Journal of Nuclear Cardiology

, Volume 20, Issue 6, pp 1002–1012 | Cite as

Stress myocardial perfusion imaging for the evaluation and triage of chest pain in the emergency department: A randomized controlled trial

  • Swee Han LimEmail author
  • Venkataraman Anantharaman
  • Felix Sundram
  • Edwin Shih-Yen Chan
  • Ee Sin Ang
  • Sui Lan Yo
  • Edward Jacob
  • Anthony Goh
  • Say Beng Tan
  • Terrance Chua
Original Article



Patients with acute coronary syndrome (ACS) often present atypically. In a randomized controlled trial, we studied whether adding stress myocardial perfusion imaging (SMPI) to an evaluation strategy for emergency department (ED) patients presenting with chest pain more effectively identifies patients with ACS.


Participants were randomized to standard ED chest pain protocol (clinical assessment) or standard protocol supplemented with SMPI results. During 6 hours of electrocardiogram (ECG) monitoring and serial cardiac markers (creatine kinase-MB isoenzyme, troponin), participants developing ST segment changes or elevated cardiac markers were admitted. Those with a negative observation period underwent SMPI (N = 1,004) or clinical assessment (N = 504) based on randomization, and admitted if their SMPI scan was abnormal or senior clinicians found a high or intermediate risk for ACS.


SMPI participants had a significantly lower admission rate than clinical assessment participants (10.16% vs 18.45%), with no significant between-group differences in risk of cardiac events (CEs) after 30 days (0.40% vs 0.79%) or 1 year (0.70% vs 0.99%).


When added to a standard triage strategy incorporating clinical evaluation, serial ECGs, and cardiac markers, SMPI improved clinical decision making for chest pain patients, significantly reducing the need for hospitalization without an increase in adverse CE rates at 30 days or 1 year.


Cardiac event acute coronary syndrome acute chest pain cardiac troponin risk stratification emergency department 



This study was supported by grants from the National Medical Research Council, Ministry of Health, Singapore [Grant Numbers NMRC/0517/2001]. We acknowledge the assistance and efforts of the doctors, nurses, and staff from the Department of Emergency Medicine, Department of Nuclear Medicine and Division of Biochemistry at Singapore General Hospital, and the Department of Cardiology at the National Heart Centre Singapore. We acknowledge Ms. Kelly Wong, Ms. Evelyn Tan, Ms. Cheong Xiu Hui Priscilla, Ms. Tang Ling Hui, Dr Thander Aye, Dr Nilar Hla, and Dr Thein Htay Oo who were instrumental in ensuring that data capture was complete, and Dr Tan Tiong Peng, Dr Fong Yuke Tien, and Dr Rabind Charles for overseeing the conduct of the stress testing. The authors appreciate the support of the editorial assistance provided by Jon Kilner, MS, MA (Pittsburgh, PA, USA), who was funded through the Singapore Clinical Research Institute, Ministry of Health Holdings.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342:1163-70.PubMedCrossRefGoogle Scholar
  2. 2.
    McClelland AJJ, Owens CG, Menown IBA, Lown M, Adgey AAJ. Comparison of the 80-lead body surface map to physician and to 12-lead electrocardiogram in detection of acute myocardial infarction. Am J cardiol 2003;92:252-7.PubMedCrossRefGoogle Scholar
  3. 3.
    Owens CG, McClelland AJJ, Walsh SJ, Smith BA, Tomlin A, Riddell JW, et al. Prehospital 80-LAD mapping: Does it add significantly to the diagnosis of acute coronary syndromes? J Electrocardiol 2004;37:223-32.PubMedCrossRefGoogle Scholar
  4. 4.
    Gibler WB, Lewis LM, Erb RE, Makens PK, Kaplan BC, Vaughn RH, et al. Early detection of acute myocardial infarction in patients presenting with chest pain and non-diagnostic ECGs. Serial CK-MB sampling in the emergency department. Ann Emerg Med 1990;19:1359-66.PubMedCrossRefGoogle Scholar
  5. 5.
    Katus HA, Remppis A, Neumann FJ, Scheffold T, Diederich KW, Vinar G, et al. Diagnostic efficiency of troponin T measurements in acute myocardial infarction. Circulation 1991;83:902-12.PubMedCrossRefGoogle Scholar
  6. 6.
    Lindahl B, Venge P, Wallentin L. Troponin T identifies patients with unstable coronary artery disease who benefit from long-term antithrombotic protection. Fragmin in Unstable Coronary Artery Disease (FRISC) Study Group. J Am Coll Cardiol 1997;29:43-8.PubMedCrossRefGoogle Scholar
  7. 7.
    Pozen MW, D’Agostino RB, Selker HP, Sytkowski PA, Hood WB. A predictive instrument to improve coronary-care unit admission practices in acute ischemic heart disease. A prospective multicentre clinical trail. N Engl J Med 1984;310:1273-8.PubMedCrossRefGoogle Scholar
  8. 8.
    Fineberg HV, Scadden D, Goldman L. Care of the patients with low probability of acute myocardial infarction: Cost effectiveness of alternative to coronary care unit admission. N Engl J Med 1984;310:1301-7.PubMedCrossRefGoogle Scholar
  9. 9.
    Kontos MC, Jesse RL, Anderson FP, Schmidt KL, Ornato JP, Tatum JL. Comparison of myocardial perfusion imaging and cardiac troponin I in patients admitted to the emergency department with chest pain. Circulation 1999;99:2073-8.PubMedCrossRefGoogle Scholar
  10. 10.
    Udelson JE, Beshansky JR, Ballin DS, Feldman JA, Griffith JL, Handler J, et al. Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia—A randomized controlled trial. J Am Med Assoc 2002;288:2693-700.CrossRefGoogle Scholar
  11. 11.
    Klocke FJ, Baird MG, Lorell BH, Bateman TM, Messer JV, Berman DS, et al. American College of Cardiology; American Heart Association Task Force on Practice Guideline; American Society for Nuclear Cardiology. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). Circulation 2003;108:1404-18.Google Scholar
  12. 12.
    Wiviott SD, Braunwald E. Unstable angina and non ST segment elevation myocardial infarction: Part I. Initial evaluation and management, and hospital care. Am Fam Physician 2004;70:525-32.PubMedGoogle Scholar
  13. 13.
    Alpert J, Thygesen K, for the Joint European Society of Cardiology/American College of Cardiology Committee. Myocardial Infarction Redefined—A consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction. J Am Coll Cardiol 2000;36:959-69.Google Scholar
  14. 14.
    Panteghini M, Pagani F, Yeo KIJ, Apple FS, Christenson RH, Dati F, et al., on behalf of the Committee on Standardization of Markers of Cardiac Damage of the IFCC. Evaluation of imprecision for cardiac troponin assays at low-range concentrations. Clin Chem 2004;50(2):327-32.Google Scholar
  15. 15.
    Machin D, Campbell MJ, Fayers PM, Pinol APY. Sample size tables for clinical studies. 2nd ed. Oxford: Blackwell; 1997.Google Scholar
  16. 16.
    Amsterdam EA, Kirk JD, Bluemke DA, Diercks D, Farkouh ME, Garvey JL, et al. American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and the Interdisciplinary Council on Quality of Care and Outcomes Research. Testing of Low-risk patients presenting to the Emergency with Chest Pain. A scientific statement from the American Heart Association. Circulation 2010;122:756-76.CrossRefGoogle Scholar
  17. 17.
    Wackers FJ. Acute chest pain of uncertain etiology, the short and long view. J Nucl Cardiol 2012;12:220-3.CrossRefGoogle Scholar
  18. 18.
    Hilton TC, Thompson RC, Williams HJ, Saylors R, Fulmer H, Stowers SA. Technetium-99m sestamibi myocardial perfusion imaging in the emergency room evaluation of chest pain. J Am Coll Cardiol 1994;23:1016-22.PubMedCrossRefGoogle Scholar
  19. 19.
    Tatum JL, Jesse RL, Kontos MC, Nicholson CS, Schmidt KL, Roberts CS, et al. Comprehensive strategy for the evaluation and triage of the chest pain patient. Ann Emerg Med 1997;29:116-25.PubMedCrossRefGoogle Scholar
  20. 20.
    Heller GV, Stowers SA, Hendel RC, Herman SD, Daher E, Ahlberg AW, et al. Clinical value of acute rest Technetium-99m tetrofosmin tomographic myocardial perfusion imaging in patients with acute chest pain and nondiagnostic electrocardiograms. J Am Coll Cardiol 1998;31:1011-7.PubMedCrossRefGoogle Scholar
  21. 21.
    deFilippi CR, Tocchi M, Parmar RJ, Rosanio S, Abreo G, Potter MA, et al. Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes. J Am Coll Cardiol 2000;35:1827-34.PubMedCrossRefGoogle Scholar
  22. 22.
    Newby LK, Ohman EM, Christenson RH, Moliterno DJ, Harrington RA, White HD, et al. Benefit of glycoprotein IIb/IIIa inhibition in patients with acute coronary syndromes and troponin T-positive status: The PARAGON-B troponin T substudy. Circulation 2001;103:2891-6.PubMedCrossRefGoogle Scholar
  23. 23.
    Nabi F, Chang SM, Xu JQ, Gigliotti E, Mahmarian JJ. Assessing risk in acute chest pain: The value of stress myocardial perfusion imaging in patients admitted through the emergency department. J Nucl Cardiol 2012;19:233-43.PubMedCrossRefGoogle Scholar
  24. 24.
    Chang SM, Nabi F, Xu J, Raza U, Mahmarian JJ. Normal stress-only versus standard stress/post myocardial perfusion imaging. J Am Coll Cardiol 2010;55:221-30.PubMedCrossRefGoogle Scholar
  25. 25.
    Farkouh ME, Smars PA, Reeder GS, Zinsmeister AR, Evans RW, Meloy TD, et al. A clinical trial of a chest-pain observation unit for patients with unstable angina. Chest Pain Evaluation in the Emergency Room (CHEER) Investigators. N Engl J Med 1998;339:1882-8.PubMedCrossRefGoogle Scholar
  26. 26.
    Abbott BG, Abdel-Aziz I, Nagula S, Monico EP, Schriver JA, Wackers FJ. Selective use of single-photon emission computed tomography myocardial perfusion imaging in a chest pain center. Am J Cardiol 2001;87:1351-5.PubMedCrossRefGoogle Scholar

Copyright information

© American Society of Nuclear Cardiology 2013

Authors and Affiliations

  • Swee Han Lim
    • 1
    Email author
  • Venkataraman Anantharaman
    • 1
  • Felix Sundram
    • 2
  • Edwin Shih-Yen Chan
    • 3
  • Ee Sin Ang
    • 2
  • Sui Lan Yo
    • 4
  • Edward Jacob
    • 5
  • Anthony Goh
    • 2
  • Say Beng Tan
    • 3
    • 6
  • Terrance Chua
    • 7
  1. 1.Department of Emergency MedicineSingapore General HospitalSingaporeSingapore
  2. 2.Department of Nuclear Medicine and PET ImagingSingapore General HospitalSingaporeSingapore
  3. 3.Singapore Clinical Research InstituteSingaporeSingapore
  4. 4.Clinical Biochemistry Laboratories, Department of PathologySingapore General HospitalSingaporeSingapore
  5. 5.Department of Clinical BiochemistrySingapore General HospitalSingaporeSingapore
  6. 6.Duke-NUS Graduate Medical SchoolSingaporeSingapore
  7. 7.Department of Cardiology, National Heart CentreSingapore General HospitalSingaporeSingapore

Personalised recommendations