Skip to main content

Deciding wisely: A case for an effective use of myocardial perfusion imaging

Journal of Nuclear Cardiology volume 25, pages 53–61 (2018)Cite this article

Abstract

There is a vast body of literature supporting the use of stress myocardial perfusion imaging (MPI) in patients with known or suspected coronary artery disease. When applied in the appropriate clinical setting, MPI can aid, not only in diagnosis and risk stratification, but also in decision-making. In a case of a 58-year-old man with suspected coronary artery disease, we highlight how the appropriate use of stress MPI can leverage the diagnostic and prognostic utility of MPI in an effective, evidence-based decision-making aimed to achieve the best patient outcome.

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

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Figure 1
Figure 2
Figure 3
Figure 4
Figure 5

Abbreviations

CAD:

Coronary artery disease

PCI:

Percutaneous coronary intervention

CABG:

Coronary artery bypass grafting

LAD:

Left anterior descending coronary artery

RCA:

Right coronary artery

MPI:

Myocardial perfusion imaging

SPECT:

Single-photon emission computed tomography

TID:

Transient ischemic dilation

SSS:

Summed stress score

SDS:

Summed difference score

DTS:

Duke Treadmill Score

LVEF:

Left ventricular ejection fraction

ETT:

Exercise tolerance test

CCTA:

Coronary computed tomographic angiography

OMT:

Optimal medical therapy

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). J Am Coll Cardiol 2002;40:1531-40.

    Article  PubMed  Google Scholar 

  2. 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.

    CAS  Article  PubMed  Google Scholar 

  3. Hachamovitch R, Hayes SW, Friedman JD, Cohen I, Berman DS. Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation 2003;107:2900-7.

    Article  PubMed  Google Scholar 

  4. Wolk MJ, Bailey SR, Doherty JU, Douglas PS, Hendel RC, Kramer CM, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014;63:380-406.

    Article  PubMed  Google Scholar 

  5. 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.

    Article  PubMed  Google Scholar 

  6. Douglas PS, Hoffmann U, Patel MR, Mark DB, Al-Khalidi HR, Cavanaugh B, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med 2015;372:1291-300.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  7. Mark DB, Federspiel JJ, Cowper PA, Anstrom KJ, Hoffmann U, Patel MR, et al. Economic outcomes with anatomical versus functional diagnostic testing for coronary artery disease. Ann Intern Med 2016;165:94-102.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Shaw LJ, Mieres JH, Hendel RH, Boden WE, Gulati M, Veledar E, et al. Comparative effectiveness of exercise electrocardiography with or without myocardial perfusion single photon emission computed tomography in women with suspected coronary artery disease: Results from the What Is the Optimal Method for Ischemia Evaluation in Women (WOMEN) trial. Circulation 2011;124:1239-49.

    Article  PubMed  Google Scholar 

  9. Doukky R, Hayes K, Frogge N, Balakrishnan G, Dontaraju VS, Rangel MO, et al. Impact of appropriate use on the prognostic value of single-photon emission computed tomography myocardial perfusion imaging. Circulation 2013;128:1634-43.

    Article  PubMed  Google Scholar 

  10. Hachamovitch R, Berman DS, Kiat H, Cohen I, Cabico JA, Friedman J, et al. Exercise myocardial perfusion SPECT in patients without known coronary artery disease: Incremental prognostic value and use in risk stratification. Circulation 1996;93:905-14.

    CAS  Article  PubMed  Google Scholar 

  11. Xu Y, Arsanjani R, Clond M, Hyun M, Lemley M Jr, Fish M, et al. Transient ischemic dilation for coronary artery disease in quantitative analysis of same-day sestamibi myocardial perfusion SPECT. J Nucl Cardiol 2012;19:465-73.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Doukky R, Frogge N, Bayissa YA, Balakrishnan G, Skelton JM, Confer K, et al. The prognostic value of transient ischemic dilatation with otherwise normal SPECT myocardial perfusion imaging: A cautionary note in patients with diabetes and coronary artery disease. J Nucl Cardiol 2013;20:774-84.

    Article  PubMed  Google Scholar 

  13. Alama M, Labos C, Emery H, Iwanochko RM, Freeman M, Husain M, et al. Diagnostic and prognostic significance of transient ischemic dilation (TID) in myocardial perfusion imaging: A systematic review and meta-analysis. J Nucl Cardiol 2017. https://doi.org/10.1007/s12350-017-1040-7.

    PubMed  Google Scholar 

  14. Johnson LL, Verdesca SA, Aude WY, Xavier RC, Nott LT, Campanella MW, et al. Postischemic stunning can affect left ventricular ejection fraction and regional wall motion on post-stress gated sestamibi tomograms. J Am Coll Cardiol 1997;30:1641-8.

    CAS  Article  PubMed  Google Scholar 

  15. Ward RP, Gundeck EL, Lang RM, Spencer KT, Williams KA. Overestimation of postischemic myocardial stunning on gated SPECT imaging: Correlation with echocardiography. J Nucl Cardiol 2006;13:514-20.

    Article  PubMed  Google Scholar 

  16. Emmett L, Iwanochko RM, Freeman MR, Barolet A, Lee DS, Husain M. Reversible regional wall motion abnormalities on exercise technetium-99m-gated cardiac single photon emission computed tomography predict high-grade angiographic stenoses. J Am Coll Cardiol 2002;39:991-8.

    Article  PubMed  Google Scholar 

  17. Gomez J, Golzar Y, Fughhi I, Olusanya A, Doukky R. The significance of post-stress decrease in left ventricular ejection fraction in patients undergoing regadenoson stress gated SPECT myocardial perfusion imaging. J Nucl Cardiol 2017. https://doi.org/10.1007/s12350-017-0802-6.

    Google Scholar 

  18. Shaw LJ, Berman DS, Maron DJ, Mancini GB, Hayes SW, Hartigan PM, et al. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: Results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation 2008;117:1283-91.

    Article  PubMed  Google Scholar 

  19. 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.

    CAS  Article  PubMed  Google Scholar 

  20. Shaw LJ, Cerqueira MD, Brooks MM, Althouse AD, Sansing VV, Beller GA, et al. Impact of left ventricular function and the extent of ischemia and scar by stress myocardial perfusion imaging on prognosis and therapeutic risk reduction in diabetic patients with coronary artery disease: Results from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. J Nucl Cardiol 2012;19:658-69.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Mohr FW, Morice MC, Kappetein AP, Feldman TE, Stahle E, Colombo A, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 2013;381:629-38.

    Article  PubMed  Google Scholar 

  22. Park SJ, Ahn JM, Kim YH, Park DW, Yun SC, Lee JY, et al. Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med 2015;372:1204-12.

    CAS  Article  PubMed  Google Scholar 

  23. 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  PubMed  Google Scholar 

  24. Alexander KP, Shaw LJ, Shaw LK, Delong ER, Mark DB, Peterson ED. Value of exercise treadmill testing in women. J Am Coll Cardiol 1998;32:1657-64.

    CAS  Article  PubMed  Google Scholar 

Download references

Disclosure

The author receives research funding from Astellas Pharma Global Development and served on Advisory Boards for Astellas Pharma Global Development.

Author information

Affiliations

  1. Division of Cardiology, Cook County Health and Hospitals System, 1901 W. Harrison St, Chicago, IL, 60612, USA

    Rami Doukky MD, MSc, FASNC

  2. Division of Cardiology, Rush University Medical Center, Chicago, IL, USA

    Rami Doukky MD, MSc, FASNC

Authors
  1. Rami Doukky MD, MSc, FASNC
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rami Doukky MD, MSc, FASNC.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Doukky, R. Deciding wisely: A case for an effective use of myocardial perfusion imaging. J. Nucl. Cardiol. 25, 53–61 (2018). https://doi.org/10.1007/s12350-017-1136-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12350-017-1136-0

Keywords

  • Myocardial perfusion imaging
  • SPECT
  • Diagnosis
  • Prognosis
  • Decision-making