Skip to main content

Assessment of the routine reporting of very low-dose exercise-first myocardial perfusion SPECT from a large-scale real-world cohort and correlation with the subsequent reporting of coronary stenosis at angiography

Abstract

Purpose

Our study assesses the routine reporting of exercise ischemia using very low-dose exercise-first myocardial perfusion SPECT in a large number of patients and under real-life conditions, by evaluating correlations with the subsequent routine reporting of coronary stenosis by angiography and with factors that predict ischemia.

Methods

Data from 13,126 routine exercise MPI reports, from 11,952 patients (31% women), using very low doses of sestamibi and a high-sensitivity cardiac CZT camera, were extracted to assess the reporting of significant MPI-ischemia (> 1 left ventricular segment), to determine the MPI normalcy rate in a group with < 5% pretest probability of coronary artery disease (CAD) (n = 378), and to assess the ability of MPI to predict a > 50% coronary stenosis in patients with available coronary angiography reports in the 3 months after the MPI (n = 713).

Results

The median effective patient dose was 2.51 [IQR: 1.00–4.71] mSv. The normalcy rate was 98%, and the MPI-ischemia rate was independently predicted by a known CAD, the male gender, obesity, and a < 50% LV ejection fraction, ranging from 29.5% with all these risk factors represented to 1.5% when there were no risk factors. A > 50% coronary stenosis was significantly predicted by MPI-ischemia, less significantly for mild (odds ratio [95% confidence interval]: 1.61 [1.26–1.96]) than for moderate-to-severe MPI-ischemia (4.05 [3.53–4.57]) and was also impacted by having a known CAD (2.17 [1.83–2.51]), by a submaximal exercise test (1.48 [1.15–1.81]) and being ≥ 65 years of age (1.43 [1.11–1.76]).

Conclusion

Ischemia detected using a very low-dose exercise-first MPI protocol in a large-scale clinical cohort and under real-life routine conditions is a highly significant predictor for the subsequent reporting of coronary stenosis, although this prediction is enhanced by other variables. This weakly irradiating approach is amenable to being repeated at shorter time intervals, in target patient groups with a high probability of MPI-ischemia.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

Availability of data and material

The data that support the findings of this study are available on request from the corresponding author (MC).

Code availability

Not applicable.

References

  1. 1.

    Neumann F-J, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87–165.

    Article  Google Scholar 

  2. 2.

    Holly TA, Abbott BG, Al-Mallah M, Calnon DA, Cohen MC, DiFilippo FP, et al. Single photon-emission computed tomography. J Nucl Cardiol Off Publ Am Soc Nucl Cardiol. 2010;17(5):941–73.

    Google Scholar 

  3. 3.

    Hesse B, Tägil K, Cuocolo A, Anagnostopoulos C, Bardiés M, Bax J, et al. EANM/ESC procedural guidelines for myocardial perfusion imaging in nuclear cardiology. Eur J Nucl Med Mol Imaging. 2005;32(7):855–97.

    CAS  Article  Google Scholar 

  4. 4.

    Claudin M, Imbert L, Djaballah W, Veran N, Poussier S, Roch V, et al. Routine evaluation of left ventricular function using CZT-SPECT, with low injected activities and limited recording times. J Nucl Cardiol Off Publ Am Soc Nucl Cardiol. 2018;25(1):249–56.

    Google Scholar 

  5. 5.

    Perrin M, Djaballah W, Moulin F, Claudin M, Veran N, Imbert L, et al. Stress-first protocol for myocardial perfusion SPECT imaging with semiconductor cameras: high diagnostic performances with significant reduction in patient radiation doses. Eur J Nucl Med Mol Imaging. 2015;42(7):1004–11.

    CAS  Article  Google Scholar 

  6. 6.

    Duvall WL, Sweeny JM, Croft LB, Barghash MH, Kulkarni NK, Guma KA, et al. Comparison of high efficiency CZT SPECT MPI to coronary angiography. J Nucl Cardiol Off Publ Am Soc Nucl Cardiol. 2011;18(4):595–604.

    Google Scholar 

  7. 7.

    Gibbons RJ, Balady GJ, Beasley JW, Bricker JT, Duvernoy WF, Froelicher VF, et al. ACC/AHA guidelines for exercise testing. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol. 1997;30(1):260–311.

    CAS  Article  Google Scholar 

  8. 8.

    Marie PY, Danchin N, Branly F, Angioï M, Grentzinger A, Virion JM, et al. Effects of medical therapy on outcome assessment using exercise thallium-201 single photon emission computed tomography imaging: evidence of a protective effect of beta-blocking antianginal medications. J Am Coll Cardiol. 1999;34(1):113–21.

    CAS  Article  Google Scholar 

  9. 9.

    Marie PY, Mercennier C, Danchin N, Djaballah K, Grentzinger A, Zannad F, et al. Residual exercise SPECT ischemia on treatment is a main determinant of outcome in patients with coronary artery disease treated medically at long-term with ß-blockers. J Nucl Cardiol. 2003;10(4):361–8.

    Article  Google Scholar 

  10. 10.

    Perrin M, Roch V, Claudin M, Verger A, Boutley H, Karcher G, et al. Assessment of myocardial CZT SPECT recording in a forward-leaning bikerlike position. J Nucl Med Off Publ Soc Nucl Med. 2019;60(6):824–9.

    CAS  Google Scholar 

  11. 11.

    Cousins C, Miller DL, Bernardi G, Rehani MM, Schofield P, Vañó E, et al. ICRP PUBLICATION 120: radiological protection in cardiology. Ann ICRP. 2013;42(1):1–125.

    CAS  Article  Google Scholar 

  12. 12.

    Verger A, Imbert L, Yagdigul Y, Fay R, Djaballah W, Rouzet F, et al. Factors affecting the myocardial activity acquired during exercise SPECT with a high-sensitivity cardiac CZT camera as compared with conventional Anger camera. Eur J Nucl Med Mol Imaging. 2014;41(3):522–8.

    Article  Google Scholar 

  13. 13.

    Gibbons RJ. Is the search for enough moderate-severe ischemia nearly over? JAMA Cardiol. 2019;4(3):203–5.

    Article  Google Scholar 

  14. 14.

    Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al. Heart disease and stroke statistics–2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28-292.

    PubMed  Google Scholar 

  15. 15.

    R Core Team (2020). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL: https://www.R-project.org/.

  16. 16.

    Cantoni V, Green R, Acampa W, Zampella E, Assante R, Nappi C, et al. Diagnostic performance of myocardial perfusion imaging with conventional and CZT single-photon emission computed tomography in detecting coronary artery disease: a meta-analysis. J Nucl Cardiol Off Publ Am Soc Nucl Cardiol. 2021;28(2):698–715.

    Google Scholar 

  17. 17.

    Cantoni V, Green R, Ricciardi C, Assante R, Zampella E, Nappi C, et al. A machine learning-based approach to directly compare the diagnostic accuracy of myocardial perfusion imaging by conventional and cadmium-zinc telluride SPECT. J Nucl Cardiol. 2020. https://doi.org/10.1007/s12350-020-02187-0.

  18. 18.

    Mannarino T, Assante R, Ricciardi C, Zampella E, Nappi C, Gaudieri V, et al. Head-to-head comparison of diagnostic accuracy of stress-only myocardial perfusion imaging with conventional and cadmium-zinc telluride single-photon emission computed tomography in women with suspected coronary artery disease. J Nucl Cardiol Off Publ Am Soc Nucl Cardiol. 2021;28(3):888–97.

    Google Scholar 

  19. 19.

    Ghobrial M, Haley HA, Gosling R, Rammohan V, Lawford PV, Hose DR, et al. The new role of diagnostic angiography in coronary physiological assessment. Heart. 2021;107(10):783–789. https://doi.org/10.1136/heartjnl-2020-318289.

  20. 20.

    Klocke FJ, Baird MG, Lorell BH, Bateman TM, Messer JV, Berman DS, et al. J Am Coll Cardiol. 2003;42(7):1318–33.

    Article  Google Scholar 

  21. 21.

    Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020;41(3):407–77.

    Article  Google Scholar 

  22. 22.

    Heusch G, Baumgart D, Camici P, Chilian W, Gregorini L, Hess O, et al. Alpha-adrenergic coronary vasoconstriction and myocardial ischemia in humans. Circulation. 2000;101(6):689–94.

    CAS  Article  Google Scholar 

  23. 23.

    Gage JE, Hess OM, Murakami T, Ritter M, Grimm J, Krayenbuehl HP. Vasoconstriction of stenotic coronary arteries during dynamic exercise in patients with classic angina pectoris: reversibility by nitroglycerin. Circulation. 1986;73(5):865–76.

    CAS  Article  Google Scholar 

  24. 24.

    Oddstig J, Martinsson E, Jögi J, Engblom H, Hindorf C. Differences in attenuation pattern in myocardial SPECT between CZT and conventional gamma cameras. J Nucl Cardiol Off Publ Am Soc Nucl Cardiol. 2019;26(6):1984–91.

    Google Scholar 

  25. 25

    Sicari R. Anti-ischemic therapy and stress testing: pathophysiologic, diagnostic and prognostic implications. Cardiovasc Ultrasound. 2004;2:14.

    Article  Google Scholar 

  26. 26.

    Imbert L, Poussier S, Franken PR, Songy B, Verger A, Morel O, et al. Compared performance of high-sensitivity cameras dedicated to myocardial perfusion SPECT: a comprehensive analysis of phantom and human images. J Nucl Med Off Publ Soc Nucl Med. 2012;53(12):1897–903.

    Google Scholar 

  27. 27.

    Einstein AJ, Knuuti J. Cardiac imaging: does radiation matter? Eur Heart J. 2012;33(5):573–8.

    Article  Google Scholar 

  28. 28.

    Einstein AJ, Weiner SD, Bernheim A, Kulon M, Bokhari S, Johnson LL, et al. Multiple testing, cumulative radiation dose, and clinical indications in patients undergoing myocardial perfusion imaging. JAMA. 2010;304(19):2137–44.

    CAS  Article  Google Scholar 

  29. 29.

    Megna R, Assante R, Zampella E, Gaudieri V, Nappi C, Cuocolo R, et al. Pretest models for predicting abnormal stress single-photon emission computed tomography myocardial perfusion imaging. J Nucl Cardiol. 2019. https://doi.org/10.1007/s12350-019-01941-3.

  30. 30.

    Mannarino T, Gaudieri V, Acampa W. Vasodilators and myocardial blood flow by CZT cameras: Make us see further. J Nucl Cardiol. 2020. https://doi.org/10.1007/s12350-020-02369-w.

  31. 31.

    Acampa W, Zampella E, Assante R, Genova A, De Simini G, Mannarino T, et al. Quantification of myocardial perfusion reserve by CZT-SPECT: A head to head comparison with 82Rubidium PET imaging. J Nucl Cardiol. 2020. https://doi.org/10.1007/s12350-020-02129-w.

  32. 32.

    Acampa W, Assante R, Mannarino T, Zampella E, D’Antonio A, Buongiorno P, et al. Low-dose dynamic myocardial perfusion imaging by CZT-SPECT in the identification of obstructive coronary artery disease. Eur J Nucl Med Mol Imaging. 2020;47(7):1705–12.

    CAS  Article  Google Scholar 

  33. 33.

    Zampella E, Assante R, Gaudieri V, Nappi C, Acampa W, Cuocolo A. Myocardial perfusion reserve by using CZT: it’s a long way to the top if you wanna standardize. J Nucl Cardiol Off Publ Am Soc Nucl Cardiol. 2021;28(3):885–7.

    Google Scholar 

Download references

Acknowledgements

The authors wish to thank Petra Neufing for critical review of the manuscript.

Author information

Affiliations

Authors

Contributions

All authors contributed significantly to the analysis and interpretation of the data (MC, TC, LI, MP, MC, KD, PM), to the writing of the manuscript (MC, TC, AV, VR, PM), and to the revision of the manuscript (MC, TC, CB, MB, AV, BP, EC, PM).

Corresponding author

Correspondence to Mohammad B. Chawki.

Ethics declarations

Ethics approval and consent to participate

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committees and with the 1964 Helsinki declaration and its latest amendments or comparable ethics standards. All patients investigated in our department are informed that their medical data may be used for research purposes, and the present study was approved by the Ethics Committee of our University Hospital.

Consent for publication

Not applicable.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Cardiology

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 36 KB)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Chawki, M.B., Goncalves, T., Boursier, C. et al. Assessment of the routine reporting of very low-dose exercise-first myocardial perfusion SPECT from a large-scale real-world cohort and correlation with the subsequent reporting of coronary stenosis at angiography. Eur J Nucl Med Mol Imaging (2021). https://doi.org/10.1007/s00259-021-05575-x

Download citation

Keywords

  • Ischemia
  • CZT camera
  • Low radiation dose
  • Coronary stenosis
  • Coronary artery disease