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J Am Coll Cardiol, 1998; 32:57-62
© 1998 by the American College of Cardiology Foundation
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CLINICAL STUDIES

Risk assessment using single-photon emission computed tomographic technetium-99m sestamibi imaging

Sherif Iskander, MDa and Ami E. Iskandrian, MD, FACCa

a Division of Cardiology, Department of Medicine, MCP–Hahnemann School of Medicine, Allegheny University of the Health Sciences, Philadelphia, Pennsylvania, USA

Manuscript received December 24, 1997; revised manuscript received March 16, 1998, accepted March 20, 1998.

Address for correspondence: Ami E. Iskandrian, Cardiovascular Research Center, Allegheny University of the Health Sciences, 230 North Broad Street, Mail Stop 471, Philadelphia, Pennsylvania 19102
iskandrian{at}auhs.edu


   Abstract
Top
 Abstract
Patients with stable chest...
 Noncardiac surgery
 Acute coronary syndromes
 Patients with chest pain...
 Conclusions
 References
 
Objectives. This review summarizes the results of single-photon emission computed tomographic (SPECT) technetium-99m (Tc-99m) tracer imaging in patients with stable symptoms, patients with acute coronary syndromes, patients undergoing major noncardiac surgery and patients with chest pain in the emergency department.

Background. Previous studies have examined the prognostic value of stress thallium imaging in several subsets of patients with ischemic heart disease. At present, >50% of myocardial perfusion studies are performed with technetium-labeled tracers in the United States. Furthermore, there is a shift from diagnostic to the prognostic utility of stress testing. There are important differences between technetium-labeled tracers and thallium-201. It is therefore important to review the prognostic value of technetium-labeled tracers.

Methods. We analyzed published reports in English on risk assessment using Tc-99m perfusion tracers.

Results. The largest experience is in patients with stable symptoms, comprising >12,000 patients in 14 studies. In these patients, normal stress SPECT sestamibi images were associated with an average annual hard event rate of 0.6% (death or nonfatal myocardial infarction [MI]). In contrast, patients with abnormal images had a 12-fold higher event rate (7.4% annually). Both fixed and reversible defects are prognostically important, and quantitative analysis shows increased risk in relation to the severity of the abnormality. These results are similar to those obtained with thallium-201.

Conclusions. Patients with stable chest pain syndromes and normal stress SPECT sestamibi images have a very low risk of death or nonfatal MI. It is highly unlikely that coronary revascularization can improve survival in such patients. Patients with abnormal images have an intermediate to high risk for future cardiac events, depending on the degree of the abnormality. Further prospective studies comparing aggressive medical therapy with coronary revascularization in these patients are warranted.

Abbreviations and Acronyms
  CABG = coronary artery bypass graft surgery
  CAD = coronary artery disease
  LV = left ventricular
  LVEF = left ventricular ejection fraction
  MI = myocardial infarction
  PTCA = percutaneous transluminal coronary angioplasty
  SPECT = single-photon emission computed tomography (tomographic)
  Tc-99m = technetium-99m
  Tl-201 = thallium-201

The Food and Drug Administration approved the clinical use of technetium-99m (Tc-99m) sestamibi for myocardial perfusion imaging in 1991 and Tc-99m tetrofosmin in 1996 (1). In 1996, technetium tracers were used in ~59% of the 4.9 million studies performed, either alone or in combination with thallium-201 (Tl-201) (dual-isotope imaging) (Technology Marketing Group).

As with thallium, there has been a gradual shift from diagnostic to prognostic applications of technetium tracers. This shift occurred at a time when the prognostic value of stress thallium imaging had been well established in many subsets of patients with coronary artery disease (CAD). For example, patients with normal stress thallium images have been shown to have a benign outcome, with a <1% hard event rate/year (death or nonfatal myocardial infarction (MI) (1). Patients with abnormal images, including those with fixed defects, reversible defects, increased lung thallium uptake, left ventricular (LV) dilation, multivessel abnormalities and large perfusion abnormalities, are at higher risk; the risk increases in proportion to the degree of the abnormality (1–13).

There are obviously many important differences between Tl-201 and technetium tracers, among which are the lower extraction of the technetium tracers and the ambiguity of the implications of the lung tracer uptake. Nevertheless, several studies, including multicenter studies, showed that the diagnostic accuracy of technetium tracers is comparable to that of Tl-201 (1). This comparability, but not superiority (despite superior imaging characteristics), has been a matter of controversy and has been attributed to many factors, including but not limited to referral bias and observer experience. However, diagnostic accuracy is a moving target, and the recent introduction of gating, which allows simultaneous assessment of perfusion and function as well as the ability to perform attenuation, scatter and depth resolution compensation, has literally made the earlier results obsolete (14,15).

It is nevertheless important to examine the prognostic value of technetium-labeled tracers, and because of the longer duration of the use of sestamibi, the latter will be the subject of this review, which includes an analysis of published reports in English in patients with stable symptoms, patients with acute coronary syndromes, patients undergoing major noncardiac surgery and patients with chest pain in the emergency department. All studies were performed with single-photon emission computed tomography (SPECT) but without gating or attenuation correction.


   Patients with stable chest pain syndromes
Top
 Abstract
 Patients with stable chest...
Noncardiac surgery
 Acute coronary syndromes
 Patients with chest pain...
 Conclusions
 References
 
A summary of the studies dealing with patients with stable chest pain syndromes is presented in Table 1 (16–29). The stress modalities included exercise in eight studies and pharmacologic modalities in six. In three studies from the same institution (16,19,20), a dual-isotope protocol (rest thallium and stress sestamibi) was used, but because the prognostic value was related to the stress images, these studies were included here. Four of the 14 studies were from the same institution; 3 of these 4 studies used exercise and 1 pharmacologic testing. It is conceivable that the largest study (20) also included patients described in earlier, smaller studies (16,23). Cumulatively, there were >12,000 patients in these studies; 55% of patients were men, and the mean age of the patients was 61 years. Traditional coronary risk factors were present in many patients, such as remote MI in 22%, hypertension in 50% and diabetes mellitus in 16%. The average follow-up period was 20 months.


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  		Table 1 Summary of Studies on Risk Assessment Using Stress Single-Photon Emission Computed Tomographic Technetium-99m Sestamibi

 
The annual rate of hard cardiac events (death or nonfatal MI) in patients with normal stress SPECT sestamibi images and in those with abnormal images is shown in Table 1. The average annual event rate was 12-fold higher in patients with abnormal images than in patients with normal images (7.4% vs. 0.6%) (Fig. 1). Therefore, patients with normal stress sestamibi images had a very low hard event rate of <1%/year, similar to the experience with stress thallium imaging. This event rate is comparable to that in the general population in the United States (30). In all studies, both fixed and reversible defects were prognostically important. Fixed defects are a more important predictor of death whereas reversible defects are an important predictor of nonfatal MI. Studies that included quantitative assessment of defect size (16,19,20,23) showed that the event rate was significantly greater in patients with severe than in those with mild abnormalities. For example, in one study (16), the annual hard event rate was 10.6% in patients with severe and 3.5% in patients with mild abnormalities and in another (19), the annual hard event rate was 6% and 3%, respectively. Furthermore, the prognostic power of normal and abnormal stress images was equally important in men and women. In fact, women with severe abnormalities had a worse outcome than men with severe abnormalities (8% vs. 4% [5]). Incorporation of other SPECT variables, such as LV dilation (transient or fixed), LV ejection fraction (LVEF) and volumes (derived from gated SPECT), are likely to further enhance the prognostic power of SPECT imaging but require further study (7,9,10,15).



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  		Figure 1 Rate of hard cardiac events (death or nonfatal MI) in patients with normal and abnormal stress SPECT images.

 
Classification of patients into low and high risk has been confirmed regardless of the pretest probability of CAD; that is, patients with a high pretest probability of CAD but normal stress SPECT images have a benign outcome, as do patients with a low pretest probability of CAD and normal images. However, because the overall risk in patients with a low pretest probability of CAD is low, stress imaging in this group is probably not cost-effective. The most cost-effective strategy is to study patients with an intermediate to high pretest probability of CAD (19,20). Furthermore, when quantitative analysis such as the summed stress score (determined by the extent and severity of abnormalities on the basis of a 20-segment model) was used, the risk of death and nonfatal MI varied according to the severity of abnormalities (19,31). For example, patients with mild abnormalities had an intermediate risk of nonfatal MI and a low risk for cardiac death, whereas patients with severe abnormalities had a high risk for death and an intermediate risk for nonfatal MI. These observations are important because coronary revascularization, including percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft surgery (CABG), have not been shown to lower the rate of nonfatal MI (32).

In our experience (5), events occurred ~2 years from the index stress test in patients with normal SPECT images. This finding may suggest that the "warranty" period for a normal stress sestamibi scan (i.e., duration of follow-up after a normal stress study) appears to be ~2 years; after that period, the event rate increases, probably reflecting the progressive nature of underlying CAD. However, the value of follow-up periodic testing in asymptomatic patients is still unclear because of improvements in medical therapy.

The prognostic value of stress testing with SPECT has also been confirmed in relation to the Duke treadmill exercise score. This score, which incorporates exercise duration and ST segment depression and angina during exercise, has been used to stratify patients into low, intermediate and high risk groups (33,34). The intermediate risk group comprised at least 50% of patients studied in a multicenter study of >4,581 patients (35). Patients with an intermediate Duke treadmill exercise score and normal SPECT images (50% of these were done with sestamibi) had an event rate of only 0.2%/year. American College of Cardiology/American Heart Association guidelines reports (36,37) have recommended that patients with an intermediate Duke score undergo either coronary angiography or an imaging modality (36,37). It is to be hoped that subsequent practice guidelines will carefully consider the new evidence and recommend the use of stress myocardial perfusion imaging in such patients.

It is equally important to note that the rate of early catheterization and coronary angiography was very low in patients with normal images (3.8% [16], 1% [19] and 1.4% [14]) and appropriately high in patients with abnormal images (17% [19] and 10% [16] for mild abnormalities, 42% [19] and 27% [16] for severe abnormalities).


   Noncardiac surgery
Top
 Abstract
 Patients with stable chest...
 Noncardiac surgery
Acute coronary syndromes
 Patients with chest pain...
 Conclusions
 References
 
Several guidelines have been published for risk assessment of patients undergoing major noncardiac surgery (38–41). This review is not intended to summarize these guidelines nor to critique them, but only to provide summary of published reports on the use of Tc-99m sestamibi. The risk after major noncardiac surgery includes perioperative and late events. The perioperative risk is exceedingly low in patients with normal stress sestamibi images. Similar to that in patients with stable symptoms, the late event rate is significantly higher in patients with abnormal than in those with normal scans (Table 2) (42–44).


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  		Table 2 Summary of Studies on Risk Assessment Using Technetium-99m Sestamibi in Coronary Artery Disease

 

   Acute coronary syndromes
Top
 Abstract
 Patients with stable chest...
 Noncardiac surgery
 Acute coronary syndromes
Patients with chest pain...
 Conclusions
 References
 
A limited number of studies in small groups of patients have evaluated the use of sestamibi imaging either at rest or during stress in patients with unstable angina or after acute MI. Again, patients with normal images or small defects have a significantly better outcome than patients with abnormal images or large defects (Table 2) (45–49). Patients with an acute MI may benefit from simultaneous assessment of myocardial perfusion and function using gated perfusion imaging because both LVEF and perfusion defect size are prognostically important. Preliminary data from a multicenter study of 268 patients demonstrated (50) that early pharmacologic stress imaging may be useful for risk stratification in patients admitted with a diagnosis of acute MI. More studies in larger series of patients with and without thrombolytic therapy and or angioplasty are needed.


   Patients with chest pain in the emergency department
Top
 Abstract
 Patients with stable chest...
 Noncardiac surgery
 Acute coronary syndromes
 Patients with chest pain...
Conclusions
 References
 
It is estimated that 6 million patients/year visit the emergency department in the United States for evaluation of chest pain (7% of all visits), and although only 10% to 15% of these patients have an acute MI, ~50% are admitted to the coronary care unit to rule out acute MI (51–56). Several studies show that patients with a low risk rest perfusion scan with Tc-99m sestamibi in the emergency department have a low subsequent cardiac event rate, whereas patients with a high risk scan have a higher probability of acute MI, revascularization or documentation of stenoses on cardiac catheterization (Table 3) (56–60).


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  		Table 3 Results of Rest Sestamibi Single-Photon Emission Computed Tomography in Patients With Chest Pain in Emergency Department

 

   Conclusions
Top
 Abstract
 Patients with stable chest...
 Noncardiac surgery
 Acute coronary syndromes
 Patients with chest pain...
 Conclusions
References
 
Several studies show that patients with chest pain syndromes but normal stress SPECT perfusion images using Tc-labeled tracers have a very low event rate (<1%/year for death or nonfatal MI). It is therefore very unlikely that further invasive strategies, including PTCA or CABG, can improve the outcome. These results are similar to those for stress SPECT thallium imaging but differ from stress two-dimensional echocardiography. Multiple studies using stress echocardiography have shown (61) a higher event rate in patients with no evidence of ischemia. The difference between the prognostic value of different stress tests underscores the fact that outcome results by one method cannot be extrapolated to another. The risk of events is substantially higher in patients with abnormal than in those with normal SPECT imaging results. The management of patients with abnormal images as well as the frequency of testing are not clear and should at present be individualized; they deserve further study.


   Acknowledgments
 
We thank Renee Brown for secretarial assistance.


   References
Top
 Abstract
 Patients with stable chest...
 Noncardiac surgery
 Acute coronary syndromes
 Patients with chest pain...
 Conclusions
 References
 

  1. Brown KA. Prognostic value of thallium-201 myocardial perfusion imaging: a diagnostic tool comes of age. Circulation. 1991;83:363–381[Free Full Text]
  2. Iskandrian AS, Verani MS. Nuclear Cardiac Imaging: Principles and Applications. 2nd ed. Philadelphia: FA Davis; 1996.
  3. Chae SC, Heo J, Iskandrian AS, Wasserleben V, Cave V. Identification of extensive coronary artery disease in women by exercise single photon emission computed tomographic (SPECT) thallium imaging. J Am Coll Cardiol. 1993;21:1305–1311[Abstract]
  4. Pollock SG, Abbot RD, Boucher CA, Beller GA, Kaul F. Independent and incremental prognostic value of tests performed in hierarchical order to evaluate patients with suspected coronary artery disease. Circulation. 1992;85:237–248[Abstract/Free Full Text]
  5. Iskandrian AS, Chae SC, Heo J, Stanberry CD, Wasserleben V, Cave V. Independent and incremental prognostic value of exercise single photon emission computed tomographic (SPECT) thallium imaging in coronary artery disease. J Am Coll Cardiol. 1993;22:665–670[Abstract]
  6. Pancholy SB, Fattah AA, Kamal AM, Ghods M, Heo J, Iskandrian AS. Independent and incremental prognostic value of exercise thallium single photon emission computed tomographic imaging in women. J Nucl Cardiol. 1995;2:110–166[CrossRef][Medline]
  7. Mazzanti M, Germano G, Kiat H, et al. Identification of severe and extensive coronary artery disease by automatic measurement of transient ischemic dilation of the left ventricle in dual-isotope myocardial perfusion SPECT. J Am Coll Cardiol. 1996;27:1612–1620[Abstract]
  8. Bateman TM, O’Keefe JH Jr, Dong VM, Barnhart C, Ligon RW. Coronary angiography rates following stress SPECT scintigraphy. J Nucl Cardiol. 1995;2:217–223[CrossRef][Medline]
  9. Nallamothu N, Pancholy SV, Lee KR, Heo J, Iskandrian AS. Impact of exercise single photon emission computed tomographic thallium imaging on patient management and outcome. J Nucl Cardiol. 1995;2:334–338[CrossRef][Medline]
  10. Germano G, Erel J, Lewin H, Kavanagh PB, Berman DS. Automatic quantitation of regional myocardial wall motion and thickening from gated technetium 99m sestamibi myocardial perfusion single photon emission computed tomography. J Am Coll Cardiol. 1997;30:1360–1367[Abstract]
  11. Brown KA. Prognostic value of thallium-201 myocardial perfusion imaging: state of the art and new developments. J Nucl Cardiol. 1996;3:516–537[CrossRef][Medline]
  12. Schalet BD, Kegel JG, Heo J, Segal BL, Iskandrian AS. Prognostic Implications of normal exercise SPECT thallium images in patients with strongly positive exercise electrocardiograms. Am J Cardiol. 1993;72:1201–1203[CrossRef][Medline]
  13. Dakik HA, Mahmarikan JJ, Kimball KT, Koutelou MG, Medrano R, Verani MS. Prognostic value of exercise tomography in patients treated with thrombolytic therapy during acute myocardial infarction. Circulation. 1996;94:2735–2742[Abstract/Free Full Text]
  14. Ficaro EP, Fessler JA, Shreve PD, Kritzman JN, Rose PA, Corbett JR. Simultaneous transmission/emission myocardial perfusion tomography: diagnostic accuracy of attenuation-corrected Tc-99m sestamibi single photon emission computed tomography. Circulation. 1996;93:463–473[Abstract/Free Full Text]
  15. Taillefer R, DePuey EG, Udelson JE, Beller GA, Latour Y, Reeves F. Comparative diagnostic accuracy of thallium-201 and Tc-99m sestamibi SPECT imaging (perfusion and ECG gated SPECT in detecting coronary artery disease in women. J Am Coll Cardiol. 1997;29:69–77[Abstract]
  16. Hachamovitch R, Berman DS, Kiat H, et al. Incremental prognostic value of adenosine stress myocardial perfusion SPECT and impact on subsequent management in patients with or suspected of having myocardial ischemia. Am J Cardiol. 1997;80:426–433[CrossRef][Medline]
  17. Boyne TS, Koplan BA, Parsons WJ, Smith WH, Watson DD, Beller GA. Predicting adverse outcome with exercise SPECT Technetium-99m sestamibi imaging in patients with suspected or known CAD. Am J Cardiol. 1997;79:270–274[CrossRef][Medline]
  18. Nallamouthu N, Araujo L, Russell J, Heo J, Iskandrian AE. Prognostic value of simultaneous perfusion and function assessment using technetium-99m sestamibi. Am J Cardiol. 1996;78:562–564[CrossRef][Medline]
  19. Hachamovitch R, Berman DS, Kiat H, et al. Exercise myocardial perfusion SPECT in patients without known CAD. Incremental prognostic value and use in risk stratification. Circulation. 1996;93:905–914[Abstract/Free Full Text]
  20. Hachamovitch R, Berman DS, Kiat H, et al. Effective risk stratification using exercise myocardial perfusion SPECT in women: gender-related differences in prognostic nuclear testing. J Am Coll Cardiol. 1996;28:34–44[Abstract]
  21. Geleijnse ML, Elhendy A, Van Domburg RT, Cornel JH, Reijs AEM, Fioretti PM. Prognostic significance of normal dobutamine-atropine stress sestamibi scintigraphy in women with chest pain. Am J Cardiol. 1996;77:1057–1061[CrossRef][Medline]
  22. Geleijnse ML, Elhendy A, Van Domburg RT, et al. Prognostic value of dobutamine-atropine stress technetium-99m sestamibi perfusion scintigraphy in patients with chest pain. J Am Coll Cardiol. 1996;28:447–454[Abstract]
  23. Berman DS, Hachamovitch R, Kiat H, et al. Incremental value of prognostic testing in patient with known or suspected ischemic heart disease: a basis for optimal utilization of exercise technetium-99m sestamibi myocardial perfusion SPECT. J Am Coll Cardiol. 1995;26:639–647[Abstract]
  24. Heller GV, Herman SD, Travin MI, Baron JI, Santos-Ocampo C, McClellan JR. Independent prognostic value of intravenous dipyridamole with technetium-99m sestamibi tomographic imaging in predicting cardiac events and cardiac-related hospital admissions. J Am Coll Cardiol. 1995;26:1202–1208[Abstract]
  25. Zanco P, Zampiero A, Favero A, et al. Myocardial technetium-99m sestamibi single-photon emission tomography as a prognostic tool in CAD: multivariate analysis in a long-term prospective study. Eur J Nucl Med. 1995;22:1023–1028[CrossRef][Medline]
  26. Brown KA, Altland E, Rowen M. Prognostic value of normal technetium-99m-sestamibi cardiac imaging. J Nucl Med. 1994;35:554–557[Abstract/Free Full Text]
  27. Stratmann HG, Williams GA, Wittry MD, Chaitman BR, Miller DD. Exercise technetium-99m sestamibi tomography for cardiac risk stratification of patients with stable chest pain. Circulation. 1994;89:615–622[Abstract/Free Full Text]
  28. Stratmann HG, Tamesis BR, Younis LT, Wittry MD, Miller DD. Prognostic value of dipyridamole technetium-99m sestamibi myocardial tomography in patients with stable chest pain who are unable to exercise. Am J Cardiol. 1994;73:647–652[CrossRef][Medline]
  29. Raiker K, Sinusas AJ, Wackers FJT, Zaret BL. One-year prognosis of patients with normal planer or single-photon emission computed tomographic technetium 99m-labeled sestamibi exercise imaging. J Nucl Cardiol. 1994;1:449–456[Medline]
  30. National Center for Health Statistics. United States life tables: US decennial life tables for 1979–1981. Vol. 1, No. 1. Washington, DC: Government Printing Office, 1985. DHHS publication no. (PHS) 85-1150-1.
  31. Hachamovitch R, Berman DS, Shaw LJ, et al. Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction. Circulation. 1998;97:535–543[Abstract/Free Full Text]
  32. Forrester JS, Shah PK. Lipid lowering versus revascularization: an idea whose time (for testing) has come. Circulation. 1997;96:1360–1362[Abstract/Free Full Text]
  33. Mark DB, Shaw L, Harrel FE, et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med. 1991;325:849–853[Abstract]
  34. Mark DB, Hlatky MA, Harrell FE, Lee KL, Califf RM, Pryor DB. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med. 1987;106:793–800[CrossRef][Medline]
  35. Gibbons R, Iskandrian AS, Okinboboye O, Heo J, Hodge DO, Berman DS. Long term outcome in patients with intermediate risk exercise electrocardiograms but normal myocardial perfusion images [abstract]. Circulation. 1997;96(Suppl I):I-195
  36. Gibbons DB, Marwick TH, McCalister BD, Thompson PD, Winters WL Jr, Yanowitz FA. ACC/AHA guidelines for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol. 1997;30:260–315[CrossRef][Medline]
  37. Ryan TJ, Anderson JL, Antman EM, et al. ACC/AHA guidelines for the management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol. 1996;28:1328–1428[CrossRef][Medline]
  38. Eagle KA, Brundage BH, Chaitman BR, et al. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol. 1996;27:910–948[CrossRef][Medline]
  39. Paldo VA, Detsky AS. Perioperative assessment and management of risk from coronary artery disease. Ann Intern Med. 1997;127:313–328[Abstract/Free Full Text]
  40. Mangano DT, Goldman L. Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med. 1995;333:1750–1756[Free Full Text]
  41. Shaw LJ, Peterson ED, Kesler K, Hasselblad V, Califf RM. A meta-analysis of predischarge risk stratification after acute myocardial infarction with stress electrocardiographic, myocardial perfusion, and ventricular function imaging. Am J Cardiol. 1996;78:1327–1337[CrossRef][Medline]
  42. Stratmann HG, Younis LT, Wittry MD, Amato M, Mark AL, Miller DD. Dipyridamole technetium 99m sestamibi myocardial tomography for preoperative cardiac risk stratification before major or minor nonvascular surgery. Am Heart J. 1996;132:536–541[CrossRef][Medline]
  43. Stratmann HG, Younis LT, Wittry MD, Amato M, Miller DD. Dipyridamole technetium-99m sestamibi myocardial tomography in patients evaluated for elective vascular surgery: prognostic value for perioperative and late cardiac events. Am Heart J. 1996;131:923–929[CrossRef][Medline]
  44. Maunoury C, Stone DA, Chen CC, Plotnick GD, Holder LE. Preoperative cardiac risk assessment with adenosine stress dual-isotope myocardial SPECT. Clin Cardiol. 1996;19:488–490[Medline]
  45. Miller DD, Stratmann HG, Shaw L, et al. Dipyridamole technetium 99m sestamibi myocardial tomography as an independent predictor of cardiac event-free survival after acute ischemic events. J Nucl Cardiol. 1994;1:172–182
  46. Travin MI, Dessouki A, Cameron T, Heller GV. Use of exercise technetium-99m sestamibi SPECT imaging to detect residual ischemia and for risk stratification after acute MI. Am J Cardiol. 1995;75:665–669[CrossRef][Medline]
  47. Miller TD, Christian TF, Hopfenspirger MR, Hodge DO, Gersh BJ, Gibbons RJ. Infarct size after acute MI measured by quantitative tomographic Tc-99m sestamibi imaging predicts subsequent mortality. Circulation. 1995;92:334–341[Abstract/Free Full Text]
  48. Stratmann HG, Younis LT, Wittry MD, Amato M, Miller DD. Exercise technetium-99m myocardial tomography for the risk stratification of men with medically treated unstable angina pectoris. Am J Cardiol. 1995;76:236–240[CrossRef][Medline]
  49. Stratmann HG, Tamesis BR, Younis LT, Wittry MD, Amato M, Miller DD. Prognostic value of predischarge dipyridamole technetium 99m sestamibi myocardial tomography in medically treated patients with unstable angina. Am Heart J. 1995;130:734–740[CrossRef][Medline]
  50. Brown KA, Heller GV, Landin R, Shaw LJ, Haber SB. Early post-myocardial infarction dipyidamole Tc-99m sestamibi myocardial perfusion imaging predicts cardiac death or myocardial infarction [abstract]. Circulation. 1997;96(Suppl I):I-195
  51. Lee TH, Rouan GW, Weisberg MC, et al. Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room. Am J Cardiol. 1987;60:219–224[CrossRef][Medline]
  52. Lee TH, Juarex G, Cook EF, et al. Ruling out acute myocardial infarction: a prospective multicenter validation of a 12-hour strategy for patients at low risk. N Engl J Med. 1991;324:1239–1246[Abstract]
  53. Goldman L, Cook EF, Johnson PA, Brand DA, Rouan GW, Lee TH. Prediction of the need for intensive care in patients who come to emergency departments with acute chest pain. N Engl J Med. 1996;334:1498–1504[Abstract/Free Full Text]
  54. Hamm CW, Goldman BU, Heeschen C, Kreymann G, Berger J, Meinertz T. Emergency room triage of patients with acute chest pain by means of raid testing for cardiac troponin T or troponin I. N Engl J Med. 1997;337:1648–1653[Abstract/Free Full Text]
  55. Sabia P, Afrooktch A, Touchstone DA, Keller MW, Esquivel L, Kaul S. Value of regional wall motion abnormality in the emergency room diagnosis of acute myocardial infarction: a prospective study using two-dimensional echocardiography. Circulation. 1991;84(Suppl I):85–92
  56. Kontos MC, Jesse RL, Schmidt KL, Ornato JP, Tatum JL. Value of acute rest sestamibi perfusion imaging for evaluation of patients admitted to the emergency department with chest pain. J Am Coll Cardiol. 1997;30:976–982[Abstract]
  57. Tatum JL, Jesse RL, Kontos MC, et al. Comprehensive strategy for the evaluation and triage of the chest pain patient. Ann Emerg Med. 1997;29:116–125[CrossRef][Medline]
  58. Hilton TC, Thompson RC, Williams HJ, Saylors R, Fulmer H, Stowers SA. Technetium-99m sestamibi myocardial perfusion imaging in the emergency room evaluation of chest pain. J Am Coll Cardiol. 1994;23:1016–1022[Abstract]
  59. Hilton TC, Fulmer H, Abuan T, Thompson RC, Stowers SA. Ninety-day follow-up of patients in the emergency department with chest pain who undergo initial single-photon emission computed tomographic perfusion scintigraphy with technetium 99m-labeled sestamibi. J Nucl Cardiol. 1996;3:308–311[CrossRef][Medline]
  60. Varetto T, Cantalupi D, Altieri A, Orlandi C. Emergency room technetium-99m sestamibi imaging to rule out acute myocardial ischemic events in patients with nondiagnostic EKG. J Am Coll Cardiol. 1993;22:1804–1808[Abstract]
  61. Brown KA. Noninvasive cardiac risk stratification of patients with know or suspected coronary artery disease: do myocardial perfusion imagina and stress echocardiography provide the same information? Am J Cardiol. In press.



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O. Gaemperli, T. Schepis, I. Valenta, P. Koepfli, L. Husmann, H. Scheffel, S. Leschka, F. R. Eberli, T. F. Luscher, H. Alkadhi, et al.
Functionally Relevant Coronary Artery Disease: Comparison of 64-Section CT Angiography with Myocardial Perfusion SPECT
Radiology, August 1, 2008; 248(2): 414 - 423.
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 JNMHome page
A. Sato, M. Hiroe, M. Tamura, H. Ohigashi, T. Nozato, H. Hikita, A. Takahashi, K. Aonuma, and M. Isobe
Quantitative Measures of Coronary Stenosis Severity by 64-Slice CT Angiography and Relation to Physiologic Significance of Perfusion in Nonobese Patients: Comparison with Stress Myocardial Perfusion Imaging
J. Nucl. Med., April 1, 2008; 49(4): 564 - 572.
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 J. Nucl. Med. Technol.Home page
M. W. Schaeffer, T. D. Brennan, J. A. Hughes, W. B. Gibler, and M. C. Gerson
Resting Radionuclide Myocardial Perfusion Imaging in a Chest Pain Center Including an Overnight Delayed Image Acquisition Protocol
J. Nucl. Med. Technol., December 1, 2007; 35(4): 242 - 245.
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 RadiologyHome page
J. C. Wu, F. M. Bengel, and S. S. Gambhir
Cardiovascular Molecular Imaging
Radiology, August 1, 2007; 244(2): 337 - 355.
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 J Am Coll CardiolHome page
K. Yoshinaga, B. J.W. Chow, K. Williams, L. Chen, R. A. deKemp, L. Garrard, A. Lok-Tin Szeto, M. Aung, R. A. Davies, T. D. Ruddy, et al.
What is the Prognostic Value of Myocardial Perfusion Imaging Using Rubidium-82 Positron Emission Tomography?
J. Am. Coll. Cardiol., September 5, 2006; 48(5): 1029 - 1039.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
T. D. Miller, R. F. Redberg, and F. J.T. Wackers
Screening Asymptomatic Diabetic Patients for Coronary Artery Disease: Why Not?
J. Am. Coll. Cardiol., August 15, 2006; 48(4): 761 - 764.
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 J Am Coll CardiolHome page
J. J. Bax, R. O. Bonow, D. Tschope, S. E. Inzucchi, E. Barrett, and on behalf of the Global Dialogue Group for the Eva
The Potential of Myocardial Perfusion Scintigraphy for Risk Stratification of Asymptomatic Patients With Type 2 Diabetes
J. Am. Coll. Cardiol., August 15, 2006; 48(4): 754 - 760.
[Abstract] [Full Text] [PDF]

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 Eur Heart JHome page
D. V. Anand, E. Lim, A. Lahiri, and J. J. Bax
The role of non-invasive imaging in the risk stratification of asymptomatic diabetic subjects
Eur. Heart J., April 2, 2006; 27(8): 905 - 912.
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 Eur Heart JHome page
E. Reyes and S. R. Underwood
Myocardial perfusion scintigraphy: an important step between clinical assessment and coronary angiography in patients with stable chest pain
Eur. Heart J., January 1, 2006; 27(1): 3 - 4.
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 British Journal of Diabetes & Vascular DiseaseHome page
J. J Bax, R. O Bonow, D. Tschoepe, S. E Inzucchi, and E. J Barrett
Early detection of coronary heart disease in diabetic patients without symptoms of coronary artery disease: implications for expanded use of myocardial perfusion imaging
The British Journal of Diabetes & Vascular Disease, September 1, 2005; 5(5): 283 - 288.
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 JNMHome page
M. Hacker, T. Jakobs, F. Matthiesen, C. Vollmar, K. Nikolaou, C. Becker, A. Knez, T. Pfluger, M. Reiser, K. Hahn, et al.
Comparison of Spiral Multidetector CT Angiography and Myocardial Perfusion Imaging in the Noninvasive Detection of Functionally Relevant Coronary Artery Lesions: First Clinical Experiences
J. Nucl. Med., August 1, 2005; 46(8): 1294 - 1300.
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 JNMHome page
L. Liao, W. T. Smith IV, R. H. Tuttle, L. K. Shaw, R. E. Coleman, and S. Borges-Neto
Prediction of Death and Nonfatal Myocardial Infarction in High-Risk Patients: A Comparison Between the Duke Treadmill Score, Peak Exercise Radionuclide Angiography, and SPECT Perfusion Imaging
J. Nucl. Med., January 1, 2005; 46(1): 5 - 11.
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R. C. Marshall, P. Powers-Risius, B. W. Reutter, J. P. O'Neil, M. La Belle, R. H. Huesman, and H. F. VanBrocklin
Kinetic Analysis of 18F-Fluorodihydrorotenone as a Deposited Myocardial Flow Tracer: Comparison to 201Tl
J. Nucl. Med., November 1, 2004; 45(11): 1950 - 1959.
[Abstract] [Full Text] [PDF]

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 HeartHome page
S L Rahman and A D Kelion
Nuclear cardiology in the UK: do we apply evidence based medicine?
Heart, August 1, 2004; 90(suppl_5): v37 - v40.
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 British Journal of Diabetes & Vascular DiseaseHome page
D. Tschoepe and W. Burchert
Non-invasive imaging for coronary artery disease in diabetes
The British Journal of Diabetes & Vascular Disease, July 1, 2004; 4(4): 245 - 250.
[Abstract] [PDF]

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 J Am Coll CardiolHome page
G. A. Beller and D. D. Watson
Risk stratification using stress myocardial perfusion imaging: don't neglect the value of clinical variables
J. Am. Coll. Cardiol., January 21, 2004; 43(2): 209 - 212.
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 J Am Coll CardiolHome page
G. S. Thomas, M. I. Miyamoto, A. P. Morello III, H. Majmundar, J. J. Thomas, C. H. Sampson, R. Hachamovitch, and L. J. Shaw
Technetium99m sestamibi myocardial perfusion imaging predicts clinical outcome in the community outpatient setting: The Nuclear Utility in the Community (NUC) Study
J. Am. Coll. Cardiol., January 21, 2004; 43(2): 213 - 223.
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 J Am Coll CardiolHome page
A. Abidov, J. J. Bax, S. W. Hayes, R. Hachamovitch, I. Cohen, J. Gerlach, X. Kang, J. D. Friedman, G. Germano, and D. S. Berman
Transient ischemic dilation ratio of the left ventricle is a significant predictor of future cardiac events in patients with otherwise normal myocardial perfusion SPECT
J. Am. Coll. Cardiol., November 19, 2003; 42(10): 1818 - 1825.
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 HeartHome page
N K Sabharwal and A Lahiri
Role of myocardial perfusion imaging for risk stratification in suspected or known coronary artery disease
Heart, November 1, 2003; 89(11): 1291 - 1297.
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 J Am Coll CardiolHome page
A. Elhendy, D. W. Mahoney, B. K. Khandheria, K. Burger, and P. A. Pellikka
Prognostic significance of impairment of heart rate response to exercise: Impact of left ventricular function and myocardial ischemia
J. Am. Coll. Cardiol., September 3, 2003; 42(5): 823 - 830.
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L. J. Shaw, R. Hendel, S. Borges-Neto, M. S. Lauer, N. Alazraki, J. Burnette, E. Krawczynska, M. Cerqueira, and J. Maddahi
Prognostic Value of Normal Exercise and Adenosine 99mTc-Tetrofosmin SPECT Imaging: Results from the Multicenter Registry of 4,728 Patients
J. Nucl. Med., February 1, 2003; 44(2): 134 - 139.
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 JNMHome page
A. F.L. Schinkel, A. Elhendy, R. T. van Domburg, J. J. Bax, J. R.T.C. Roelandt, and D. Poldermans
Prognostic Value of Dobutamine-Atropine Stress 99mTc-Tetrofosmin Myocardial Perfusion SPECT in Patients with Known or Suspected Coronary Artery Disease
J. Nucl. Med., June 1, 2002; 43(6): 767 - 772.
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 J Am Coll CardiolHome page
S. A. J. Chamuleau, R. A. Tio, C. C. de Cock, E. D. de Muinck, N. H. J. Pijls, B. L. F. van Eck-Smit, K. T. Koch, M. Meuwissen, M. G. W. Dijkgraaf, A. de Jong, et al.
Prognostic value of coronary blood flow velocity and myocardial perfusion in intermediate coronary narrowings and multivessel disease
J. Am. Coll. Cardiol., March 6, 2002; 39(5): 852 - 858.
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 J Am Coll CardiolHome page
R. Wayhs, A. Zelinger, and P. Raggi
High coronary artery calcium scores pose an extremely elevated risk for hard events
J. Am. Coll. Cardiol., January 16, 2002; 39(2): 225 - 230.
[Abstract] [Full Text] [PDF]

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 CirculationHome page
S. Giri, L. J. Shaw, D. R. Murthy, M. I. Travin, D. D. Miller, R. Hachamovitch, S. Borges-Neto, D. S. Berman, D. D. Waters, and G. V. Heller
Impact of Diabetes on the Risk Stratification Using Stress Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging in Patients With Symptoms Suggestive of Coronary Artery Disease
Circulation, January 1, 2002; 105(1): 32 - 40.
[Abstract] [Full Text] [PDF]

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 Emerg. Med. J.Home page
B S McGlone and K K Balan
The use of nuclear medicine techniques in the emergency department
Emerg. Med. J., November 1, 2001; 18(6): 424 - 429.
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L. J. Shaw, A. E. Iskandrian, R. Hachamovitch, G. Germano, H. C. Lewin, T. M. Bateman, and D. S. Berman
Evidence-Based Risk Assessment in Noninvasive Imaging
J. Nucl. Med., September 1, 2001; 42(9): 1424 - 1436.
[Abstract] [Full Text]