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(Circulation. 2008;118:2540-2549.)
© 2008 American Heart Association, Inc.

Imaging

Predictive Value of Myocardial Perfusion Single-Photon Emission Computed Tomography and the Impact of Renal Function on Cardiac Death

Abdul Hakeem, MD; Sabha Bhatti, MD; Kathryn Sullivan Dillie, MD, PhD; Jeffrey R. Cook, MD; Zainab Samad, MD; Michelle D. Roth-Cline, PhD; Su Min Chang, MD

From the Division of Cardiovascular Medicine (A.H., S.B.), University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Internal Medicine (K.S.D., J.R.C., M.D.R.-C.), University of Wisconsin Hospital and Clinics and William S. Middleton VA Hospital, Madison, Wis; Division of Cardiology (Z.S.), Duke University Medical Center, Durham, NC; and Methodist DeBakey Heart and Vascular Center (S.M.C.), Houston, Tex.

Correspondence to Abdul Hakeem, MD, University of Cincinnati Hospital, 231 Albert Sabin Way, Academic Health Center, PO Box 670542, Cincinnati, OH 45257-0542. E-mail ahakeem{at}gmail.com

Received September 24, 2007; accepted October 7, 2008.

Background— Patients with chronic kidney disease (CKD) have worse cardiovascular outcomes than those without CKD. The prognostic utility of myocardial perfusion single-photon emission CT (MPS) in patients with varying degrees of renal dysfunction and the impact of CKD on cardiac death prediction in patients undergoing MPS have not been investigated.

Methods and Results— We followed up 1652 consecutive patients who underwent stress MPS (32% exercise, 95% gated) for cardiac death for a mean of 2.15±0.8 years. MPS defects were defined with a summed stress score (normal summed stress score <4, abnormal summed stress score4). Ischemia was defined as a summed stress score 4 plus a summed difference score 2, and scar was defined as a summed difference score <2 plus a summed stress score 4. Renal function was calculated with the Modified Diet in Renal Disease equation. CKD (estimated glomerular filtration rate <60 mL · min^–1 · 1.73 m^–2) was present in 36%. Cardiac death increased with worsening levels of perfusion defects across the entire spectrum of renal function. Presence of ischemia was independently predictive of cardiac death, all-cause mortality, and nonfatal myocardial infarction. Patients with normal MPS and CKD had higher unadjusted cardiac death event rates than those with no CKD and normal MPS (2.7% versus 0.8%, P=0.001). Multivariate Cox proportional hazards models revealed that both perfusion defects (hazard ratio 1.90, 95% CI 1.47 to 2.46) and CKD (hazard ratio 1.96, 95% CI 1.29 to 2.95) were independent predictors of cardiac death after accounting for risk factors, left ventricular dysfunction, pharmacological stress, and symptom status. Both MPS and CKD had incremental power for cardiac death prediction over baseline risk factors and left ventricular dysfunction (global ² 207.5 versus 169.3, P<0.0001).

Conclusions— MPS provides effective risk stratification across the entire spectrum of renal function. Renal dysfunction is also an important independent predictor of cardiac death in patients undergoing MPS. Renal function and MPS have additive value in risk stratisfying patients with suspected coronary artery disease. Patients with CKD appear to have a relatively less benign prognosis than those without CKD, even in the presence of a normal scan.

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