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.
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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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