A hypothetical protocol for the provisional use of perfusion imaging with exercise stress testing

Duvall, W. Lane; Levine, Elliot J.; Moonthungal, Sunitha; Fardanesh, Mahmoudreza; Croft, Lori B.; Henzlova, Milena J.

doi:10.1007/s12350-013-9710-6

Cited by 17 publications

(12 citation statements)

References 29 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…In this issue of the journal, Duvall et al, 10 recognizing that the results of MPI seemed to add little to risk assessment of patients who exercise to 10 METs or more during stress testing, seek to determine if a provisional tracer injection protocol could be developed in which a patient would not have the tracer administered intravenously if C10 METs was achieved without symptoms and with a negative stress ECG response. They retrospectively reviewed all patients who underwent a SPECT MPI study over a 6.5-year period and estimated how many patients might have been eligible for a ''standby injection'' protocol with provisional MPI.…”

mentioning

confidence: 99%

“…The number of patients who might not have been injected with tracer for MPI could have been expanded if Duvall et al 10 did not include shortness of breath as an endpoint or included patients with an intermediate pretest likelihood of CAD who were [65 years of age. Patients were withdrawn from the provisional imaging protocol if they had right bundle branch block on their resting ECG.…”

mentioning

confidence: 99%

See 1 more Smart Citation

Provisional use of myocardial perfusion imaging in patients undergoing exercise stress testing: A worthy concept fraught with challenges

Bateman

2013

Journal of Nuclear Cardiology

View full text Add to dashboard Cite

See related article, pp. 739-747It has been recognized for many years that patients who achieve a high workload on exercise stress testing have an excellent prognosis, particularly in the absence of ischemic ST segment depression. [1][2][3][4] Outpatients with a low-risk Duke Treadmill Score (based on exercise duration, magnitude of ST deflection and an angina index) had an observed annual mortality rate of only 0.25%. 5 Exercise capacity has been shown to be a better predictor of all-cause mortality than maximum exercise heart rate.1 Myers et al 1 reported that patients achieving a workload of C10 metabolic equivalents (METs), even in the presence of cardiovascular disease, had a relatively low risk of death during follow-up. For every 1-MET increment in peak treadmill workload, there was an associated 12% improvement in survival. These investigators found that, in both healthy subjects and those with cardiovascular disease, the peak exercise capacity was a stronger predictor of an increased risk of death than clinical variables or coronary artery disease (CAD) risk factors such as hypertension, smoking, and diabetes. It had greater prognostic value than peak exercise heart rate, ST depression, or exercise-induced arrhythmias. Morise et al 6 found a 14% reduction in cardiac events among subjects \65 years of age, and an 18% reduction among subjects C65 years of age for each 1-MET increase in workload. After adjustment for age, the peak METs achieved was the strongest predictor of subsequent mortality. In another study, among patients with a positive exercise ECG, who achieved C10 METs, 93% had a negative exercise echocardiogram and less than 1% mortality after 7.2 years of follow-up. 7More recently, Bourque et al 8 from the University of Virginia reported that in more than 470 consecutive patients referred for exercise SPECT myocardial perfusion imaging (MPI), who achieved C85% of maximum predicted heart rate (MPHR) and C10 METs, the prevalence of significant ischemia defined as comprising 10% or more of the left ventricle (LV), was only 0.4%. In fact, no patient who achieved C10 METs without ischemic ST depression had significant ischemia on MPI. The prevalence of 5-9% LV ischemia in such patients was also very low at 0.7%. This population had an intermediate-to-high pretest likelihood of CAD, with 20% having known CAD and 70% with chest pain as the indication for testing. Ischemia involving C10% of the LV was also low (2.4%) in the 82 patients who achieved C10 METs, but \85% of MPHR. Bourque et al 9 then published the subsequent cardiac mortality and nonfatal cardiac event rates in this patient cohort achieving C10 METs. They reported a remarkably low annual cardiac mortality of 0.1% and a combined annual cardiac death or nonfatal myocardial infarction rate of 0.4%. None of the event patients had either [5% or [10% LV ischemia, and none was in the subsets which achieved \85% of MPHR or who had ST depression. Therefore, even if perfusion imaging was performed, it would not have identified the patients who subs...

show abstract

mentioning

confidence: 99%

mentioning

confidence: 99%

Provisional use of myocardial perfusion imaging in patients undergoing exercise stress testing: A worthy concept fraught with challenges

Bateman

2013

Journal of Nuclear Cardiology

View full text Add to dashboard Cite

show abstract

“…ETT is an even faster diagnostic test for the low-risk patient and a provisional isotope injection protocol might provide the time savings of ETT with the flexibility of imaging when needed. 38 More progress can and has been made at reducing patient radiation exposure with both CTA and SPECT MPI since 2011. CTA has made great strides in a short period of time through software, hardware, and protocol advances.…”

Section: 6mentioning

confidence: 99%

“…44,45 The use of time imaging software which incorporates iterative image reconstruction with resolution recovery thereby improving count statistics can decrease imaging time or decrease injected activity. 46 Stress protocol changes such as performing more ETTs, 47 developing a provisional isotope injection protocol, 38 and stress-first imaging 10 will all decrease radiation exposure to the patient by not giving it in the first place. Perhaps the greatest saving of radiation exposure and resources would be the elimination of any diagnostic testing for most of the very low-and low-risk patients (''less is more'').…”

Section: 6mentioning

confidence: 99%

A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department

Duvall

Savino

Levine

et al. 2014

Journal of Nuclear Cardiology

Self Cite

View full text Add to dashboard Cite

Background. Recent studies have compared CTA to stress testing and MPI using older Na-I SPECT cameras and traditional rest-stress protocols, but are limited by often using optimized CTA protocols but suboptimal MPI methodology. We compared CTA to stress testing with modern SPECT MPI using high-efficiency CZT cameras and stress-first protocols in an ED population.Methods. In a retrospective, non-randomized study, all patients who underwent CTA or stress testing (ETT or Tc-99m sestamibi SPECT MPI) as part of their ED assessment in 2010-2011 driven by ED attending preference and equipment availability were evaluated for their disposition from the ED (admission vs discharge, length of time to disposition), subsequent visits to the ED and diagnostic testing (within 3 months), and radiation exposure. CTA was performed using a 64-slice scanner (GE Lightspeed VCT) and MPI was performed using a CZT SPECT camera (GE Discovery 530c). Data were obtained from prospectively acquired electronic medical records and effective doses were calculated from published conversion factors. A propensity-matched analysis was also used to compare outcomes in the two groups.Results. A total of 1,458 patients underwent testing in the ED with 192 CTAs and 1,266 stress tests (327 ETTs and 939 MPIs). The CTA patients were a lower-risk cohort based on age, risk factors, and known heart disease. A statistically similar proportion of patients was discharged directly from the ED in the stress testing group (82% vs 73%, P 5 .27), but their time to disposition was longer (11.0 ± 5 vs 20.5 ± 7 hours, P < .0001). There was no significant difference in cardiac return visits to the ED (5.7% CTA vs 4.3% stress testing, P 5 .50), but more patients had follow-up studies in the CTA cohort compared to stress testing (14% vs 7%, P 5 .001). The mean effective dose of 12.6 ± 8.6 mSv for the CTA group was higher (P < .0001) than 5.0 ± 4.1 mSv for the stress testing group (ETT and MPI). A propensity score-matched cohort showed similar results to the entire cohort.Conclusions. Stress testing with ETT, high-efficiency SPECT MPI, and stress-only protocols had a significantly lower patient radiation dose and less follow-up diagnostic testing than CTA with similar cardiac return visits. CTA had a shorter time to disposition, but there was a trend toward more revascularization than with stress testing. (J Nucl Cardiol 2014;21:305-18.)

show abstract

“…28 Thus, the relationship among METS, stress-induced ischemia, and prognosis in diabetic subjects remains unclear. In another recent study, Duvall et al 29 showed that a provisional injection protocol defined as age \65, normal rest ECG, no history of CAD, and high level exercise (C10 METS) with a negative ECG response and no symptoms has a very low 5-year all-cause mortality and low yield of MPS. If adopted, this protocol would decrease radiation exposure and save time and health care costs without jeopardizing prognosis.…”

Section: Prognostic Value Of Exercise Level In Diabetic Patientsmentioning

confidence: 99%

Cardiovascular risk stratification in diabetic patients: Is all in METS?

Petretta

Acampa

Cuocolo

2014

Journal of Nuclear Cardiology

View full text Add to dashboard Cite

A hypothetical protocol for the provisional use of perfusion imaging with exercise stress testing

Cited by 17 publications

References 29 publications

Provisional use of myocardial perfusion imaging in patients undergoing exercise stress testing: A worthy concept fraught with challenges

Provisional use of myocardial perfusion imaging in patients undergoing exercise stress testing: A worthy concept fraught with challenges

A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department

Cardiovascular risk stratification in diabetic patients: Is all in METS?

Contact Info

Product

Resources

About