The diagnostic and prognostic value of near-normal perfusion or borderline ischemia on stress myocardial perfusion imaging

Kassab, Kameel; Hussain, Kifah; Torres, Andrea; Iskander, Fady; Iskander, Mina; Khan, Rashid; Doukky, Rami

doi:10.1007/s12350-020-02375-y

Cited by 8 publications

(8 citation statements)

References 30 publications

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“…Normal SPECT-MPI has been associated with low rates of cardiac death and non-fatal myocardial infarction (<1%/year) [ 10 ]. A recent study by Kassab et al stated that, compared with patients with normal SPECT-MPI (SSS = 0), patients with near normal perfusion (SSS 1-3) had a higher rate of obstructive CAD, although no difference was found in the incidence of hard cardiac events [ 11 ]. The purpose of our study was to evaluate the incidence of significant CAD in patients with non-perfusion high-risk markers of ischemia, namely LVEF reduction on stress study and TID, despite a normal SPECT-MPI.…”

Section: Discussionmentioning

confidence: 99%

The Impact of Left Ventricle Ejection Fraction Reduction and Transient Ischemic Dilation in Patients With Normal Single-Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging

Medeiros¹,

Pereira²,

Rodrigues³

2022

Cureus

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Introduction: Coronary artery disease (CAD) is a leading cause of death in developed countries. Noninvasive functional imaging modalities are currently recommended as initial diagnostic tests in patients with an intermediate-high pretest probability of CAD. Single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) creates images of regional myocardial tracer uptake, reflecting relative myocardial blood flow. However, there are other non-perfusion predictors of CAD, such as transient ischemic dilatation (TID) and reduced post-stress left ventricle ejection fraction (LVEF). Available data regarding these parameters is controversial. The aim of our study was to evaluate the incidence of significant CAD in patients with non-perfusion high-risk markers of ischemia despite a normal SPECT-MPI.Methods: Single-center, observational, retrospective, and longitudinal study. Inclusion criteria were age ≥18 years, normal SPECT-MPI, and availability of gated study for LVEF and volume analysis. Exclusion criteria were any known cardiomyopathy or congenital heart disease and known CAD. Non-perfusion high-risk markers: LVEF reduction ≥5% on post-stress images; TID (defined as a stress/rest left ventricle volume ratio ≥ 1.15), including end-systolic, end-diastolic, and mean volumes. The primary endpoint was the identification of significant CAD (stenosis >70% on an epicardial coronary artery or >50% on the left main artery) on invasive coronary angiography.Results: A total of 197 patients met the inclusion criteria. Mean age was 64 ± 12.6 years and 59.4% (n = 117) of patients were male. Overall, 26% of patients had LVEF reduction ≥5% on stress study; 24.9% had a stress/rest end-systolic volume ratio ≥ 1.15; 7.1% had a stress/rest mean volume ratio ≥ 1.15; 7.1% had a stress/rest end-diastolic volume ratio ≥ 1.15. Time-to-primary endpoint was significantly lower in patients with LVEF reduction ≥5% on stress study ); p = 0.003) and in patients with stress/rest end-systolic volume ratio ≥ 1. ); p = 0.013). Conclusion:In patients with normal perfusion on SPECT-MPI, the incidence of significant CAD was significantly higher in those with LVEF reduction ≥ 5% on stress study and in those with a stress/rest endsystolic volume ratio ≥ 1.15, during a follow-up period of five years.

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Section: Discussionmentioning

confidence: 99%

The Impact of Left Ventricle Ejection Fraction Reduction and Transient Ischemic Dilation in Patients With Normal Single-Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging

Medeiros¹,

Pereira²,

Rodrigues³

2022

Cureus

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“…Ischemia changes can develop even without obvious severe coronary artery obstruction [7][8][9]. Single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is the most reliable noninvasive method by which to detect myocardial ischemia [10][11][12][13]; the technique directly examines coronary artery perfusion and determines the speci c location, scope, and extent of ischemia [14]. MPI accurately evaluates the prognosis of patients with coronary heart disease.…”

Section: Introductionmentioning

confidence: 99%

Prognostic utility of 99mTc-MIBI single photon emission computerized tomography myocardial perfusion imaging in patients with ischemia and non-obstructive coronary artery disease

Wang

Xie

et al. 2023

Preprint

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Purpose The prognosis of patients with ischemia and non-obstructive coronary artery disease (INOCA) remains controversial; most do not undergo accurate disease evaluation and treatment, and the symptoms recur. Here, we used single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI) to evaluate patients with INOCA. We sought to stratify patients more accurately and thus derive more reliable prognostic information. Materials and methods In total, 167 patients with INOCA were enrolled. All underwent invasive coronary angiography (CAG) and SPECT MPI within 1 week. The patients were divided into different groups according to their test results. Patients were followed-up regularly in terms of major adverse cardiovascular events (MACEs), including cardiac death, nonfatal myocardial infarction, stroke, re-hospitalization with angina pectoris, and recurrent angina pectoris. Kaplan-Meier curves and Cox’s proportional hazards models were used to analyze survival and identify predictive factors. Results Adverse cardiac events occurred in 33 cases (19.8%). The rate of MACEs was higher in the summed stress score (SSS) ≥ 4 group than in the SSS 0–3 group (30.1% vs 9.5%, respectively, P = 0.001) and event-free survival was lower (annual survival of 87.5% vs 96.2%, respectively, P = 0.003). Event-free survival was consistently higher in patients with normal arteries than in those with non-obstructive coronary artery disease (annual survival rates of 96.1% and 88.4%, P = 0.035). When the SSS scores and the CAG results were combined, patients with normal coronary arteries (SSS 0–3) had the best prognosis and those with non-obstructive coronary artery stenosis (SSS ≥ 4) had the worst. However, the early prognosis of patients with non-obstructive coronary artery disease and SSS scores of 0–3 was comparable to that of patients with normal coronary arteries and SSS scores ≥ 4 (annual survival rates of 100%, 94.6%, 93.1%, and 78.2%, respectively). Multivariate Cox’s regression indicated that the SSS score (hazard ratio [HR] = 1.126, 95% confidence interval [CI] 1.042–1.217, P = 0.003) and non-obstructive coronary artery disease (HR = 2.559, 95% CI 1.249–5.246, P = 0.01) were predictors of adverse cardiac events. Conclusion SPECT MPI data were prognostic for INOCA patients, thus identifying groups at high risk. The long-term predictive efficacy of such data exceeded that of CAG data. A combination of the two measures more accurately stratified INOCA patients in terms of risk.

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“…However, SPECT-MPI has several disadvantages and a high false negative rate ( 4 , 5 ). Even if the results of the MPI are normal, there is still a potential risk of cardiac death, myocardial infarction (MI), or late coronary revascularization ( 6 , 7 ). Therefore, improving the risk stratification of populations with suspected or known CAD with normal LVEF and the prediction of MPI for MACE is necessary.…”

Section: Introductionmentioning

confidence: 99%

“…In addition, it quantitatively assesses the coronary artery calcium score (CACS) and epicardial fat volume (EFV) simultaneously. CACS has been reported to be associated with MACE, which is controversial ( 8 ), and there are racial differences in CACS, with the lowest levels found in Asians ( 9 ).…”

Section: Introductionmentioning

confidence: 99%

“…In addition, a large population study ( 16 ) which included 5,743 Chinese patients showed that EFV improved the prediction of CAD, compared with clinical risk factors and CACS. There were significant racial differences in EFV ( 17 , 18 ), and it was reported that EFV had an increased value in predicting MACE in western populations ( 8 ). The relationship between EFV and MACE and whether EFV can provide an incremental prognostic value to MPI in Chinese populations with suspected or known CAD with normal LVEF is still unknown.…”

Section: Introductionmentioning

confidence: 99%

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Epicardial fat volume, an independent risk factor for major adverse cardiovascular events, had an incremental prognostic value to myocardial perfusion imaging in Chinese populations with suspected or known coronary artery disease with a normal left ventricular ejection fraction

Yang,

Yu,

Wan

et al. 2023

Front. Cardiovasc. Med.

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BackgroundMost coronary artery disease (CAD) patients with a normal left ventricular ejection fraction (LVEF) experience a poor prognosis. Single-photon emission computerized tomography (SPECT)–myocardial perfusion imaging (MPI), a routine examination, is useful in assessing risk and predicting major adverse cardiovascular events (MACEs) in populations with suspected or known CAD. SPECT/CT is a “one-stop shop” examination, which, through non-contrast CT, can produce attenuation correction for MPI and obtain information on coronary artery calcium (CAC) and epicardial fat volume (EFV) simultaneously. This study aims to investigate the predictive and incremental value of EFV to MPI for MACE in Chinese populations with suspected or known CAD with a normal LVEF.Methods and resultsWe retrospectively studied 290 suspected or known CAD inpatients with a normal LVEF who underwent SPECT/CT between February 2014 and December 2017. Abnormal MPI was defined as a summed stress score ≥4 or summed difference score ≥2. EFV and CAC were calculated using non-contrast CT. The end date of follow-ups was in February 2022. The follow-up information was obtained from the clinical case notes of the patients or reviews of telephone calls. MACE was defined as cardiac death, late coronary revascularization ≥3 months after MPI, non-fatal myocardial infarction, angina-related rehospitalization, heart failure, and stroke. During the 76-month follow-up, the event rate was 32.0% (93/290). Univariate and multivariate Cox regression analyses concluded that high EFV (>108.3 cm3) [hazard ratio (HR): 3.3, 95% CI: 2.1–5.2, P < 0.000] and abnormal MPI (HR: 1.8, 95% CI: 1.1–2.8, P = 0.010) were independent risk factors for MACE. The event-free survival of patients with high EFV was significantly lower than that of the low EFV group (log-rank test P < 0.001). In the subgroup with normal MPI, high EFV was associated with reduced event-free survival (log-rank P < 0.01), with a higher annualized event rate (8.3% vs. 1.9%). Adding high EFV to MPI could predict MACEs more effectively, with a higher concordance index (0.56–0.69, P < 0.01), higher global chi square (7.2–41.4, P < 0.01), positive integrated discrimination improvement (0.10, P < 0.01), and net reclassification index (0.37, P < 0.01).ConclusionsIn Chinese populations with suspected or known CAD with normal LVEF, high EFV was an independent risk factor for MACE after adjusting for traditional risk factors, CAC and MPI. In subgroups with normal MPI, EFV could also improve risk stratification. Adding EFV to MPI had an incremental value for predicting MACE.

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The diagnostic and prognostic value of near-normal perfusion or borderline ischemia on stress myocardial perfusion imaging

Cited by 8 publications

References 30 publications

The Impact of Left Ventricle Ejection Fraction Reduction and Transient Ischemic Dilation in Patients With Normal Single-Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging

The Impact of Left Ventricle Ejection Fraction Reduction and Transient Ischemic Dilation in Patients With Normal Single-Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging

Prognostic utility of 99mTc-MIBI single photon emission computerized tomography myocardial perfusion imaging in patients with ischemia and non-obstructive coronary artery disease

Epicardial fat volume, an independent risk factor for major adverse cardiovascular events, had an incremental prognostic value to myocardial perfusion imaging in Chinese populations with suspected or known coronary artery disease with a normal left ventricular ejection fraction

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