Current Cardiology Reports

, 16:472

Assessing the Prognostic Implications of Myocardial Perfusion Studies: Identification of Patients at Risk vs Patients who May Benefit from Intervention?

Nuclear Cardiology (V Dilsizian, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Nuclear Cardiology

Abstract

Stress myocardial perfusion imaging (MPI) has a well-established role in improving risk stratification. Recent analyses, compared with older data, suggest that the yield of stress MPI has decreased. In part, this trend relates to testing patients with heterogeneous, but improved, risk factor modification. In this setting, positron emission tomography with myocardial flow reserve enhances risk stratification as it reflects the end result of atherosclerosis. Recent studies have also emphasized the clinical impact of incremental risk stratification by assessing net reclassification improvement (NRI). Previous retrospective studies have favored an ischemic threshold to select patients that benefit from revascularization, but this finding has not been corroborated in randomized trials. However, no large randomized trial has directly tested a strategy of revascularization for patients with at least a moderate amount of ischemia at risk. Unfortunately, even when faced with a significantly abnormal MPI result, subsequent action is too often absent.

Keywords

Coronary artery disease Diabetes mellitus Early revascularization Myocardial perfusion imaging Single photon emission computed tomography Positron emission tomography Net reclassification improvement Myocardial flow reserve 

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Hachamovitch R, Berman DS, Shaw LJ, et al. Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction. Circulation. 1998;97:535–43.PubMedCrossRefGoogle Scholar
  2. 2.
    Hachamovitch R, Hayes S, Friedman JD, et al. Determinants of risk and its temporal variation in patients with normal stress myocardial perfusion scans. J Am Coll Cardiol. 2003;41:1329–40.PubMedCrossRefGoogle Scholar
  3. 3.
    Hachamovitch R, Hayes SW, Friedman JD, et al. Stress myocardial perfusion single-photon emission computed tomography is clinically effective and cost effective in risk stratification of patients with a high likelihood of coronary artery disease (CAD) but no known CAD. J Am Coll Cardiol. 2004;43:200–8.PubMedCrossRefGoogle Scholar
  4. 4.••
    Rozanski A, Gransar H, Hayes SW, et al. Temporal trends in the frequency of inducible myocardial ischemia during cardiac stress testing1991 to 2009. J Am Coll Cardiol. 2013;61:1054–65. This study documents the decline in abnormal SPECT tests over the past 2 decades even though pre-test probability of CAD did not decrease. Google Scholar
  5. 5.•
    Shaw LJ, Wilson PWF, Hachamovitch R, et al. Improved near-term coronary artery disease risk classification with gated stress myocardial perfusion SPECT. J Am Coll Cardiol Imaging. 2010;3:1139–48. This study demonstrated NRI with SPECT ischemia. Google Scholar
  6. 6.•
    Dorbala S, Di Carli MF, Beanlands RS, et al. Prognostic value of stress myocardial perfusion positron emission tomography: results from a multicenter observational registry. J Am Coll Cardiol. 2013;61:176–84. This study demonstrated NRI with PET ischemia and/or scar. Google Scholar
  7. 7.
    Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM, et al. ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina: Executive Summary and Recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). Circulation. 1999;99:2829–48.PubMedCrossRefGoogle Scholar
  8. 8.
    Ziadi MC, Williams KA, Guo A, et al. Impaired myocardial flow reserve on rubidium-82 positron emission tomography imaging predicts adverse outcomes in patients assessed for myocardial ischemia. J Am Coll Cardiol. 2011;58:740–8.PubMedCrossRefGoogle Scholar
  9. 9.•
    Murthy VL, Naya M, Foster CR, et al. Improved cardiac risk assessment with noninvasive measures of coronary flow reserve. Circulation. 2011;124:2215–24. There is a significant NRI with PET MFR even when added to clinical and other imaging variables. Google Scholar
  10. 10.
    Zellweger MJ, Weinbacher M, Zutter AW, et al. Long-term outcome of patients with silent vs symptomatic ischemia six months after percutaneous coronary intervention and stenting. J Am Coll Cardiol. 2003;42:33–40.PubMedCrossRefGoogle Scholar
  11. 11.
    Zellweger MJ, Lewin HC, Lai S, et al. When to stress patients after coronary artery bypass surgery? Risk stratification in patients early and late post-CABG using stress myocardial perfusion SPECT: implications of appropriate clinical strategies. J Am Coll Cardiol. 2001;37:144–52.PubMedCrossRefGoogle Scholar
  12. 12.
    Zellweger M. Risk stratification in patients with remote prior myocardial infarction using rest-stress myocardial perfusion SPECT: prognostic value and impact on referral to early catheterization. J Nucl Cardiol. 2002;9:23–32.PubMedCrossRefGoogle Scholar
  13. 13.••
    Aldweib N, Negishi K, Hachamovitch R, et al. Impact of repeat myocardial revascularization on outcome in patients with silent ischemia after previous revascularization. J Am Coll Cardiol. 2013;61:1616–23. This study showed that imaging variables did not prognosticate asymptomatic patients after revascularization and outcomes were not improved with repeat revascularization. Google Scholar
  14. 14.
    Roger VL, Go AS, Lloyd-Jones DM, et al. Heart Disease and Stroke Statistics—2011 update: a report from the American Heart Association. Circulation. 2011;123:e18–e209.PubMedCrossRefGoogle Scholar
  15. 15.
    Giri S, Shaw LJ, Murthy DR, et al. Impact of diabetes on the risk stratification using stress single-photon emission computed tomography myocardial perfusion imaging in patients with symptoms suggestive of coronary artery disease. Circulation. 2002;105:32–40.PubMedCrossRefGoogle Scholar
  16. 16.
    Young LH, Frans JT, Chyun DA, et al. Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes. JAMA. 2009;301:1547–55.PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Bourque JM, Patel CA, Ali MM, et al. Prevalence and predictors of ischemia and outcomes in outpatients with diabetes mellitus referred for single-photon emission computed tomography myocardial perfusion imaging. Circ Cardiovasc Imaging. 2013;6:466–77.PubMedCrossRefGoogle Scholar
  18. 18.••
    Murthy VL, Naya M, Foster CR, et al. Association between coronary vascular dysfunction and cardiac mortality in patients with and without diabetes mellitus. Circulation. 2012;126:1858–68. This study showed that diabetics without known CAD but with reduced MFR were at similar risk as diabetics with CAD. Google Scholar
  19. 19.
    The BARI 2D Study Group. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009;360:2503–15.Google Scholar
  20. 20.•
    Shaw LJ, Cerqueira MD, Brooks MM, et al. Impact of left ventricular function and the extent of ischemia and scar by stress myocardial perfusion imaging on prognosis and therapeutic risk reduction in diabetic patients with coronary artery disease: results from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. J Nucl Cardiol. 2012;19:658–69. Upon follow-up SPECT of diabetics with CAD, fixed perfusion defect was the strongest predictor of cardiac event, and patients assigned to revascularization had less perfusion abnormality. Google Scholar
  21. 21.
    Hachamovitch R, Hayes SW, Friedman JD, et al. Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation. 2003;107:2900–7.PubMedCrossRefGoogle Scholar
  22. 22.•
    Hachamovitch R, Rozanski A, Shaw LJ, et al. Impact of ischaemia and scar on the therapeutic benefit derived from myocardial revascularization vs medical therapy among patients undergoing stress-rest myocardial perfusion scintigraphy. Eur Heart J. 2011;32:1012–24. In patients without significant scar and moderate to severe ischemia on SPECT MPI, survival was improved with early revascularization. Google Scholar
  23. 23.
    Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356:1503–16.PubMedCrossRefGoogle Scholar
  24. 24.
    Shaw LJ, Berman DS, Maron DJ, et al. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the clinical outcomes utilizing revascularization and aggressive drug evaluation (COURAGE) Trial nuclear substudy. Circulation. 2008;117:1283–91.PubMedCrossRefGoogle Scholar
  25. 25.
    Berman D, Kang X, Schisterman EF, et al. Serial changes on quantitative myocardial perfusion SPECT in patients undergoing revascularization or conservative therapy. J Nucl Cardiol. 2001;8:428–37.PubMedCrossRefGoogle Scholar
  26. 26.•
    Shaw LJ, Weintraub WS, Maron DJ, et al. Baseline stress myocardial perfusion imaging results and outcomes in patients with stable ischemic heart disease randomized to optimal medical therapy with or without percutaneous coronary intervention. Am Heart J. 2012;164:243–50. Most SPECT tests inCOURAGE were not interpreted in a core lab and a six 6-segment model was used, raising issues about reliability and generalizability. Google Scholar
  27. 27.
    Berman DS, Kang X, Gransar H, et al. Quantitative assessment of myocardial perfusion abnormality on SPECT myocardial perfusion imaging is more reproducible than expert visual analysis. J Nucl Cardiol. 2009;16:45–53.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.••
    ISCHEMIA. Available at https://www.ischemiatrial.org/. A randomized controlled trial that is enrolling to assess whether patients with moderate to severe ischemia benefit from early revascularization.
  29. 29.
    Schaap J, de Groot JAH, Nieman K, et al. Hybrid myocardial perfusion SPECT/CT coronary angiography and invasive coronary angiography in patients with stable angina pectoris lead to similar treatment decisions. Heart. 2012;99:188–94.PubMedCrossRefGoogle Scholar
  30. 30.
    Maron DJ, Stone GW, Berman DS, et al. Is cardiac catheterization necessary before initial management of patients with stable ischemic heart disease? Results from a Web-based survey of cardiologists. Am Heart J. 2011;162:1034–43. e13.PubMedCrossRefGoogle Scholar
  31. 31.
    Beanlands RSB, Nichol G, Huszti E, et al. F-18-Fluorodeoxyglucose positron emission tomography imaging-assisted management of patients with severe left ventricular dysfunction and suspected coronary disease. J Am Coll Cardiol. 2007;50:2002–12.PubMedCrossRefGoogle Scholar
  32. 32.
    Bonow RO, Maurer G, Lee KL, et al. Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med. 2011;364:1617–25.PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Dilsizian V, Bonow RO. Current diagnostic techniques of assessing myocardial viability in patients with hibernating and stunned myocardium [published erratum appears in Circulation 1993;87:2070]. Circulation. 1993;87:1–20.PubMedCrossRefGoogle Scholar
  34. 34.
    Ling LF, Marwick TH, Flores DR, et al. Identification of therapeutic benefit from revascularization in patients with left ventricular systolic dysfunction: inducible ischemia versus hibernating myocardium. Circ Cardiovasc Imaging. 2013;6:363–72.PubMedCrossRefGoogle Scholar
  35. 35.
    Hachamovitch R, Fong Ling L, Jaber WA, Brunken RC, Cerqueira MC, Marwick TH. Impact of LV remodeling on the threshold of jeopardized myocardium needed for a survival benefit with CABG in patients with left ventricular systolic dysfunction: was STICH too simplistic? Circulation. 2012;126:A16450.Google Scholar
  36. 36.••
    Hachamovitch R, Nutter B, Hlatky MA, et al. Patient management after noninvasive cardiac imaging: results from SPARC (Study of Myocardial Perfusion and Coronary Anatomy Imaging Roles in Coronary Artery Disease). J Am Coll Cardiol. 2012;59:462–74. Rates of changes in medical therapy and referral to cardiac catheterization were low after moderately to severely abnormal stress tests. Google Scholar
  37. 37.
    Bateman TM, O'Keefe JH, Dong VM, et al. Coronary angiographic rates after stress single-photon emission computed tomographic scintigraphy. J Nucl Cardiol. 1995;2:217–23.PubMedCrossRefGoogle Scholar
  38. 38.
    Patel MR, Peterson ED, Dai D, Brennan JM, Redberg RF, Anderson HV, et al. Low diagnostic yield of elective coronary angiography. N Engl J Med. 2010;362:886–95.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Section of Cardiovascular Imaging, Department of Cardiovascular MedicineHeart and Vascular Institute, Cleveland ClinicClevelandUSA

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