Diagnostic Accuracy of Stress Myocardial Perfusion Imaging Compared to Invasive Coronary Angiography With Fractional Flow Reserve Meta-Analysis

Abstract

Background— Hemodynamically significant coronary artery disease is an important indication for revascularization. Stress myocardial perfusion imaging is a noninvasive alternative to invasive fractional flow reserve for evaluating hemodynamically significant coronary artery disease. The aim was to determine the diagnostic accuracy of myocardial perfusion imaging by single-photon emission computed tomography, echocardiography, MRI, positron emission tomography, and computed tomography compared with invasive coronary angiography with fractional flow reserve for the diagnosis of hemodynamically significant coronary artery disease. Methods and Results— The meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. PubMed, EMBASE, and Web of Science were searched until May 2014. Thirty-seven studies, reporting on 4721 vessels and 2048 patients, were included. Meta-analysis yielded pooled sensitivity, pooled specificity, pooled likelihood ratios (LR), pooled diagnostic odds ratio, and summary area under the receiver operating characteristic curve. The negative LR (NLR) was chosen as the primary outcome. At the vessel level, MRI (pooled NLR, 0.16; 95% confidence interval [CI], 0.13–0.21) was performed similar to computed tomography (pooled NLR, 0.22; 95% CI, 0.12–0.39) and positron emission tomography (pooled NLR, 0.15; 95% CI, 0.05–0.44), and better than single-photon emission computed tomography (pooled NLR, 0.47; 95% CI, 0.37–0.59). At the patient level, MRI (pooled NLR, 0.14; 95% CI, 0.10–0.18) performed similar to computed tomography (pooled NLR, 0.12; 95% CI, 0.04–0.33) and positron emission tomography (pooled NLR, 0.14; 95% CI, 0.02–0.87), and better than single-photon emission computed tomography (pooled NLR, 0.39; 95% CI, 0.27–0.55) and echocardiography (pooled NLR, 0.42; 95% CI, 0.30–0.59). Conclusions— Stress myocardial perfusion imaging with MRI, computed tomography, or positron emission tomography can accurately rule out hemodynamically significant coronary artery disease and can act as a gatekeeper for invasive revascularization. Single-photon emission computed tomography and echocardiography are less suited for this purpose.

Advanced Noninvasive Cardiac Imaging using Cardiac Magnetic Resonance Imaging in the Diagnosis and Evaluation of Coronary Artery Disease

“…Previous multicenter, multivendor head-to-head comparison trials have suggested that perfusion MRI is a valuable alternative to SPECT for the detection of significant anatomic CAD, with superior diagnostic performance, especially in multivessel disease (17)(18)(19). In a recent metaanalysis, myocardial perfusion MRI demonstrated a sensitivity of 89% and specificity of 87% for the diagnosis of hemodynamically significant CAD using a X-ray coronary angiography with fractional flow reserve as a reference standard on a per-patient level, which are similar to those of PET (84% and 87%, respectively) and superior to those of SPECT (74% and 79%, respectively) (20). In addition, vasodilator stress myocardial perfusion MRI provides prognostic value in patients with biomarker negative angina and reclassifies risk in patients with prior CAD (21,22).…”

Fractional Flow Reserve and Coronary Computed Tomographic Angiography

“…A recent meta-analysis (Table 1) highlighted the inferior accuracy of MPI and stress echocardiography to CTA alone for identifying invasive FFR of ≤0.80 and may explain the better outcomes discussed above for CTA-guided treatment. 28 In addition, in a study of 67 patients with multivessel disease, MPI was particularly suboptimal, with 61% sensitivity, 69% specificity, 47% positive predictive value (PPV), and 80% negative predictive value (NPV). 29 Interestingly, stress MRI and positron emission tomography (PET) performed at least as well as CTA alone, but these technologies are expensive and are not widely used.…”

PET should not replace routine SPECT MPS for the assessment of patients with known or suspected CAD

“…When compared with invasive coronary angiography with fractional flow reserve, sensitivity is maintained but specificity is lower (61%). 5 Regardless, the prognostic value of normal MPS is well recognized, with an annual coronary event rate\1%. 6 Although such patients may be further stratified by anatomical tests such as invasive or CT coronary angiography, patients with a normal study can usually be reassured without the need for further testing.…”

“…These disadvantages may explain in part the performance of SPECT MPS in modern comparisons with other techniques such as CMR 12 and fractional flow reserve. 5 Positron emission tomography (PET) MPS has many of the virtues of SPECT and it is often considered to be superior because of its spatial resolution and the ability to quantify perfusion in absolute terms. However, proposing PET as a routine replacement for SPECT requires several questions to be answered: …”