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Combined evaluation of regional coronary artery calcium and myocardial perfusion by 82Rb PET/CT in predicting lesion-related outcome

European Journal of Nuclear Medicine and Molecular Imaging volume 47, pages 1698–1704 (2020)Cite this article

Abstract

Purpose

Cardiac imaging with positron emission tomography/computed tomography (PET/CT) allows measurement of coronary artery calcium (CAC), stress-induced myocardial ischemia and myocardial perfusion reserve (MPR). We evaluated the prognostic role of the combined assessment of regional CAC score, ischemic total perfusion defect (ITPD) and MPR in predicting lesion-related outcome in patients with suspected coronary artery disease (CAD).

Methods

We studied 206 patients with suspected CAD referred to 82Rb PET/CT cardiac imaging and available coronary angiographic data. The outcome end points were cardiac death, target vessel-related myocardial infarction or coronary revascularization.

Results

Compared to vessels without event, those with event showed higher CAC score and ITPD, and lower hyperemic myocardial blood flow and MPR (all p < 0.001). At Cox regression multivariable analysis, significant CAD (≥50% stenosis) (p < 0.001), CAC score ≥ 300 (p < 0.01) and MPR <2 (p < 0.01) were independent predictors of events. The decision trees analysis for the identification of events produced five terminal nodes. The initial split was on CAC score values. For vessels with CAC <300 and MPR ≥2, no further split was performed, while vessels with CAC <300 and MPR <2 were further stratified by ITPD. For vessels with CAC ≥300 a further stratification was performed only by MPR. The worst prognosis was observed in vessels with CAC ≥300 and MPR <2 and in vessels with CAC <300, MPR <2 and ITPD ≥5%.

Conclusion

The combination of CAC score and MPR is useful to predict the lesion-related outcome in the presence of significant CAD.

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References

  1. Murthy VL, Naya M, Foster CR, Hainer J, Gaber M, Di Carli G, et al. Improved cardiac risk assessment with noninvasive measures of coronary flow reserve. Circulation. 2011;124:2215–24.

    Article  Google Scholar 

  2. Naya M, Murthy VL, Blankstein R, Sitek A, Hainer J, Foster C, et al. Quantitative relationship between the extent and morphology of coronary atherosclerotic plaque and downstream myocardial perfusion. J Am Coll Cardiol. 2011;58:1807–16.

    Article  Google Scholar 

  3. Ford TJ, Berry C, De Bruyne B, Yong ASC, Barlis P, Fearon WF, et al. Physiological predictors of acute coronary syndromes: emerging insights from the plaque to the vulnerable patient. JACC Cardiovasc Interv. 2017;10:2539–47.

    Article  Google Scholar 

  4. Assante R, Zampella E, Arumugam P, Acampa W, Imbriaco M, Tout D, et al. Quantitative relationship between coronary artery calcium and myocardial blood flow by hybrid rubidium-82 PET/CT imaging in patients with suspected coronary artery disease. J Nucl Cardiol. 2017;24:494–501.

    Article  Google Scholar 

  5. Gupta A, Taqueti VR, van de Hoef TP, Bajaj NS, Bravo PE, Murthy VL, et al. Integrated noninvasive physiological assessment of coronary circulatory function and impact on cardiovascular mortality in patients with stable coronary artery disease. Circulation. 2017;136:2325–36.

    Article  Google Scholar 

  6. Brodov Y, Gransar H, Dey D, Shalev A, Germano G, Friedman JD, et al. Combined quantitative assessment of myocardial perfusion and coronary artery calcium score by hybrid 82Rb PET/CT improves detection of coronary artery disease. J Nucl Med. 2015;56:1345–50.

    CAS  Article  Google Scholar 

  7. Zampella E, Acampa W, Assante R, Nappi C, Gaudieri V, Mainolfi CG, et al. Combined evaluation of regional coronary artery calcium and myocardial perfusion by (82) Rb PET/CT in the identification of obstructive coronary artery disease. Eur J Nucl Med Mol Imaging. 2018;45:521–9.

    CAS  Article  Google Scholar 

  8. Assante R, Acampa W, Zampella E, Arumugam P, Nappi C, Gaudieri V, et al. Prognostic value of atherosclerotic burden and coronary vascular function in patients with suspected coronary artery disease. Eur J Nucl Med Mol Imaging. 2017;44:2290–8.

    Article  Google Scholar 

  9. Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34:2949–3003.

    Article  Google Scholar 

  10. Cerqueira M, Weissman N, Dilsizian V, Jacobs A, Kaul S, Laskey W, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the cardiac imaging Committee of the Council on clinical cardiology of the American Heart Association. Circulation. 2002;105:539–42.

    Article  Google Scholar 

  11. Nakazato R, Dey D, Alexánderson E, Meave A, Jiménez M, Romero E, et al. Automatic alignment of myocardial perfusion PET and 64-slice coronary CT angiography on hybrid PET/CT. J Nucl Cardiol. 2012;19:482–91.

    Article  Google Scholar 

  12. Klein R, Renaud JM, Ziadi MC, Thorn SL, Adler A, Beanlands RS, et al. Intra- and inter-operator repeatability of myocardial blood flow and myocardial flow reserve measurements using rubidium-82 PET and a highly automated analysis program. J Nucl Cardiol. 2010;17:600–16.

    Article  Google Scholar 

  13. Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M Jr, Detrano R. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol. 1990;15:827–32.

    CAS  Article  Google Scholar 

  14. Blaha MJ, Budoff MJ, Tota-Maharaj R, Dardari ZA, Wong ND, Kronmal RA, et al. Improving the CAC score by addition of regional measures of calcium distribution: multi-ethnic study of atherosclerosis. JACC Cardiovasc Imaging. 2016;9:1407–16.

    Article  Google Scholar 

  15. Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014;64:1929–49.

    Article  Google Scholar 

  16. Nappi C, Nicolai E, Daniele S, Acampa W, Gaudieri V, Assante R, et al. Long-term prognostic value of coronary artery calcium scanning, coronary computed tomographic angiography and stress myocardial perfusion imaging in patients with suspected coronary artery disease. J Nucl Cardiol. 2018;25:833–41.

    Article  Google Scholar 

  17. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ. Morrow DA et al; ESC scientific document group. Fourth universal definition of myocardial infarction. Eur Heart J. 2019;40:237–69.

    Article  Google Scholar 

  18. Barbato E, Toth GG, Johnson NP, Pijls NH, Fearon WF, Tonino PA, et al. A prospective natural history study of coronary atherosclerosis using fractional flow reserve. J Am Coll Cardiol. 2016;68:2247–55.

    Article  Google Scholar 

  19. Therneau TM, Atkinson EJ. An introduction to recursive partitioning using the RPART routines. Mayo Foundation February 23, 2018. https://cran.r-project.org/web/packages/rpart/vignettes/longintro.pdf. Accessed 29 Mar 2019

  20. Chow BJ, Dennie C, Hoffmann U, So D, de Kemp RA, Ruddy TD, et al. Comparison of computed tomographic angiography versus rubidium-82 positron emission tomography for the detection of patients with anatomical coronary artery disease. Can J Cardiol. 2007;23:801–7.

    Article  Google Scholar 

  21. Sampson UK, Dorbala S, Limaye A, Kwong R, Di Carli MF. Diagnostic accuracy of rubidium-82 myocardial perfusion imaging with hybrid positron emission tomography/computed tomography in the detection of coronary artery disease. J Am Coll Cardiol. 2007;49:1052–8.

    CAS  Article  Google Scholar 

  22. Naya M, Murthy VL, Taqueti VR, Foster CR, Klein J, Garber M, et al. Preserved coronary flow reserve effectively excludes high-risk coronary artery disease on angiography. J Nucl Med. 2014;55:248–55.

    Article  Google Scholar 

  23. Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356:1503–16.

    CAS  Article  Google Scholar 

  24. Frye RL, August P, Brooks MM, Hardison RM, Kelsey SF, MacGregor JM, et al. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009;360:2503–15.

  25. Gould KL, Johnson NP, Bateman TM, Beanlands RS, Bengel FM, Bober R, et al. Anatomic versus physiologic assessment of coronary artery disease. Role of coronary flow reserve, fractional flow reserve, and positron emission tomography imaging in revascularization decision-making. J Am Coll Cardiol. 2013;62:1639–53.

  26. Taqueti VR, Hachamovitch R, Murthy VL, Naya M, Foster CR, Hainer J, et al. Global coronary flow reserve is associated with adverse cardiovascular events independently of luminal angiographic severity and modifies the effect of early revascularization. Circulation. 2015;131:19–27.

    Article  Google Scholar 

  27. Dikic M, Tesic M, Markovic Z, Giga V, Djordjevic-Dikic A, Stepanovic J, et al. Prognostic value of calcium score and coronary flow velocity reserve in asymptomatic diabetic patients. Cardiovasc Ultrasound. 2015;13:41.

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Affiliations

  1. Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy

    Emilia Zampella, Wanda Acampa, Roberta Assante, Valeria Gaudieri, Carmela Nappi, Teresa Mannarino, Ciro Gabriele Mainolfi & Alberto Cuocolo

  2. Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy

    Wanda Acampa

  3. Department of Nuclear Medicine, Central Manchester Foundation Trust, Manchester, UK

    Parthiban Arumugam

  4. Department of Translational Medical Sciences, University Federico II, Naples, Italy

    Mario Petretta

Authors
  1. Emilia Zampella
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  2. Wanda Acampa
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  3. Roberta Assante
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  4. Valeria Gaudieri
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  5. Carmela Nappi
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  6. Teresa Mannarino
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  7. Ciro Gabriele Mainolfi
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  8. Parthiban Arumugam
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  9. Mario Petretta
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  10. Alberto Cuocolo
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Correspondence to Roberta Assante.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

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Zampella, E., Acampa, W., Assante, R. et al. Combined evaluation of regional coronary artery calcium and myocardial perfusion by 82Rb PET/CT in predicting lesion-related outcome. Eur J Nucl Med Mol Imaging 47, 1698–1704 (2020). https://doi.org/10.1007/s00259-019-04534-x

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Keywords

  • Coronary artery calcium
  • Coronary artery disease
  • Myocardial perfusion reserve
  • Hybrid PET/CT
  • Prognosis