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CLINICAL RESEARCH: CARDIAC IMAGING

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

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

^* Cardiovascular Division, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
Departments of Imaging (Division of Nuclear Medicine) and Medicine (Division of Cardiology), Cedars-Sinai Medical Center and Department of Medicine, University of California at Los Angeles School of Medicine, Los Angeles, California, USA

Manuscript received March 17, 2003; revised manuscript received July 23, 2003, accepted July 24, 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

This work was presented in part at the 45th Annual Scientific Sessions of the American College of Cardiology, Orlando, Florida, March 1996.

OBJECTIVES: We sought to evaluate the prognostic and cost implications of stress myocardial perfusion single-photon emission computed tomography (SPECT), or MPS, in patients with a high pretest likelihood (>0.85) of coronary artery disease (CAD) with no previous CAD.

BACKGROUND: Sparse data are available regarding the prognostic performance characteristics of MPS in this patient group.

METHODS: We followed up 1,270 consecutive patients with no previous revascularization or myocardial infarction (MI), with a pre–exercise tolerance test (ETT) likelihood of CAD 0.85, who underwent exercise or adenosine stress MPS (follow-up 94.4% complete; 2.2 ± 1.2 years; 60 hard events [5.9%, 2.6%/year]). Risk adjustment of survival data was done using Cox proportional hazards analysis. Costs per reclassification of risk were calculated using assumed costs and threshold analyses.

RESULTS: In patients treated medically after MPS, normal MPS had a low risk of cardiac death and hard events (0.6% and 1.3% per year, respectively). With increasing extent and severity of MPS defects, the risk of both cardiac death and hard events increased significantly (p < 0.05). Cox models indicated that the addition of MPS data resulted in incremental prognostic value over pre-MPS data (chi-square increase 48 to 87, p < 0.0001). Compared with strategies of initial referral to ETT in patients able to exercise, initial referral to MPS appeared to be a more cost-effective strategy. Similarly, compared with a strategy of direct referral to catheterization in patients with a high likelihood of CAD, initial referral to MPS is a cost-saving approach.

CONCLUSIONS: In patients with a high likelihood of CAD but without known CAD, stress MPS yields incremental value and achieves risk stratification in a cost-effective manner. The current results support a strategy of initial stress imaging in this patient cohort, as a reasonable alternative to direct referral to catheterization or initial ETT.

Abbreviations and Acronyms   CAD = coronary artery disease   ETT = exercise tolerance test   MI = myocardial infarction   MPS = myocardial perfusion SPECT   SPECT = single-photon emission computed tomography   SDS = summed difference score   SRS = summed rest score   SSS = summed stress score   Tc-99m = technetium-99m   Tl-201 = thallium-201

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