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Prevalence, location, and extent of significant coronary artery disease in patients with normal myocardial perfusion imaging

Journal of Nuclear Cardiology volume 21, pages 284–290 (2014)Cite this article

Abstract

Background

False-negative myocardial perfusion imaging (MPI) can by due to left main (LM) or three-vessel disease causing “balanced ischemia”. However, so far prevalence of LM or three-vessel-disease in patients with normal MPI is unclear. We assessed prevalence, location, and extent of significant coronary artery disease (CAD) in patients with normal MPI.

Methods

Between 2006 and 2010, 256 patients with normal MPI who had invasive angiography because of persisting or worsening of the same initial symptoms were studied. Significant CAD was defined as stenosis > 70% or LM > 50%.

Results

A total of 93 patients (36%) had significant CAD. Significant CAD was observed more frequently in males, higher age and those with typical angina complaints. Significant LM disease was present in 7%, three-vessel disease in 10%, two-vessel disease in 22%, and single vessel disease (not left main) in 61%. In those with single vessel disease, the location was the LAD in 40%, the RCA in 30%, and the LCX in 30%.

Conclusions

In selected patients with normal MPI, one-third had significant CAD. The majority of these patients had single vessel disease (not left main). LM or three vessel disease, causing “balanced ischemia”, is a less common cause of false-negative MPI.

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References

  1. Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, et al. ACC/AHA 2002 Guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation 2002;106:1883-92.

    PubMed  Article  Google Scholar 

  2. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, et al. ACC/AHA 2002 Guideline Update for the Management of Patients with Chronic Stable Angina-Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients with Chronic Stable Angina). Circulation 2003;107:149-58.

    PubMed  Article  Google Scholar 

  3. Shaw JL, Iskandrian AE. Prognostic Value of Gated Myocardial Perfusion SPECT. J Nucl Cardiol 2004;11:171-85.

    PubMed  Article  Google Scholar 

  4. Marcassa C, Bax JJ, Bengel F, Hesse B, Petersen CL, Reyes E, et al. Clinical Value, Cost-Effectiveness, and Safety of Myocardial Perfusion Scintigraphy: A Position Statement. Eur Heart J 2008;29:557-63.

    PubMed  Article  Google Scholar 

  5. Lima RSL, Watson DD, Goode AR, Siadaty MS, Ragosta M, Beller GA, et al. Incremental Value of Combined Perfusion and Function Over Perfusion alone by Gated SPECT Myocardial Perfusion Imaging for Detection of Severe Three-Vessel Coronary Artery Disease. J Am Coll Cardiol 2003;42:64-70.

    PubMed  Article  Google Scholar 

  6. Berman DS. Fourth Annual Mario S. Verani, MD Memorial Lecture: Noninvasive Imaging in Coronary Artery Disease: Changing Roles, Changing Players. J Nucl Cardiol 2006;13:457-73.

    PubMed  Article  Google Scholar 

  7. Berman DS, Kang X, Slomka PJ, Gerlach J, de Yang L, Hayes SW, et al. Underestimation of Extent of Ischemia by Gated SPECT Myocardial Perfusion Imaging in Patients with Left Main Coronary Disease. J Nucl Cardiol 2007;14:521-8.

    PubMed  Article  Google Scholar 

  8. Duvernoy CS, Ficaro EP, Karabajakian MZ, Rose PA, Corbett JR. Improved Detection of Left Main Coronary Artery Disease with Attenuation-Corrected SPECT. J Nucl Cardiol 2000;7:639-48.

    PubMed  Article  CAS  Google Scholar 

  9. Diamond GA, Forrester JS. Analysis of Probability as an aid in the Clinical Diagnosis of Coronary-Artery Disease. N Engl J Med 1979;300:1350-8.

    PubMed  Article  CAS  Google Scholar 

  10. Ragosta M, Dee S, Sarembock IJ, Lipson LC, Gimple LW, Powers ER. Prevalence of Unfavorable Angiographic Characteristics for Percutaneous Intervention in Patients with Unprotected Left Main Coronary Artery Disease. Catheter Cardiovasc Interv 2006;68:357-62.

    PubMed  Article  Google Scholar 

  11. Fajadet J, Chieffo A. Current Management of Left Main Coronary Artery Disease. Eur Heart J 2012;33:36-50.

    PubMed  Article  Google Scholar 

  12. Herzog BA, Buechel RR, Katz R, Brueckner M, Husmann L, Burger IA, et al. Nuclear Myocardial Perfusion Imaging with a Cadmium-Zinc-Telluride Detector Technique: Optimized Protocol for Scan Time Reduction. J Nucl Med 2010;51:46-51.

    PubMed  Article  Google Scholar 

  13. Berman DS, Kiat H, van Train K, Garcia E, Friedman J, Maddahi J. Technetium 99m Sestamibi in the Assessment of Chronic Coronary Artery Disease. Semin Nucl Med 1991;21:190-212.

    PubMed  Article  CAS  Google Scholar 

  14. Berman DS, Kiat H, Friedman JD, Wang FP, van Train K, Matzer L, et al. Seperate Acquisition Rest Thallium-201/Stress Technetium-99m Sestamibi Dual Isotope Myocardial Perfusion Single-Photon Emission Computed Tomography: A Clinical Validation Study. J Am Coll Cardiol 1993;22:1455-64.

    PubMed  Article  CAS  Google Scholar 

  15. Bateman TM, Maddahi J, Gray RJ, Murphy FL, Garcia EV, Conklin CM, et al. Diffuse Slow Washout of Myocardial Thallium-201: A New Scintigraphic Indicator of Extensive Coronary Artery Disease. J Am Coll Cardiol 1984;4:55-64.

    PubMed  Article  CAS  Google Scholar 

  16. Aarnoudse WH, Botman KJ, Pijls NH. False-Negative Myocardial Scintigraphy in Balanced Three-Vessel Disease Revealed by Coronary Pressure Measurement. Int J Cardiovasc Intervent 2003;5:67-71.

    PubMed  Google Scholar 

  17. Ragosta M, Bishop AH, Lipson LC, Watson DD, Gimple LW, Sarembock IJ, et al. Comparison Between Angiography and Fractional Flow Reserve Versus Single-Photon Emission Computed Tomographic Myocardial Perfusion Imaging for Determining Lesion Significance in Patients with Multivessel Coronary Disease. Am J Cardiol 2007;99:896-902.

    PubMed  Article  Google Scholar 

  18. Marshall RC, Leidholdt EM Jr, Zhang DY, Barnett CA. Technetium-99m Hexakis 2-Methoxy-2-Isobutyl Isonitrile and Thallium-201 Extraction, Washout, and Retention at Varying Coronary Flow Rates in Rabbit Heart. Circulation 1990;82:998-1007.

    PubMed  Article  CAS  Google Scholar 

  19. Reyes E. Detection of Left Main Stem and Three-Vessel Coronary Artery Disease by Myocardial Perfusion SPECT Imaging. EuroIntervention 2010;6:G72-8.

    PubMed  Article  Google Scholar 

  20. Kostkiewicz M, Szot W. The Prognostic Value of Normal Myocardial Perfusion SPECT with Positive Coronary Angiography. Nucl Med Rev Cent East Eur 2012;15:22-5.

    PubMed  Article  Google Scholar 

  21. Diamond JA, Makaryus AN, Sandler DA, Machac J, Henzlova MJ. Normal or Near Normal Myocardial Perfusion Stress Imaging in Patients with Severe Coronary Artery Disease. J Cardiovasc Med (Hagerstown) 2008;9:820-5.

    Article  Google Scholar 

  22. Hoilund-Carlsen PF, Johansen A, Christensen HW, Vach W, Moldrup M, Bartram P, et al. Potential Impact of Myocardial Perfusion Scintigraphy as Gatekeeper for Invasive Examination and Treatment in Patients with Stable Angina Pectoris: Observational Study Without Post-test Referral Bias. Eur Heart J 2006;27:29-34.

    PubMed  Article  Google Scholar 

  23. Ghadri JR, Pazhenkottil AP, Nkoulou RN, Goetti R, Buechel RR, Husmann L, et al. Very High Coronary Calcium Score Unmasks Obstructive Coronary Artery Disease in Patients with Normal SPECT MPI. Heart 2011;97:998-1003.

    PubMed  Article  Google Scholar 

  24. Mouden M, Ottervanger JP, Timmer JR, Reiffers S, Oostdijk AH, Knollema S, et al. Myocardial Perfusion Imaging in Stable Symptomatic Patients with Extensive Coronary Atherosclerosis. Eur J Nucl Med Mol Imaging 2013;41:136-43. doi:10.1007/s00259-013-2539-z.

    PubMed  Article  Google Scholar 

  25. Marie PY, Danchin N, Durand JF, Feldmann L, Grentzinger A, Olivier P, et al. Long-Term Prediction of Major Ischemic Events by Exercise Thallium-201 Single-Photon Emission Computed Tomography. Incremental Prognostic Value Compared with Clinical, Exercise Testing, Catheterization and Radionuclide Angiographic Data. J Am Coll Cardiol 1995;26:879-86.

    PubMed  Article  CAS  Google Scholar 

  26. Pijls NH, De Bruyne B, Peels K, Van Der Voort PH, Bonnier HJ, Bartunek J, et al. Measurement of Fractional Flow Reserve to Assess the Functional Severity of Coronary Artery Stenoses. N Engl J Med 1996;334:1703-8.

    PubMed  Article  CAS  Google Scholar 

  27. Bech GJ, Droste H, Pijls NH, De Bruyne B, Bonnier JJ, Michels HR, et al. Value of Fractional Flow Reserve in Making Decisions About Bypass Surgery for Equivocal Left Main Coronary Artery Disease. Heart 2001;86:547-52.

    PubMed Central  PubMed  Article  CAS  Google Scholar 

  28. Botman KJ, Pijls NH, Bech JW, Aarnoudse W, Peels K, van Straten B, et al. Percutaneous Coronary Intervention or Bypass Surgery in Multivessel Disease? A Tailored Approach Based on Coronary Pressure Measurement. Catheter Cardiovasc Interv 2004;63:184-91.

    PubMed  Article  Google Scholar 

  29. Koolen JJ, Pijls NH. Coronary Pressure Never Lies. Catheter Cardiovasc Interv 2008;72:248-56.

    PubMed  Article  Google Scholar 

  30. Li J, Elrashidi MY, Flammer AJ, Lennon RJ, Bell MR, Holmes DR, et al. Long-Term Outcomes of Fractional Flow Reserve-Guided Vs. Angiography-Guided Percutaneous Coronary Intervention in Contemporary Practice. Eur Heart J 2013;34:1375-83.

    PubMed  Article  CAS  Google Scholar 

  31. Segall GM, Atwood JE, Botvinick EH, Dae MW, Lucas JR. Variability of Normal Coronary Anatomy: Implications for the Interpretation of Thallium SPECT Myocardial Perfusion Images in Single-Vessel Disease. J Nucl Med 1995;36:944-51.

    PubMed  CAS  Google Scholar 

  32. Pijls NHJ, Tanaka N, Fearon WF. Functional Assessment of Coronary Stenoses: Can We Live Without It? Eur Heart J 2013;34:1335-44.

    PubMed  Article  Google Scholar 

  33. Simons M, Parker JA, Donohoe KJ, Udelson JE, Gervino EV. The Impact of Clinical Data on Interpretation of Thallium Scintigrams. J Nucl Cardiol 1994;1:365-71.

    PubMed  Article  CAS  Google Scholar 

  34. Sharma P, Patel CD, Karunanithi S, Maharjan S, Malhotra A. Comparative Accuracy of CT Attenuation-Corrected and Non-attenuation-Corrected SPECT Myocardial Perfusion Imaging. Clin Nucl Med 2012;37:332-8.

    PubMed  Article  Google Scholar 

  35. Mouden M, Timmer JR, Ottervanger JP, Reiffers S, Oostdijk AHJ, Knollema S, et al. Impact of a New Ultrafast CZT SPECT Camera for Myocardial Perfusion Imaging: Fewer Equivocal Results and Lower Radiation Dose. Eur J Nucl Med Mol Imaging 2012;39:1048-55.

    PubMed  Article  Google Scholar 

  36. Mouden M, Ottervanger JP, Timmer JR, Reiffers S, Oostdijk AHJ, Knollema S et al. The Influence of Coronary Calcium Score on Interpretation of Myocardial Perfusion Imaging (Abstract). ICNC11 2013.

  37. Rana JS, Rozanski A, Berman DS. Combination of Myocardial Perfusion Imaging and Coronary Artery Calcium Scanning: Potential Synergies for Improving Risk Assessment in Subjects with Suspected Coronary Artery Disease. Curr Atheroscler Rep 2011;13:381-9.

    PubMed  Article  Google Scholar 

  38. Kaufmann PA, Di Carli MF. Hybrid SPECT/CT and PET/CT Imaging: The Next Step in Noninvasive Cardiac Imaging. Semin Nucl Med 2009;39:341-7.

    PubMed  Article  Google Scholar 

  39. Dilsizian V, Taillefer R. Journey in Evolution of Nuclear Cardiology: Will There be Another Quantum Leap with the F-18-Labeled Myocardial Perfusion Tracers? JACC Cardiovasc Imaging 2012;5:1269-84.

    PubMed  Article  Google Scholar 

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Conflict of interest

The authors have indicated that they have no financial conflict of interest.

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Author information

Affiliations

  1. Department of Cardiology, Isala Klinieken, Dokter Van Heesweg 2, 8025 AB, Zwolle, The Netherlands

    Shu Yokota MD, Jan Paul Ottervanger MD, PhD, FESC, Mohamed Mouden MD & Jorik R. Timmer MD, PhD

  2. Department of Nuclear Medicine, Isala Klinieken, Dokter Van Heesweg 2, 8025 AB, Zwolle, The Netherlands

    Siert Knollema MD, PhD & Pieter L. Jager MD, PhD

Authors
  1. Shu Yokota MD
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  2. Jan Paul Ottervanger MD, PhD, FESC
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  3. Mohamed Mouden MD
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  4. Jorik R. Timmer MD, PhD
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  5. Siert Knollema MD, PhD
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  6. Pieter L. Jager MD, PhD
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Corresponding author

Correspondence to Jan Paul Ottervanger MD, PhD, FESC.

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See related editorial, doi:10.1007/s12350-013-9849-1.

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Yokota, S., Ottervanger, J.P., Mouden, M. et al. Prevalence, location, and extent of significant coronary artery disease in patients with normal myocardial perfusion imaging. J. Nucl. Cardiol. 21, 284–290 (2014). https://doi.org/10.1007/s12350-013-9837-5

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  • DOI: https://doi.org/10.1007/s12350-013-9837-5

Keywords

  • Single-photon emission computed tomography
  • myocardial perfusion imaging
  • coronary artery disease