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CLINICAL RESEARCH: CARDIAC IMAGING

A prognostic score for prediction of cardiac mortality risk after adenosine stress myocardial perfusion scintigraphy

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

^* Division of Cardiovascular Medicine, Department of Medicine, Keck School of Medicine, University of Southern California
Department of Imaging (Division of Nuclear Medicine), Department of Medicine (Division of Cardiology), the CSMC Burns & Allen Research Institute, Cedars-Sinai Medical Center, and Department of Medicine, University of California at Los Angeles, School of Medicine, Los Angeles, California

Manuscript received November 26, 2002; revised manuscript received August 23, 2004, accepted August 30, 2004.

^* Reprint requests and correspondence: Dr. Daniel S. Berman, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Room T1254, Los Angeles, California 90048 (Email: bermand{at}cshs.org).

OBJECTIVES: We sought to derive and validate a score to estimate risk after adenosine stress.

BACKGROUND: Maximizing the prognostic information extracted from adenosine stress myocardial perfusion scintigraphy, a commonly performed test, is often challenging for referring physicians.

METHODS: A split-set validation of a score predicting cardiovascular mortality was performed in 5,873 consecutive patients studied by adenosine stress, dual-isotope single-photon emission computed tomography (SPECT; follow-up 94% complete, mean 2.2 ± 1.1 years).

RESULTS: On follow-up, 387 cardiac deaths occurred (6.6%). The Cox proportional hazards model most predictive of cardiac death included age, % myocardium ischemic, % myocardium fixed, early revascularization, dyspnea, diabetes mellitus, rest and peak stress heart rates, abnormal rest electrocardiogram (ECG), and an interaction between % myocardium ischemic and early revascularization (chi-square = 376). The final prognostic score was calculated as follows: (age [decades] x 5.19) + (% myocardium ischemic [per 10%] x 4.66) + (% myocardium fixed [per 10%] x 4.81) + (diabetes mellitus x 3.88) + (if patient treated with early revascularization, 4.51) + (if dyspnea was a presenting symptom, 5.47) + (resting heart rate [per 10 beats] x 2.88) – (peak heart rate [per 10 beats] x 1.42) + (ECG score x 1.95) – (if patient treated with early revascularization, % myocardium ischemic [per 10%] x 4.47). Scores of <49, 49 to 57, and >57 identified low, intermediate, and high risk (0.9%, 3.3%, and 9.5% cardiac death/year, respectively). Score results further risk stratified patients with respect to cardiac death in all categories of SPECT abnormality.

CONCLUSIONS: We derived and validated a score incorporating data available after adenosine stress perfusion SPECT. This score maximizes the prognostic information extracted from this test and may enhance the application of this test as part of an overall strategy.

Abbreviations and Acronyms   CAD = coronary artery disease   ECG = electrocardiogram   ETT = exercise treadmill test   MPS = myocardial perfusion single-photon emission computed tomography   SPECT = single-photon emission computed tomography   Tc-99m = technetium-99m   Tl-201 = thallium-201

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