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Implications of transient ischemic dilatation and impaired left ventricular ejection fraction reserve in patients with normal stress myocardial perfusion imaging and elevated coronary artery calcium

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Abstract

Purpose

Guidelines recommend stress only (SO) myocardial perfusion imaging (MPI) without follow-up rest imaging if perfusion and left ventricular ejection fraction (LVEF) are normal. However additional rest imaging may show transient ischaemic dilation (TID) and/or impaired LVEF reserve (iLVEFr) suggestive of ‘balanced ischemia’. Concurrent coronary artery calcium (CAC) scoring helps to identify subclinical atherosclerosis. The safety of SO MPI when CAC is elevated is unclear. We aim to assess the incidence and outcomes of TID and iLVEFr amongst stress/rest MPIs with normal SO images and elevated CAC.

Methods

Retrospective analysis of normal stress/rest MPIs performed between 1 March 2016 to 31 January 2017 with concurrently measured CAC >300. Cases were stratified by presence of TID and/or iLVEFr. Major adverse cardiac events (MACE, defined as cardiac death, non-fatal myocardial infarction and revascularization) within 24 months were compared.

Results

There were 230 cases included of which 43 (18.7%) had TID and/or iLVEFr. Presence of TID and/or iLVEFr was associated with higher 24-month MACE (23.3 vs. 8.6%, p = 0.013), driven by more elective revascularizations (18.6 vs. 4.3%, p = 0.001). Cardiac death and non-fatal myocardial infarction rates were similar. TID and/or iLVEFr significantly predicted overall MACE after multivariate analysis (OR 2.933 [1.214 - 7.087], p = 0.017).

Conclusions

TID and/or iLVEFr is seen in the minority of normal stress MPI with elevated CAC, and is associated with higher 24-month MACE, driven by higher elective revascularizations. Overall cardiac death and non-fatal myocardial infarction rates were low and not significantly different between both groups.

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Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

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Authors and Affiliations

  1. Internal Medicine Residency, National Healthcare Group, Singapore, Singapore

    Jonathan Jia Jun Wong

  2. Department of Cardiology, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, 308433, Singapore, Singapore

    Min Sen Yew

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  1. Jonathan Jia Jun Wong
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Jonathan Wong and Min Sen Yew. The first draft of the manuscript was written by Jonathan Wong and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Min Sen Yew.

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The authors have no relevant financial or non-financial interests to disclose.

Ethics Statement

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the National Healthcare Group Domain Specific Review Board (2017/00625). The requirement for written informed consent was waived.

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Wong, J.J.J., Yew, M.S. Implications of transient ischemic dilatation and impaired left ventricular ejection fraction reserve in patients with normal stress myocardial perfusion imaging and elevated coronary artery calcium. Int J Cardiovasc Imaging 38, 1651–1658 (2022). https://doi.org/10.1007/s10554-022-02549-4

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