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Sex differences in the long-term prognostic value of 13N-ammonia myocardial perfusion positron emission tomography

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Abstract

Purpose

Evidence to date on the unique female determinants of cardiovascular risk is inadequate. Positron Emission Tomography (PET) is considered to have the highest accuracy for the assessment of myocardial perfusion in patients with suspected coronary artery disease (CAD), but its long-term prognostic accuracy in women has not been established.

Methods

A total of 619 consecutive patients (138 women, mean age 60.0 ± 11.8 years) underwent clinically indicated 13N-ammonia PET at our institution and were followed up (median 5.7 years) for major adverse cardiovascular events (MACE) including cardiac death, nonfatal myocardial infarction, hospitalization for any cardiac reason and late revascularization.

Results

During follow-up, 271 patients had at least one cardiac event, including 64 cardiac deaths and 33 nonfatal myocardial infarctions. In both women and men, abnormal myocardial perfusion was associated with reduced event-free survival (log rank p < 0.001). In women, abnormal myocardial perfusion was associated with a higher risk of a worse outcome than in men (adjusted HR 4.1, 95% CI 1.8–9.0 in women; HR 2.4, 95% CI 1.5–3.8 in men; pinteraction < 0.001). In contrast, abnormal coronary flow reserve (CFR) was a significant predictor of 10-year MACE in men (p = 0.006) but not in women (p = NS). Accordingly, an interaction term of sex and abnormal myocardial perfusion or CFR was significant (p < 0.001).

Conclusion

While perfusion findings in 13N-ammonia PET provide effective risk stratification in women and men, CFR adds incremental prognostic value for long-term cardiac outcomes only in men. Refined strategies in noninvasive imaging are needed in women to improve CAD risk prediction.

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Funding

This study was funded by the Swiss National Science Foundation (SNSF), the Olga Mayenfisch Foundation, Switzerland, the OPO Foundation, Switzerland, the Novartis Foundation, Switzerland, and the Swissheart Foundation (to C.G.).

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Authors and Affiliations

  1. Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland

    Catherine Gebhard, Michael Fiechter, Bernhard A. Herzog, Christine Lohmann, Susan Bengs, Valerie Treyer, Michael Messerli, Dominik C. Benz, Andreas A. Giannopoulos, Christoph Gräni, Aju P. Pazhenkottil, Ronny R. Buechel & Philipp A. Kaufmann

  2. Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland

    Catherine Gebhard, Christine Lohmann & Susan Bengs

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  1. Catherine Gebhard
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Correspondence to Catherine Gebhard.

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Ethical approval

Our study was approved by the Cantonal Ethics Board in Zurich, Switzerland (BASEC No. 2017–01112). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the principles of the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards, and were conducted in accordance with institutional guidelines.

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Informed consent was obtained from all individual participants included in the study.

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Gebhard, C., Fiechter, M., Herzog, B.A. et al. Sex differences in the long-term prognostic value of 13N-ammonia myocardial perfusion positron emission tomography. Eur J Nucl Med Mol Imaging 45, 1964–1974 (2018). https://doi.org/10.1007/s00259-018-4046-8

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  • DOI: https://doi.org/10.1007/s00259-018-4046-8

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