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ARTICLE

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

Rory Hachamovitch, MD, MSc, FACC^*, Sean W. Hayes, MD, John D. Friedman, MD, FACC, Ishac Cohen, PhD, Xingping Kang, MD, Guido Germano, PhD, FACC and Daniel S. Berman, MD, FACC^,*

^* Cardiovascular Division, 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, Los Angeles, California, USA
Department of Medicine, UCLA School of Medicine, Los Angeles, California, USA

Manuscript received December 23, 2002; revised manuscript received June 2, 2003, accepted June 13, 2003.

^* 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 objective of this work was to define the relationship between left ventricular perfusion/ function measures and referral rates to catheterization and revascularization early after stress gated myocardial perfusion single-photon emission computed tomography (MPS).

BACKGROUND: Although revascularization yields the greatest survival benefit in patients with low ejection fraction (EF) and extensive coronary artery disease, referral patterns to catheterization and revascularization after noninvasive testing are not well defined.

METHODS: We identified 3,369 patients without previous myocardial infarction or revascularization who underwent exercise or adenosine stress MPS and who were followed-up (97% complete) for occurrence of early (<60 days) post–single-photon emission computed tomography (SPECT) revascularization. Multivariable logistic regression modeling was used to determine the association of various patient characteristics and test results with performance of catheterization and revascularization as separate end points.

RESULTS: In the first 60 days after stress MPS, 445 catheterizations (13.2%) and 254 revascularizations (7.5%) occurred, including 140 coronary artery bypass graft surgeries (4.1%) and 114 percutaneous coronary interventions (3.4%). Both post-stress gated EF and percent of the myocardium ischemic by stress MPS were independent predictors of revascularization. Logistic regression revealed that the likelihood of catheterization increased with both increasing ischemia and decreasing EF (c-index = 0.94, chi-square = 590). Predicted referral rates to catheterization increased with decreasing EF except in patients with severe ischemia (>15% of myocardium), where rates decreased with decreasing EF. Similar modeling of revascularization (c-index = 0.94, chi-square = 329) revealed that the likelihood of revascularization increased with increasing ischemia but, in general, decreased with decreasing EF.

CONCLUSIONS: Although post-SPECT referral to both catheterization and revascularization is driven by ischemia, EF has the opposite effect on these two outcomes. Further studies evaluating the appropriateness of these referral patterns are warranted.

Abbreviations and Acronyms   CABG = coronary artery bypass graft surgery   CAD = coronary artery disease   ECG = electrocardiogram/electrocardiographic   EF = ejection fraction   LV = left ventricle/left ventricular   MPS = myocardial perfusion single-photon emission computed tomography   PCI = percutaneous coronary intervention   SPECT = single-photon emission computed tomography

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