A multi-center assessment of the temporal trends in myocardial perfusion imaging

Duvall, W. Lane; Rai, Mridula; Ahlberg, Alan W.; O’Sullivan, David; Henzlova, Milena J.

doi:10.1007/s12350-014-0051-x

Cited by 60 publications

(39 citation statements)

References 21 publications

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“…5 The population of coronary disease patients has grown over the past two decades and a greater percentage of patients now studied by nuclear stress testing are those with known coronary artery disease than in the past. 2 The Duval study also confirms that there has been a particularly big drop in the number of patients with severe ischemia. This likely reflects larger trends in how our patients are managed, their outcomes, and public knowledge about heart disease.…”

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confidence: 74%

“…The frequency of angiographic one vessel and multivessel coronary artery disease has shown similar decreases in the author's institutions cardiac catheterization laboratories as well. 2 Although there are several potential explanations for these finding, (i.e., changing referral patterns and improved camera technology) the data taken together particularly support the conclusion that the burden of coronary atherosclerotic disease is less than it used to be.…”

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confidence: 93%

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More risk factors, less ischemia, and the relevance of MPI testing

Thompson

Allam

2015

Journal of Nuclear Cardiology

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Section: See Related Article Pp 539-551mentioning

confidence: 74%

Section: See Related Article Pp 539-551mentioning

confidence: 93%

More risk factors, less ischemia, and the relevance of MPI testing

Thompson

Allam

2015

Journal of Nuclear Cardiology

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“…16,17 In a study by Rozanski et al of 39,515 patients with no history of CAD that underwent diagnostic stress MPI from 1991 to 2009, the prevalence of normal MPI studies was noted to have increased among all subgroups from a prevalence rate of 59.1% in 1991, to 91.3% in 2009. 16 In a recent multicenter study of 108,654 patients undergoing clinically indicated stress MPI studies, an overall increase in the prevalence of normal studies was seen from 1996 to 2012 in all patients (46.2% to 68.2%), patients without CAD (67.8% to 82%), and patients with CAD (25.3% to 39.2%).…”

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confidence: 99%

“…16 In a recent multicenter study of 108,654 patients undergoing clinically indicated stress MPI studies, an overall increase in the prevalence of normal studies was seen from 1996 to 2012 in all patients (46.2% to 68.2%), patients without CAD (67.8% to 82%), and patients with CAD (25.3% to 39.2%). 17 If only half of the patients who undergo a stress-first protocol are normal and do not undergo rest imaging, the ASNC goal could be met solely by converting a laboratory to a stress-first approach instead of the standard rest-stress structure of most nuclear laboratories.…”

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confidence: 99%

Nuclear cardiology as it should look in the twenty-first century

Duvall

Henzlova

2016

Journal of Nuclear Cardiology

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The currently used Tc-99m-based myocardial perfusion imaging (MPI) protocols were developed over 25 years ago. Considering the length of the tests (4 hours), consequent inconvenience to the patients, and radiation doses ([12 mSV), the decline in competiveness with other non-invasive modalities used for the diagnosis of coronary artery disease (cardiac CTA and stress echocardiography) seen in recent years becomes apparent. For SPECT MPI to remain relevant, the field must evolve which requires new approaches to the old problems. Recent technological advances (new software and advent of high-efficiency cameras) present the field an opportunity to emerge into the twenty-first century reinvigorated. European practices (mostly performed and regulated by non-cardiologists) are ahead of the United States in one important respect: the stress portion of the test is done first and the rest portion is done selectively only if needed.In this issue of the Journal, Sharir et al from Assuta Medical Center in Tel Aviv tested a combination of a stress-first protocol and low tracer doses using a highefficiency SPECT camera for its diagnostic accuracy. 1 They evaluated 284 patients without known CAD undergoing stress-first imaging, 208 of which underwent coronary angiography. Diagnostic performance using automated quantification of the stress perfusion images was compared in patients who underwent a ''half-dose'' 5 mCi stress/15 mCi rest protocol to those who had a ''standard dose'' 10 mCi stress/30 mCi rest protocol during different time periods. The very low-stress dose (5 mCi) used in this work is below the 10 mCi low-dose stress-first protocol used with conventional Na-I cameras (even with iterative reconstruction time software) and is made possible by the high-efficiency SPECT camera hardware employed. As expected, sensitivity, specificity, and accuracy were acceptable and similar in the low and standard tracer dose groups.In 2010, an ASNC Information Statement on recommendations for reducing radiation exposure suggested that by 2014 on average a total radiation exposure of B9 mSv could be achieved in 50% of MPI studies.2 Determining whether this goal has been met in general clinical practice is problematic, but one cannot argue that we do not have the tools to easily achieve this goal. High-efficiency SPECT cameras, new iterative reconstruction time software on conventional SPECT cameras, as well as a stress-first approach to most patients can all achieve this goal individually and in combination.The reduction in effective dose to the patient which was seen in the current study was impressive (Figure 1). The average doses of 10.2 and 30.3 mCi in the standard dose protocol results in 11.7 mSv of exposure which is reduced by 74% to 3 mSv when a stress-only study is performed. When high-efficiency SPECT technology is added by cutting the administered activity in half, further reduction in effective dose by 42% is achieved. The dose stress-rest protocol of 5 and 15 mCi results in 6.9 mSv of exposure which is cut to 1.7 mSv if a s...

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“…First, it may be related to the downtrend in the burden of myocardial ischemia and coronary disease burden which has been reported in recent literature. 7,8 Second, this observation may be due to MPI testing of lower risk population over the years, coinciding with the switch from adenosine to regadenoson. Testing a lower risk population may be directly related to the switch to regadenoson.…”

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The prognostic value of regadenoson stress: Has the case been made?

Doukky

2015

Journal of Nuclear Cardiology

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Since its approval by the Food and Drug Administration in April of 2008, regadenoson has enjoyed a wide implementation by nuclear cardiology laboratories. Presently, it is the preferred vasodilator stress agent in the United States, being used in 8 out of 10 pharmacologic stress SPECT myocardial perfusion imaging (MPI) studies.1 The initial approval of regadenoson was based on two phase 3 ADVANCE-MPI trials, in which regadenoson was demonstrated to produce perfusion defects similar to those induced by standard 6 minute adenosine infusion.2,3 Although diagnostic noninferiority of regadenoson was effectively demonstrated, prognostic noninferiority was beyond the scope of the ADVANCE-MPI trials. Nonetheless, given the similarity in perfusion images, the prognostic value of regadenoson stress was presumed to parallel that of adenosine.In nuclear cardiology, a field that prides itself on vast wealth of outcomes data, extending the prognostic utility of adenosine to regadenoson is just not good enough. In recent years, several studies have investigated the prognostic value of regadenoson stress MPI. Iqbal et al compared the 2-year outcome of patients with normal regadenoson MPI (n = 1,000) to those with normal adenosine MPI (n = 1,000) for the composite endpoint of cardiac death, myocardial infarction, and coronary revascularization. 4 The annual event rate was 1.1% in the regadenoson group and 1.7% in the adenosine group (P = 0.090) and the annual cardiac death rate was 0.9% and 1.15% (P = 0.404), respectively. In propensity score matched analysis of 505 patients from each group, the respective annual event rates in the regadenoson and adenosine groups were 0.7% and 1.3% (P = 0.257) for the primary outcome, and 0.5% and 0.7% (P = 0.763) for cardiac death. Thus, the study effectively demonstrated that, as with normal adenosine MPI, a normal regadenoson MPI predicts very low event rates. 4 More recently, Hage et al evaluated the prognostic value of regadenoson stress in 1,400 subjects (700 consecutive normal MPI and 700 consecutive abnormal MPI).5 Based on the quantitative perfusion defect size (percentage of left ventricular myocardium), the cohort was divided into four groups: Group 1, normal (\5%); Groups 2, small defect (\10%); Group 3, moderate sized defect (10%-20%); Group 4, large defect ([20%). During a mean follow-up of 4 years, the composite endpoint of cardiac death, myocardial infarction, and late coronary revascularization ([90 days after MPI) occurred in 10, 27, 31, and 43% (P \ 0.001); while early revascularization (\90 days) occurred in 0.4, 9, 17, and 17% in Groups 1-4, respectively (P \ 0.001). The authors demonstrated a step-wise increase in event rates commensurate with the size of regadenoson-induced defect. The study showed that, as with other stress agents, regadenoson MPI provides powerful prognostic information which can guide clinical decision-making. 5In this issue of the journal, Farzaneh-Far et al compared the prognostic value of regadenoson and adenosine MPI in 3,698 consecutive patients (...

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A multi-center assessment of the temporal trends in myocardial perfusion imaging

Cited by 60 publications

References 21 publications

More risk factors, less ischemia, and the relevance of MPI testing

More risk factors, less ischemia, and the relevance of MPI testing

Nuclear cardiology as it should look in the twenty-first century

The prognostic value of regadenoson stress: Has the case been made?

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