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*,*,
Leslee J. Shaw, PhD ,
Neil G. Filipchuk, MD ,
Habib A. Dakik, MD ,
Sherif S. Iskander, MD||,
Terrence D. Ruddy, MD¶,
Milena J. Henzlova, MD#,
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, TexasUSA
Cedars-Sinai Medical Center, Los Angeles, CaliforniaUSA
University of Calgary, Calgary, Alberta, Canada
American University of Beirut, Beirut, Lebanon
|| Cardiovascular Associates of East Texas, Tyler, TexasUSA
¶ University of Ottawa Heart Institute, Ottawa, Ontario, Canada
# Mount Sinai Medical Center, New York, New YorkUSA
** National Heart Centre, Singapore, Singapore
Al-Azhar University, Cairo, Egypt
University of Texas School of Public Health, Houston, TexasUSA
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.
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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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