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(Circulation. 1996;93:905-914.)
© 1996 American Heart Association, Inc.
Articles |
Exercise Myocardial Perfusion SPECT in Patients Without Known Coronary Artery Disease
Incremental Prognostic Value and Use in Risk Stratification
Presented in part at the 41st annual meeting of the Society of Nuclear Medicine, Orlando, Fla, June 1994.
From the Departments of Imaging (Division of Nuclear Medicine) and Medicine (Division of Cardiology), Cedars-Sinai Medical Center, and the Department of Medicine, UCLA School of Medicine, Los Angeles, Calif.
Correspondence to Daniel S. Berman, MD, Co-Chairman, Department of Imaging, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048.
Background We evaluated the incremental prognostic value, the role in risk stratification, and the impact on patient management of myocardial perfusion single-photon emission computed tomography (SPECT) in a population of patients without prior myocardial infarction, catheterization, or revascularization.
Methods and Results We examined 2200 consecutive patients
who at the time of their dual-isotope SPECT had not undergone
catheterization, coronary artery bypass
surgery, or percutaneous transluminal coronary
angioplasty and had no known history of previous myocardial infarction.
Follow-up was performed at a mean of 566±142 days (97% complete)
for hard events (cardiac death and myocardial infarction) and for
referral to cardiac catheterization or
revascularization within 60 days after nuclear
testing. Examination of clinical, exercise, and nuclear models by use
of pre–exercise tolerance test (ETT), post-ETT, and nuclear
information using a stepwise Cox proportional hazards model and
receiver-operating characteristic curve analysis revealed
that nuclear testing added incremental prognostic value after inclusion
of the most predictive clinical and exercise variables (global
2=12 for clinical variables; 31 for
clinical+exercise variables; 169 for nuclear variables; gain in
2, P<.0001 for all;
receiver-operating characteristic areas: 0.66±0.04 for clinical,
0.73±0.04 for clinical+ exercise variables, 0.87±0.03 for
nuclear
variables, P=.03 for gain in area with exercise
variables; P<.001 for increase with nuclear
variables). Multiple logistic regression analysis revealed
that scan information contributed 95% of the information regarding
referral to catheterization with further additional
information provided by presenting symptoms and
exercise-induced ischemia. Referral rates to early
catheterization and
revascularization paralleled the hard event
rates in all scan categories-very low referral rates in patients
with normal scans and significant increases in referral rates as a
function of worsening scan results. Even after stratification by
clinical and exercise variables such as the Duke treadmill score,
pre- and post-ETT likelihood of coronary artery disease,
presenting symptoms, sex, and age, the nuclear scan results further
risk-stratified the patient subgroups, thus demonstrating clinical
incremental value.
Conclusions In a patient population with no evidence of previous coronary artery disease at overall low risk (1.8% hard event rate), myocardial perfusion SPECT adds incremental prognostic information and risk-stratifies patients even after clinical and exercise information is known. It appears that referring physicians use this test in an appropriate manner in selecting patients to be referred to catheterization or revascularization.
Key Words: sestamibi • prognosis • tomography • perfusion
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R. Hachamovitch, S. W. Hayes, J. D. Friedman, I. Cohen, and D. S. Berman Comparison of the Short-Term Survival Benefit Associated With Revascularization Compared With Medical Therapy in Patients With No Prior Coronary Artery Disease Undergoing Stress Myocardial Perfusion Single Photon Emission Computed Tomography Circulation, June 17, 2003; 107(23): 2900 - 2907. [Abstract] [Full Text] [PDF]
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R. C. Pasternak, J. Abrams, P. Greenland, L. A. Smaha, P. W. F. Wilson, and N. Houston-Miller Task force #1--identification of coronary heart disease risk: is there a detection gap? J. Am. Coll. Cardiol., June 4, 2003; 41(11): 1863 - 1874. [Full Text] [PDF]
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T.H. Marwick, L. Shaw, C. Case, C. Vasey, and J.D. Thomas Clinical and economic impact of exercise electrocardiography and exercise echocardiography in clinical practice Eur. Heart J., June 2, 2003; 24(12): 1153 - 1163. [Abstract] [Full Text] [PDF]
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 D V. Anand, D. Lipkin, and A. Lahiri Finding the age of the patient's heart BMJ, May 15, 2003; 326(7398): 1045 - 1046. [Full Text] [PDF]
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R. Hachamovitch, S. Hayes, J. D. Friedman, I. Cohen, L. J. Shaw, G. Germano, and D. S. Berman Determinants of risk and its temporal variation in patients with normal stress myocardial perfusion scans: What is the warranty period of a normal scan? J. Am. Coll. Cardiol., April 16, 2003; 41(8): 1329 - 1340. [Abstract] [Full Text] [PDF]
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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. [Abstract] [Full Text] [PDF]
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Committee Members, R. J. Gibbons, G. J. Balady, J. Timothy Bricker, B. R. Chaitman, G. F. Fletcher, V. F. Froelicher, D. B. Mark, B. D. McCallister, A. N. Mooss, et al. ACC/AHA 2002 guideline update for exercise testing: summary article: A report of the American college of cardiology/American heart association task force on practice guidelines (committee to update the 1997 exercise testing guidelines) J. Am. Coll. Cardiol., October 16, 2002; 40(8): 1531 - 1540. [Full Text] [PDF]
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R. J. Gibbons, G. J. Balady, J. Timothy Bricker, B. R. Chaitman, G. F. Fletcher, V. F. Froelicher, D. B. Mark, B. D. McCallister, A. N. Mooss, M. G. O'Reilly, et al. ACC/AHA 2002 Guideline Update for Exercise Testing: Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines) Circulation, October 1, 2002; 106(14): 1883 - 1892. [Full Text] [PDF]
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 A. F.L. Schinkel, A. Elhendy, R. T. van Domburg, J. J. Bax, E. C. Vourvouri, F. B. Sozzi, R. Valkema, J. R.T.C. Roelandt, and D. Poldermans Prognostic Value of Dobutamine-Atropine Stress Myocardial Perfusion Imaging in Patients With Diabetes Diabetes Care, September 1, 2002; 25(9): 1637 - 1643. [Abstract] [Full Text] [PDF]
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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. [Abstract] [Full Text] [PDF]
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K.-T. Ho, T. D. Miller, D. O. Hodge, K. R. Bailey, and R. J. Gibbons Use of a Simple Clinical Score to Predict Prognosis of Patients With Normal or Mildly Abnormal Resting Electrocardiographic Findings Undergoing Evaluation for Coronary Artery Disease Mayo Clin. Proc., June 1, 2002; 77(6): 515 - 521. [Abstract] [PDF]
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 T. H. Marwick, C. Case, S. Sawada, C. Vasey, and J. D. Thomas Prediction of Outcomes in Hypertensive Patients With Suspected Coronary Disease Hypertension, June 1, 2002; 39(6): 1113 - 1118. [Abstract] [Full Text] [PDF]
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M. S. Lauer The "exercise" part of exercise echocardiography J. Am. Coll. Cardiol., April 17, 2002; 39(8): 1353 - 1355. [Full Text] [PDF]
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L. Emmett, R. M. Iwanochko, M. R. Freeman, A. Barolet, D. S. Lee, and M. Husain Reversible regional wall motion abnormalities on exercise technetium-99m-gated cardiac single photon emission computed tomography predict high-grade angiographic stenoses J. Am. Coll. Cardiol., March 20, 2002; 39(6): 991 - 998. [Abstract] [Full Text] [PDF]
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P. B. Gibson, D. Demus, R. Noto, W. Hudson, and L. L. Johnson Low event rate for stress-only perfusion imaging in patients evaluated for chest pain J. Am. Coll. Cardiol., March 20, 2002; 39(6): 999 - 1004. [Abstract] [Full Text] [PDF]
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D. D. Miller Coronary flow studies for risk stratification in multivessel disease: A physiologic bridge too far? J. Am. Coll. Cardiol., March 6, 2002; 39(5): 859 - 863. [Full Text] [PDF]
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O. Blagosklonov, A. Sabbah, J. Verdenet, M. Baud, and J.-C. Cardot Poststress Motionlike Artifacts Caused by the Use of a Dual-Head Gamma Camera for 201Tl Myocardial SPECT J. Nucl. Med., March 1, 2002; 43(3): 285 - 291. [Abstract] [Full Text] [PDF]
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 P. G. Danias and J. A. Parker Novel Internet-based Tool for Correcting Apparent Sensitivity and Specificity of Diagnostic Tests to Adjust for Referral (Verification) Bias RadioGraphics, March 1, 2002; 22(2): e4 - e4. [Abstract] [Full Text]
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H. Yamagishi, N. Shirai, M. Yoshiyama, M. Teragaki, K. Akioka, K. Takeuchi, J. Yoshikawa, and H. Ochi Incremental Value of Left Ventricular Ejection Fraction for Detection of Multivessel Coronary Artery Disease in Exercise 201Tl Gated Myocardial Perfusion Imaging J. Nucl. Med., February 1, 2002; 43(2): 131 - 139. [Abstract] [Full Text] [PDF]
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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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J. T. Kuvin, A. R. Patel, K. A. Sliney, N. G. Pandian, W. M. Rand, J. E. Udelson, and R. H. Karas Peripheral vascular endothelial function testing as a noninvasive indicator of coronary artery disease J. Am. Coll. Cardiol., December 1, 2001; 38(7): 1843 - 1849. [Abstract] [Full Text] [PDF]
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S. V. Williams, S. D. Fihn, and R. J. Gibbons Guidelines for the Management of Patients with Chronic Stable Angina: Diagnosis and Risk Stratification Ann Intern Med, October 2, 2001; 135(7): 530 - 547. [Abstract] [Full Text] [PDF]
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T. D. Miller, V. L. Roger, D. O. Hodge, M. R. Hopfenspirger, K. R. Bailey, and R. J. Gibbons Gender differences and temporal trends in clinical characteristics, stress test results and use of invasive procedures in patients undergoing evaluation for coronary artery disease J. Am. Coll. Cardiol., September 1, 2001; 38(3): 690 - 697. [Abstract] [Full Text] [PDF]
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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] [PDF]
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 K.C. Allman and L.E.J. Thomson Prognostic value of myocardial perfusion imaging in patients with known or suspected coronary artery disease Eur. Heart J. Suppl., September 1, 2001; 3(suppl_F): F5 - F7. [Abstract] [PDF]
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T. H. Lee and C. A. Boucher Noninvasive Tests in Patients with Stable Coronary Artery Disease N. Engl. J. Med., June 14, 2001; 344(24): 1840 - 1845. [Full Text] [PDF]
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T. Sharir, G. Germano, X. Kang, H. C. Lewin, R. Miranda, I. Cohen, R. D. Agafitei, J. D. Friedman, and D. S. Berman Prediction of Myocardial Infarction Versus Cardiac Death by Gated Myocardial Perfusion SPECT: Risk Stratification by the Amount of Stress-Induced Ischemia and the Poststress Ejection Fraction J. Nucl. Med., June 1, 2001; 42(6): 831 - 837. [Abstract] [Full Text] [PDF]
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S. T. Mast, L. K. Shaw, G. C. Ravizzini, M. Chambless, P. Joski, R. E. Coleman, and S. Borges-Neto Incremental Prognostic Value of RNA Ejection Fraction Measurements During Pharmacologic Stress Testing: A Comparison with Clinical and Perfusion Variables J. Nucl. Med., June 1, 2001; 42(6): 871 - 877. [Abstract] [Full Text] [PDF]
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B Haluska, C Case, L Short, J Anderson, and T H Marwick Effect of power Doppler and digital subtraction techniques on the comparison of myocardial contrast echocardiography with SPECT Heart, May 1, 2001; 85(5): 549 - 555. [Abstract] [Full Text]
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T. H. Marwick, C. Case, S. Sawada, C. Rimmerman, P. Brenneman, R. Kovacs, L. Short, and M. Lauer Prediction of mortality using dobutamine echocardiography J. Am. Coll. Cardiol., March 1, 2001; 37(3): 754 - 760. [Abstract] [Full Text] [PDF]
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 M. E. Tavel Stress Testing in Cardiac Evaluation : Current Concepts With Emphasis on the ECG Chest, March 1, 2001; 119(3): 907 - 925. [Full Text] [PDF]
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 S. Yoder, R. G. Schwartz, and M. S. Lauer Abnormal Heart Rate Recovery and Risk of Death JAMA, February 21, 2001; 285(7): 879 - 880. [Full Text] [PDF]
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D.R. Holdright The role of pharmacological stress echo for evaluating chest pain in women Eur. Heart J., January 2, 2001; 22(2): 107 - 109. [PDF]
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