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CLINICAL RESEARCH: CARDIAC IMAGING

Technetium^99m sestamibi myocardial perfusion imaging predicts clinical outcome in the community outpatient setting

The Nuclear Utility in the Community (NUC) Study

Gregory S. Thomas, MD, MPH, FACC^*,*, Michael I. Miyamoto, MD, MS, FACC^*, A. Peter Morello, III, ScB^*, Haresh Majmundar, CNMT^*, Jennifer J. Thomas, BA^*, Christine H. Sampson^*, Rory Hachamovitch, MD, MSc, FACC and Leslee J. Shaw, PhD

^* Mission Internal Medical Group, Mission Viejo, California, USA
Cardiovascular Division, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
Atlanta Cardiovascular Research Institute, Atlanta, Georgia, USA

Manuscript received May 22, 2003; revised manuscript received July 10, 2003, accepted July 22, 2003.

^* Reprint requests and correspondence: Dr. Gregory S. Thomas, Mission Internal Medical Group, 26732 Crown Valley Parkway, Suite 155, Mission Viejo, California 92691, USA.
gthomas{at}mimg.com

Presented, in part, at the 2002 Annual Scientific Session of the American College of Cardiology.

OBJECTIVES: The purpose of this study was to evaluate the prognostic value of community-based myocardial perfusion imaging (MPI) and to assess the incremental value of individual components of ^99mTc-sestamibi single photon emission computed tomography (SPECT).

BACKGROUND: Although the most rapid growth of MPI has been in community outpatient laboratories, its prognostic value has not been validated in this setting.

METHODS: We prospectively followed 1,612 consecutive patients undergoing stress ^99mTc-sestamibi SPECT in an outpatient community laboratory who experienced 71 hard events over 24 ± 7 months (0.2% lost to follow-up).

RESULTS: Patients whose scans were normal incurred an annualized event rate of 0.4%, compared with 2.3% for those with abnormal scans (p < 0.0001). Subset analysis demonstrated comparable risk stratification for women and men, diabetics, patients with normal resting ECGs, and those referred for pharmacologic and exercise stress. After adjusting for pre-test variables, multivariable Cox regression analysis found the most potent independent components of MPI to be, in order of importance, transient ischemic dilation, extent of reversibility, post-stress ejection fraction, extent and severity of the stress perfusion defect, and the overall test result (normal or abnormal). Each 1% decrement of ejection fraction predicted a 3% increase in risk (p = 0.0009). Post-MPI angiography and revascularization increased commensurate with the extent and severity of MPI result.

CONCLUSIONS: The prognostic value of perfusion imaging is portable and transferable to the outpatient community setting, with multiple components of MPI providing incremental prognostic information.

Abbreviations and Acronyms   CABG = coronary artery bypass graft   CAD = coronary artery disease   ECG = electrocardiogram/electrocardiographic/ electrocardiography   EF = ejection fraction   LV = left ventricular   MI = myocardial infarction   MPI = myocardial perfusion imaging   PCI = percutaneous coronary intervention   SPECT = single photon emission computed tomography   TID = transient ischemic dilation

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