the Global Dialogue Group for the Eva
Cardiac Imaging for Risk Stratification in Diabetes
Diabetes Care,
May 1, 2007;
30(5):
1295 - 1304.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A H Gershlick, M de Belder, J Chambers, D Hackett, R Keal, A Kelion, S Neubauer, D J Pennell, M Rothman, M Signy, et al.
Role of non-invasive imaging in the management of coronary artery disease: an assessment of likely change over the next 10 years. A report from the British Cardiovascular Society Working Group
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April 1, 2007;
93(4):
423 - 431.
[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]
|
|
|
|
|
|
|
L. J. Shaw, D. Polk, and C. N. Bairey Merz
Assessing Mature Technology: What Is the Effect of High-Quality Risk Stratification Evidence With Exercise Echocardiography and Single-Photon Emission Computed Tomography Imaging?
J. Am. Coll. Cardiol.,
January 16, 2007;
49(2):
238 - 239.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. J. Bax, R. O. Bonow, D. Tschope, S. E. Inzucchi, E. Barrett, and on behalf of the Global Dialogue Group for the Eva
The Potential of Myocardial Perfusion Scintigraphy for Risk Stratification of Asymptomatic Patients With Type 2 Diabetes
J. Am. Coll. Cardiol.,
August 15, 2006;
48(4):
754 - 760.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. V. Anand, E. Lim, A. Lahiri, and J. J. Bax
The role of non-invasive imaging in the risk stratification of asymptomatic diabetic subjects
Eur. Heart J.,
April 2, 2006;
27(8):
905 - 912.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Funk, D. L. Kirch, J. E. Koss, E. Botvinick, and B. H. Hasegawa
A Novel Approach to Multipinhole SPECT for Myocardial Perfusion Imaging
J. Nucl. Med.,
April 1, 2006;
47(4):
595 - 602.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. R. Albers, M. Z. Krichavsky, and G. J. Balady
Stress Testing in Patients With Diabetes Mellitus: Diagnostic and Prognostic Value
Circulation,
January 31, 2006;
113(4):
583 - 592.
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Reyes and S. R. Underwood
Myocardial perfusion scintigraphy: an important step between clinical assessment and coronary angiography in patients with stable chest pain
Eur. Heart J.,
January 1, 2006;
27(1):
3 - 4.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Pellegrino, G. Storto, P. P. Filardi, A. R. Sorrentino, A. Silvestro, M. Petretta, G. Brevetti, M. Chiariello, M. Salvatore, and A. Cuocolo
Relationship Between Brachial Artery Flow-Mediated Dilation and Coronary Flow Reserve in Patients with Peripheral Artery Disease
J. Nucl. Med.,
December 1, 2005;
46(12):
1997 - 2002.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. J.W. Chow, J. W. Wong, K. Yoshinaga, T. D. Ruddy, K. Williams, R. A. deKemp, J. DaSilva, and R. S. Beanlands
Prognostic Significance of Dipyridamole-Induced ST Depression in Patients with Normal 82Rb PET Myocardial Perfusion Imaging
J. Nucl. Med.,
July 1, 2005;
46(7):
1095 - 1101.
[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]
|
|
|
|
|
|
|
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]
|
|
|
|
|
|
|
R. J. Gibbons and P. A. Araoz
The year in cardiac imaging
J. Am. Coll. Cardiol.,
November 16, 2004;
44(10):
1937 - 1944.
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. N. Giedd and S. R. Bergmann
Myocardial perfusion imaging following percutaneous coronary intervention: the importance of restenosis, disease progression, and directed reintervention
J. Am. Coll. Cardiol.,
February 4, 2004;
43(3):
328 - 336.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Hachamovitch, S. W. Hayes, J. D. Friedman, I. Cohen, and D. S. Berman
Stress myocardial perfusion single-photon emission computed tomography is clinically effective and cost effective in risk stratification of patients with a high likelihood of coronary artery disease (CAD) but no known CAD
J. Am. Coll. Cardiol.,
January 21, 2004;
43(2):
200 - 208.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. N. DeMaria, O. Ben-Yehuda, D. Berman, G. K. Feld, B. H. Greenberg, J. D. Knoke, K. U. Knowlton, W. Y. W. Lew, and S. Tsimikas
Highlights of the year in JACC 2003
J. Am. Coll. Cardiol.,
December 17, 2003;
42(12):
2156 - 2166.
[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]
|
|
|
|
|
|
|
R. Hachamovitch, S. W. Hayes, J. D. Friedman, I. Cohen, X. Kang, G. Germano, and D. S. Berman
Is there a referral bias againstcatheterization of patients withreduced left ventricular ejection fraction?: Influence of ejection fraction and inducible ischemia onpost-single-photon emission computed tomographymanagement of patients without a history of coronary artery disease
J. Am. Coll. Cardiol.,
October 1, 2003;
42(7):
1286 - 1294.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Committee Members, F. J. Klocke, M. G. Baird, B. H. Lorell, T. M. Bateman, J. V. Messer, D. S. Berman, P. T. O'Gara, B. A. Carabello, R. O. Russell Jr, et al.
ACC/AHA/ASNC Guidelines for the Clinical Use of Cardiac Radionuclide Imaging--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging)
J. Am. Coll. Cardiol.,
October 1, 2003;
42(7):
1318 - 1333.
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. J. Klocke, M. G. Baird, B. H. Lorell, T. M. Bateman, J. V. Messer, D. S. Berman, P. T. O'Gara, B. A. Carabello, R. O. Russell Jr, M. D. Cerqueira, et al.
ACC/AHA/ASNC Guidelines for the Clinical Use of Cardiac Radionuclide Imaging--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging)
Circulation,
September 16, 2003;
108(11):
1404 - 1418.
[Full Text]
[PDF]
|
|
|
|
