Impact of Appropriate Use on the Prognostic Value of Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging

• Published in: Circulation (New York, N.Y.) Vol. 128; no. 15; pp. 1634 - 1643
• Main Authors: Doukky, Rami, Hayes, Kathleen, Frogge, Nathan, Balakrishnan, Gautam, Dontaraju, Venkata Satish, Rangel, Maria O., Golzar, Yasmeen, Garcia-Sayan, Enrique, Hendel, Robert C.
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD by the American College of Cardiology Foundation and the American Heart Association, Inc 08.10.2013; Lippincott Williams & Wilkins
• Subjects: Aged; Angioplasty, Balloon, Coronary; Biological and medical sciences; Blood and lymphatic vessels; Cardiology. Vascular system; Death; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Exercise Test - methods; Female; Follow-Up Studies; Humans; Male; Medical sciences; Middle Aged; Myocardial Ischemia - diagnostic imaging; Myocardial Ischemia - mortality; Myocardial Ischemia - therapy; Myocardial Perfusion Imaging - methods; Outcome and Process Assessment (Health Care); Physicians' Offices; Prognosis; Prospective Studies; Risk Factors; Tomography, Emission-Computed, Single-Photon - methods; Radionuclide study; Prognosis; myocardial perfusion imaging; tomography, emission-computed, single-photon; Radiodiagnosis; Use; Emission; Cardiovascular disease; Single photon emission tomography; Photon; Recommendation; Perfusion imaging; outcome assessment (health care); Myocardium; Tomography; Predictive value; Evolution; Healthcare; Circulatory system; Cardiology; prognosis
• ISSN: 0009-7322; 1524-4539; 1524-4539
• DOI: 10.1161/CIRCULATIONAHA.113.002744

BACKGROUND—Appropriate use criteria (AUC) have been developed to aid in the optimal use of single-photon emission computed tomography (SPECT)–myocardial perfusion imaging (MPI), a technique that is a mainstay of risk assessment for ischemic heart disease. The impact of appropriate use on the prognostic value of SPECT-MPI is unknown. METHODS AND RESULTS—A prospective cohort study of 1511 consecutive patients undergoing outpatient, community-based SPECT-MPI was conducted. Subjects were stratified on the basis of the 2009 AUC for SPECT-MPI into an appropriate or uncertain appropriateness group and an inappropriate group. Patients were prospectively followed up for 27±10 months for major adverse cardiac events of death, death or myocardial infarction, and cardiac death or myocardial infarction. In the entire cohort, the 167 subjects (11%) with an abnormal scan experienced significantly higher rates of major adverse cardiac events and coronary revascularization than those with normal MPI. Among the 823 subjects (54.5%) whose MPIs were classified as appropriate (779, 51.6%) or uncertain (44, 2.9%), an abnormal scan predicted a multifold increase in the rates of death (9.2% versus 2.6%; hazard ratio, 3.1; P=0.004), death or myocardial infarction (11.8% versus 3.3%; hazard ratio, 3.3; P=0.001), cardiac death or myocardial infarction (6.7% versus 1.7%; hazard ratio, 3.7; P=0.006), and revascularization (24.7% versus 2.7%; hazard ratio, 11.4; P<0.001). Among the 688 subjects (45.5%) with MPI classified as inappropriate, an abnormal MPI failed to predict major adverse cardiac events, although it was associated with a high revascularization rate. Furthermore, appropriate MPI use provided incremental prognostic value beyond myocardial perfusion and ejection fraction data. CONCLUSIONS—When performed for appropriate indications, SPECT-MPI continues to demonstrate high prognostic value. However, inappropriate use lacks effectiveness for risk stratification, further emphasizing the need for optimal patient selection for cardiac testing.