Interrelation of Coronary Calcification, Myocardial Ischemia, and Outcomes in Patients With Intermediate Likelihood of Coronary Artery Disease

Schenker, Matthew P.; Dorbala, Sharmila; Hong, Eric; Rybicki, Frank J.; Hachamovitch, Rory; Kwong, Raymond Y.; Carli, Marcelo F. Di

doi:10.1161/circulationaha.107.717512

Cited by 347 publications

(252 citation statements)

References 34 publications

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“…We assume such patients might have low risk in the short-term but high risk in the long term for cardiovascular events, since patients with high CAC have been reportedly regarded as high risk patients [17]. Previous studies suggest patients without ischemia on MPI exhibit a stepwise increase in their risk of cardiac events with increasing CAC scores, indicating there might exist a warranty period for normal SPECT imaging [18,19]. Even if the MPI is normal, the addition of the CAC score may improve the detection of CAD, particularly severe multivessel CAD.…”

Section: Cac In Patients With Normal Spectmentioning

confidence: 99%

“…Also, another previous study showed that normal stress myocardial perfusion imaging is associated with low risk of cardiovascular risk with an annual event rate of 0.6-0.9% [2,11,18]. However, the wide range of CAC scores in patients with normal MPI suggests that stress perfusion imaging is limited in its ability to detect subclinical atherosclerosis.…”

Section: Cac In Patients With Normal Spectmentioning

confidence: 99%

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The relationship between stress-induced myocardial ischemia and coronary artery atherosclerosis measured by hybrid SPECT/CT camera

et al. 2011

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Objective: The coronary artery calcium (CAC) score and myocardial perfusion imaging can now be detected simultaneously using a hybrid SPECT/CT camera. However, there has been little evaluation on the relationship between stress-induced ischemia and coronary artery calcification in a Japanese population. The aim of this study was to investigate the relationship between these parameters and to elucidate the diagnostic value of the CAC score as an adjunct to myocardial perfusion imaging (MPI) for the assessment of coronary artery disease (CAD) in an intermediate-risk population.Methods: We retrospectively analyzed 105 patients (63% men, mean age 71 years) with CAD or suspected CAD who underwent MPI using SPECT/CT. CAC scanning was performed by using a SPECT/CT camera. Results: There was a significant difference in the CAC score between patients with ischemia (n=42) and those without ischemia

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Section: Cac In Patients With Normal Spectmentioning

confidence: 99%

Section: Cac In Patients With Normal Spectmentioning

confidence: 99%

The relationship between stress-induced myocardial ischemia and coronary artery atherosclerosis measured by hybrid SPECT/CT camera

et al. 2011

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“…The detection of CAC by SPECTor PET has been shown to provide incremental value to myocardial perfusion results (3,4,12). Specifically, when perfusion is normal, the addition of a CAC score can improve the detection of CAD-notably, severe multivessel CAD.…”

Section: Added Value Of Determination Of Coronary Calcium With Stressmentioning

confidence: 99%

Risk Assessment and Predictive Value of Coronary Artery Disease Testing

Shaw

Narula²

2009

J Nucl Med

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This review highlights and compares risk assessment, predictive accuracy, and economic outcomes for 3 commonly applied cardiac imaging procedures: stress myocardial perfusion SPECT or PET and coronary CT angiography (CCTA). This review highlights an expansive evidence base for stress myocardial perfusion imaging and reveals a decided advantage for higher-risk patients, notably those who have established coronary artery disease (CAD). It is likely that the use of CCTA will continue to expand, particularly for patients with more atypical symptoms and patients with a lower likelihood of CAD. Despite a high level of evidence, comparative research is not available across modalities that could definitively drive utilization of cardiac imaging modalities. Evi dence about the accuracy of a variety of noninvasive imaging tests for the identification of at-risk patients with known and suspected coronary artery disease (CAD) has been evolving. Most of the early published research on noninvasive cardiology, from the 1980s and early 1990s, focused on the diagnostic accuracy of a test. More recent research has focused on evaluating the ensuing risk in patients with normal and abnormal cardiac imaging findings. Further exploration has been aimed at the graded or directly proportional relationships between the extent and the severity of imaging risk markers and major adverse cardiovascular events. These relationships highlight a common theme throughout the literature of ever-increasing and worsening cardiac event risk with more extensive and severe imaging abnormalities. More recent topics in the prognosis literature are the utility of new technology, such as coronary CT angiography (CCTA), and its accuracy compared with that of conventional testing, such as stress nuclear imaging. For this report, we compare risk assessment, predictive accuracy, and economic outcomes for 3 commonly applied cardiac imaging procedures: stress myocardial perfusion SPECT or PET and CCTA. We further highlight the potential value of hybrid imaging with PET/CT or even sequential imaging with SPECT plus CT. CORRELATION BETWEEN MYOCARDIAL ISCHEMIA AND CORONARY ANATOMYEarly research focused on the accuracy of stress nuclear imaging for detecting obstructive coronary stenosis. Lessons learned from these evaluations were that the detection of obstructive stenosis was related to the severity of the stenosis, collateral flow, and underlying endothelial function. Documentation of high rates of false-positive results (i.e., ischemia with no obstructive CAD) with stress myocardial perfusion may be related to vascular dysfunction, an early marker of atherosclerosis. In addition, normal stress perfusion results in patients with CAD are related to many factors, including collateral blood flow or prior coronary revascularization. It is for these reasons that much of the recent imaging research has focused on risk determination. However, for discussion purposes, it is helpful to understand the relationship between ischemia and coronary anatomy. INDUCIBLE ISCHEMIA D...

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“…A study by Thilo et al [39] demonstrated that fast assessment of CAD is possible with an integrated SPECT/CT system. The combination of CAC and MPI SPECT is needed for optimal evaluation of CAD [40,41]. Combined SPECT/CT acquisition is more patient friendly, and only one visit to the imaging department is requested.…”

Section: Combined Spect/ctmentioning

confidence: 99%

Diagnostic pathway of integrated SPECT/CT for coronary artery disease

Slart

Tio

Zijlstra

et al. 2009

Eur J Nucl Med Mol Imaging

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Treatment strategy in patients with suspected coronary artery disease (CAD) is driven by symptomatology in combination with diagnostic evaluation of the extent and/or severity of atherosclerosis in the coronary arteries and ischemia in the myocardium, i.e., the anatomic and functional correlates of CAD. Whereas multislice row computed tomography (MSCT) has the advantage of detecting coronary atherosclerosis at its earliest stages, thereby allowing initiation of appropriate therapeutic measures well before development of obstructive CAD, myocardial perfusion imaging (MPI) SPECT can clarify the hemodynamic consequences of the anatomic findings on MSCT based on a functional assessment of myocardial blood flow. There is a lack of correlation between coronary artery calcium (CAC), coronary artery stenosis, and MPI SPECT. Therefore CAC scoring and stress MPI should be thus considered complementary approaches rather than exclusionary in the evaluation of the patient at risk for CAD. The integration of anatomic and functional information may provide additional information for the clinician by the improved risk stratification and diagnostic accuracy of integrated techniques. The majority of previous studies are based on a sequential flowchart, starting with either SPECT or CAC scoring that finally directs the therapeutic strategy. Patients at low risk for CAD can be selected for primary prevention, and patients at high risk for CAD can be directly selected for coronary angiography (CAG). The remaining group of patients at intermediate risk for CAD can be substratified into lower-and higher-risk categories based on the presence or absence of stress-induced ischemia on MPI SPECT and CAC scoring. An integration of SPECT and CAC as a starting point for CAD detection in symptomatic patients at intermediate risk for CAD may facilitate a tailored diagnostic as well as therapeutic approach. Finally, using SPECT/CT, MPI SPECT, and CAC findings may be completed with CT angiography. The development of SPECT/ CT hybrid systems is therefore of important value for the nuclear cardiology armamentarium. This editorial commentary outlines a diagnostic pathway of integrated SPECT/CT for CAD assessment in symptomatic patients at intermediate risk for CAD.

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Interrelation of Coronary Calcification, Myocardial Ischemia, and Outcomes in Patients With Intermediate Likelihood of Coronary Artery Disease

Cited by 347 publications

References 34 publications

The relationship between stress-induced myocardial ischemia and coronary artery atherosclerosis measured by hybrid SPECT/CT camera

The relationship between stress-induced myocardial ischemia and coronary artery atherosclerosis measured by hybrid SPECT/CT camera

Risk Assessment and Predictive Value of Coronary Artery Disease Testing

Diagnostic pathway of integrated SPECT/CT for coronary artery disease

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