CORRESPONDENCE: LETTER TO THE EDITOR
Relationship Between Noninvasive Coronary Angiography With Multislice Computerized Tomography and Myocardial Perfusion Imaging
Daniel M. Spevack, MD* and
Jeffrey M. Levsky, MD, PhD
* Noninvasive Laboratory, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York 10467 (Email: dspevack{at}montefiore.org).
In the paper by Schuijf et al. (1), they report findings on myocardial perfusion imaging (MPI) and multislice computerized tomography (MSCT) in symptomatic patients referred for MPI. Although the findings were of great interest, we were concerned with several of the conclusions the authors drew from them. In a subset of the patients reported (58 of 114) invasive coronary angiography was performed. Of the 27 patients demonstrated to have angiographically severe coronary stenosis, MSCT identified 27 (100%) and MPI identified only 16 (59%). Of the 31 patients shown not to have severe coronary stenosis, MSCT identified 25 (82%) and MPI identified 15 (48%). From these results, the investigators’ conclusion was that "the discrepant results provided by the 2 techniques underscore that MSCT and MPI provide complementary information." This conclusion is surprising, because although the authors offer reasonable evidence that the 2 techniques yield discrepant results, they give no evidence that the techniques are complementary. Because the authors do not offer any prestated hypothesis, their conclusion seems to be imposed on post hoc data that showed surprisingly poor efficacy for the current reference standard noninvasive examination, MPI. Although other studies have shown a relatively low clinical event rate in patients with normal MPI exams, it is not known if a benign prognosis can be generalized to symptomatic patients with severe coronary artery disease (CAD) demonstrated on angiography (2–4).
The authors also state that "patients with an abnormal MSCT and abnormal MPI should be referred for invasive angiography with potential revascularization." This conclusion, too, is not based on their presented data. The decision to pursue invasive testing is complex and generally based on the patient’s clinical features. It is therefore an overly broad conclusion to base this decision solely on the suggestion of abnormal perfusion seen on MPI. Sequential testing, which the authors advocate, seems a costly and unnecessary step.
The accuracy with which MSCT demonstrates the presence and extent of CAD makes it a welcome addition to the noninvasive armamentarium. Based on the authors’ findings of frequent discrepant results between these techniques, further investigation is warranted to test patient outcomes when clinical decisions are guided by MSCT versus MPI.
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References
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- Schuijf JD, Wijns W, Jukema W, et al. Relationship between noninvasive coronary angiography with multi-slice computed tomography and myocardial perfusion imaging J Am Coll Cardiol 2006;48:2508-2514.[Abstract/Free Full Text]
- Yang MF, Dou KF, Liu XJ, et al. Prognostic value of normal exercise 99mTc-sestamibi myocardial tomography in patients with angiographic coronary artery disease Nucl Med Comm 2006;27:333-338.[CrossRef][ISI][Medline]
- Elhendy A, Schinkel A, Bax JJ, et al. Long-term prognosis after a normal exercise stress Tc-99m sestamibi SPECT study J Nucl Cardiol 2003;10:261-266.[CrossRef][ISI][Medline]
- Ravin D, Delonca J, Siegenthaler M, et al. Long-term (10 years) prognostic value of a normal thallium-201 myocardial exercise scintigraphy in patients with coronary artery disease documented by angiography Eur Heart J 1997;18:69-77.[Abstract/Free Full Text]
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References