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J Am Coll Cardiol, 2006; 48:2448-2457, doi:10.1016/j.jacc.2006.07.069 (Published online 28 November 2006). © 2006 by the American College of Cardiology Foundation

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CLINICAL RESEARCH: POST-INFARCTION MYOCARDIAL PERFUSION IMAGING

A Multinational Study to Establish the Value of Early Adenosine Technetium-99m Sestamibi Myocardial Perfusion Imaging in Identifying a Low-Risk Group for Early Hospital Discharge After Acute Myocardial Infarction

John J. Mahmarian, MD, FACC^_*,1,_*, Leslee J. Shaw, PhD^,2, Neil G. Filipchuk, MD^,3, Habib A. Dakik, MD, Sherif S. Iskander, MD^||,4, Terrence D. Ruddy, MD^¶, Milena J. Henzlova, MD^#,4, Felix Keng, MD^_**, Adel Allam, MD, Lemuel A. Moyé, MD, PhD, Craig M. Pratt, MD, FACC^_* for the INSPIRE Investigators

^_* Methodist DeBakey Heart Center, Department of Cardiology, The Methodist Hospital, Houston, Texas
Cedars-Sinai Medical Center, Los Angeles, California
University of Calgary, Calgary, Alberta, Canada
American University of Beirut, Beirut, Lebanon
^|| Cardiovascular Associates of East Texas, Tyler, Texas
^¶ University of Ottawa Heart Institute, Ottawa, Ontario, Canada
^# Mount Sinai Medical Center, New York, New York
^_** National Heart Centre, Singapore, Singapore
Al-Azhar University, Cairo, Egypt
University of Texas School of Public Health, Houston, Texas.

Manuscript received March 30, 2006; revised manuscript received July 5, 2006, accepted July 6, 2006.

^_* Reprint requests and correspondence: Dr. John J. Mahmarian, Department of Cardiology, Methodist DeBakey Heart Center, 6550 Fannin Street, SM-677, Houston, Texas 77030. (Email: jmahmarian{at}tmh.tmc.edu).

OBJECTIVES: The purpose of this study was to determine whether gated adenosine Tc-99m sestamibi single-photon emission computed tomography (ADSPECT) could accurately define risk and thereby guide therapeutic decision making in stable survivors of acute myocardial infarction (AMI).

BACKGROUND: Controversy continues as to the role of noninvasive stress imaging in stratifying risk early after AMI.

METHODS: The INSPIRE (Adenosine Sestamibi Post-Infarction Evaluation) trial is a prospective multicenter trial which enrolled 728 clinically stable survivors of AMI who had gated ADSPECT within 10 days of hospital admission and subsequent 1-year follow-up. Event rates were assessed within prospectively defined INSPIRE risk groups based on the adenosine-induced left ventricular perfusion defect size, extent of ischemia, and ejection fraction.

RESULTS: Total cardiac events/death and reinfarction significantly increased within each INSPIRE risk group from low (5.4%, 1.8%), to intermediate (14%, 9.2%), to high (18.6%, 11.6%) (p < 0.01). Event rates at 1 year were lowest in patients with the smallest perfusion defects but progressively increased when defect size exceeded 20% (p < 0.0001). The perfusion results significantly improved risk stratification beyond that provided by clinical and ejection fraction variables. The low-risk INSPIRE group, comprising one-third of all enrolled patients, had a shorter hospital stay with lower associated costs compared with the higher-risk groups (p < 0.001).

CONCLUSIONS: Gated ADSPECT performed early after AMI can accurately identify a sizeable low-risk group who have a <2% death and reinfarction rate at 1 year. Identifying these low-risk patients for early hospital discharge may improve utilization of health care resources at considerable cost savings.

Abbreviations and Acronyms   ADSPECT = adenosine technetium-99m sestamibi single-photon emission computed tomography   ACS = acute coronary syndromes   AMI = acute myocardial infarction   ANOVA = analysis of variance   CI = confidence interval   CR = coronary revascularization   ETT = exercise treadmill testing   GLM = general linear modeling   LVEF = left ventricular ejection fraction   PDS = perfusion defect size   RR = relative risk   SDS = summed difference score   SRS = summed rest score   SSS = summed stress score   TIMI = Thrombolysis In Myocardial Infarction

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