Skip to main content

Long-term prognostic value of low-dose normal stress-only myocardial perfusion imaging by wide beam reconstruction: A competing risk analysis



A normal stress myocardial perfusion single-photon emission computed tomography (MPS) is associated with a good clinical outcome. New iterative algorithms, such as wide beam reconstruction (WBR), which improve image interpretation with half-dose or half-time acquisition, have been proposed for cardiac MPS. The aim of this study was to assess the long-term predictive value of a low-dose normal stress-only MPS with WBR using conventional Anger camera in patients with known or suspected coronary artery disease (CAD).

Methods and Results

A total of 2106 patients with known or suspected CAD and normal perfusion at half-dose stress-only MPS protocol were followed for a mean of 6.6 ± 2.7 years. MPS data were reconstructed with WBR iterative algorithm. End-point events were cardiac death or nonfatal myocardial infarction. Noncardiac death was considered the competing event. During follow-up, 149 cardiac events occurred with an annualized event rate of 1.2%. Independent predictors of cardiac events at Cox analysis were age, male gender, diabetes mellitus, previous myocardial infarction and the need for pharmacologic stress testing. At Fine-Gray analysis the cumulative incidence of cardiac events progressively increases with age and in the presence of diabetes for any combination of gender and stress type. Survival tree analysis confirmed that long-term prognosis considerably varies according of risk factors profile.


Low-dose normal stress-only WBR MPS has a reliable long-term prognostic value in patients with suspected or known CAD. This finding supports the introduction of such a method into clinical practice with a consistent dose optimization in the interest of patients and exposed staff.

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

Figure 1
Figure 2
Figure 3
Figure 4
Figure 5



Myocardial perfusion single-photon emission computed tomography


Coronary artery disease


Wide beam reconstruction




  1. 1.

    Simonsen JA, Gerke O, Rask CK, Tamadoni M, Thomassen A, Hess S, et al. Prognosis in patients with suspected or known ischemic heart disease and normal myocardial perfusion: Long-term outcome and temporal risk variations. J Nucl Cardiol 2013;20:347-57.

    Article  Google Scholar 

  2. 2.

    Metz LD, Beattie M, Hom R, Redberg RF, Grady D, Fleischmann KE. The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: A meta-analysis. J Am Coll Cardiol 2007;49:227-37.

    Article  Google Scholar 

  3. 3.

    Yao SS, Rozanski A. Principal uses of myocardial perfusion scintigraphy in the management of patients with known or suspected coronary artery disease. Prog Cardiovasc Dis 2001;43:281-302.

    CAS  Article  Google Scholar 

  4. 4.

    Elhendy A, Schinkel A, Bax JJ, van Domburg RT, Poldermans D. Long-term prognosis after a normal exercise stress Tc-99m sestamibi SPECT study. J Nucl Cardiol 2003;10:261-6.

    Article  Google Scholar 

  5. 5.

    Bhavnani SP, Heller GV. Stress-only myocardial perfusion imaging …it is time for a change! J Nucl Cardiol 2011;18:836-9.

    Article  Google Scholar 

  6. 6.

    Duvall WL, Baber U, Levine EJ, Croft LB, Henzlova MJ. A model for the prediction of a successful stress-first Tc-99m SPECT MPI. J Nucl Cardiol. 2012;19:1124-34.

    Article  Google Scholar 

  7. 7.

    Chang SM, Nabi F, Xu J, Raza U, Mahmarian JJ. Normal stress-only versus standard stress/rest myocardial perfusion imaging: Similar patient mortality with reduced radiation exposure. J Am Coll Cardiol 2010;55:221-30.

    Article  Google Scholar 

  8. 8.

    Fazel R, Gerber TC, Balter S, Brenner DJ, Carr JJ, Cerqueira MD, et al. American Heart Association Council on Quality of Care and Outcomes Research, Council on Clinical Cardiology, and Council on Cardiovascular Radiology and Intervention. Approaches to enhancing radiation safety in cardiovascular imaging: A scientific statement from the American Heart Association. Circulation 2014;130:1730-48.

    Article  Google Scholar 

  9. 9.

    Douglas PS, Carr JJ, Cerqueira MD, Cummings JE, Gerber TC, Mukherjee D, et al. Developing an action plan for patient radiation safety in adult cardiovascular medicine. Proceedings from the Duke University Clinical Research Institute/American College of Cardiology Foundation/American Heart Association Think Tank Held on 2011. J Nucl Cardiol 2011;19:534-50.

    Article  Google Scholar 

  10. 10.

    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;42:1004-11.

    CAS  Article  Google Scholar 

  11. 11.

    Gaemperli O, Kaufmann PA. Lower dose and shorter acquisition: Pushing the boundaries of myocardial perfusion SPECT. J Nucl Cardiol 2011;18:830-2.

    Article  Google Scholar 

  12. 12.

    DePuey EG, Ata P, Wray R, Friedman M. Very low-activity stress/high-activity rest, single-day myocardial perfusion SPECT with a conventional sodium iodide camera and wide beam reconstruction processing. J Nucl Cardiol 2012;19:931-44.

    Article  Google Scholar 

  13. 13.

    Marcassa C, Campini R, Zoccarato O, Calza P. Wide beam reconstruction for half-dose or half time cardiac gated SPECT acquisitions: Optimization of resources and reduction in radiation exposure. Eur J Nucl Med Mol Imaging 2011;38:499-508.

    Article  Google Scholar 

  14. 14.

    Verberne HJ, Acampa W, Anagnostopoulos C, Ballinger J, Bengel F, De Bondt P, et al. European Association of Nuclear Medicine (EANM). EANM procedural guidelines for radionuclide myocardial perfusion imaging with SPECT and SPECT, CT: 2015 revision. Eur J Nucl Med Mol Imaging 2015;2015:1929-40.

    Article  Google Scholar 

  15. 15.

    Acampa W, Petretta M, Daniele S, Del Prete G, Assante R, Zampella E, et al. Incremental prognostic value of stress myocardial perfusion imaging in asymptomatic diabetic patients. Atherosclerosis 2013;227:307-12.

    CAS  Article  Google Scholar 

  16. 16.

    Acampa W, Petretta M, Evangelista L, Daniele S, Xhoxhi E, De Rimini ML, et al. Myocardial perfusion imaging and risk classification for coronary heart disease in diabetic patients. The IDIS study: A prospective, multicentre trial. Eur J Nucl Med Mol Imaging 2012;39:387-95.

    Article  Google Scholar 

  17. 17.

    Acampa W, Rozza F, Zampella E, Assante R, Mannarino T, Nappi C, et al. Warranty period of normal stress myocardial perfusion imaging in hypertensive patients: A parametric survival analysis. J Nucl Cardiol 2018.

    Article  PubMed  Google Scholar 

  18. 18.

    Austin PC, Lee DS, Fine JP. Introduction to the analysis of survival data in the presence of competing risks. Circulation 2016;133:601-9.

    Article  Google Scholar 

  19. 19.

    Aban I. Time to event analysis in the presence of competing risks. J Nucl Cardiol 2015;22:466-7.

    Article  Google Scholar 

  20. 20.

    Fine JP, Gray RJ. A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc 1999;94:496-509.

    Article  Google Scholar 

  21. 21.

    Gaudieri V, Nappi C, Acampa W, Zampella E, Assante R, Mannarino T, et al. Added prognostic value of left ventricular shape by gated SPECT imaging in patients with suspected coronary artery disease and normal myocardial perfusion. J Nucl Cardiol 2017.

    Article  PubMed  Google Scholar 

  22. 22.

    Green R, Cantoni V, Petretta M, Acampa W, Panico M, Buongiorno P, et al. Negative predictive value of stress myocardial perfusion imaging and coronary computed tomography angiography: A meta-analysis. J Nucl Cardiol 2017.

    Article  PubMed  Google Scholar 

  23. 23.

    Lau B, Cole SR, Gange SJ. Competing risk regression models for epidemiologic data. Am J Epidemiol 2009;170:244-56.

    Article  Google Scholar 

  24. 24.

    Hachamovitch R, Hayes S, Friedman JD, Cohen I, Shaw LJ, Germano G, et al. Determinants of risk and its temporal variation in patients with normal stress myocardial perfusion scans: What is the warranty period of a normal scan? J Am Coll Cardiol 2003;41:1329-40.

    Article  Google Scholar 

  25. 25.

    Shaw LJ, Iskandrian AE. Prognostic value of gated myocardial perfusion SPECT. J Nucl Cardiol 2004;11:171-85.

    Article  Google Scholar 

  26. 26.

    Rozanski A, Gransar H, Hayes SW, Friedman JD, Hachamovitch R, Berman DS. Comparison of long-term mortality risk following normal exercise vs adenosine myocardial perfusion SPECT. J Nucl Cardiol 2010;17:999-1008.

    Article  Google Scholar 

  27. 27.

    Romero-Farina G, Candell-Riera J, Aguadé-Bruix S, Ferreira-González I, Cuberas-Borrós G, Pizzi N, et al. Warranty periods for normal myocardial perfusion stress SPECT. J Nucl Cardiol 2015;22:44-54.

    Article  Google Scholar 

  28. 28.

    Acampa W, Petretta M, Cuocolo R, Daniele S, Cantoni V, Cuocolo A. Warranty period of normal stress myocardial perfusion imaging in diabetic patients: A propensity score analysis. J Nucl Cardiol 2014;21:50-6.

    Article  Google Scholar 

  29. 29.

    Acampa W, Cantoni V, Green R, Maio F, Daniele S, Nappi C, et al. Prognostic value of normal stress myocardial perfusion imaging in diabetic patients: A meta-analysis. J Nucl Cardiol 2014;21:893-902.

    Article  Google Scholar 

  30. 30.

    Picano E, Vañó E, Rehani MM, Cuocolo A, Mont L, Bodi V, et al. The appropriate and justified use of medical radiation in cardiovascular imaging: A position document of the ESC Associations of Cardiovascular Imaging, Percutaneous Cardiovascular Interventions an Electrophysiology. Eur Heart J 2014;35:665-72.

    Article  Google Scholar 

  31. 31.

    National Council on Radiation Protection and Measurements, National Council on Radiation Protection and Measurements. Scientific Committee 6-2 on Radiation Exposure of the U.S. Population. Ionizing radiation exposure of the population of the United States: Recommendations of the National Council on Radiation Protection and Measurements. Bethesda, MD.: National Council on Radiation Protection and Measurements; 2009.

  32. 32.

    Borges-Neto S, Pagnanelli RA, Shaw LK, Honeycutt E, Shwartz SC, Adams GL, et al. Clinical results of a novel wide beam reconstruction method for shortening scan time of Tc-99m cardiac SPECT perfusion studies. J Nucl Cardiol 2007;14:555-65.

    Article  Google Scholar 

  33. 33.

    DePuey EG, Bommireddipalli S, Clark J, Leykekhman A, Thompson LB, Friedman M. A comparison of the image quality of full-time myocardial perfusion SPECT vs wide beam reconstruction half-time and half-dose SPECT. J Nucl Cardiol 2011;18:273-80.

    Article  Google Scholar 

  34. 34.

    Einstein AJ, Berman DS, Min JK, Hendel RC, Gerber TC, Carr JJ, et al. Patient-centered imaging: shared decision making for cardiac imaging procedures with exposure to ionizing radiation. J Am Coll Cardiol 2014;22:1480-9.

    Article  Google Scholar 

Download references


C. Nappi, W. Acampa, E. Nicolai, S. Daniele, E. Zampella, R. Assante, V. Gaudieri, T. Mannarino, M. Petretta, A. Cuocolo declare that they have no conflict of interest.

Author information



Corresponding author

Correspondence to Alberto Cuocolo MD.

Additional information

The authors of this article have provided a PowerPoint file, available for download at SpringerLink, which summarises the contents of the paper and is free for re-use at meetings and presentations. Search for the article DOI on

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PPTX 1518 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Nappi, C., Acampa, W., Nicolai, E. et al. Long-term prognostic value of low-dose normal stress-only myocardial perfusion imaging by wide beam reconstruction: A competing risk analysis. J. Nucl. Cardiol. 27, 547–557 (2020).

Download citation


  • MPI
  • diagnostic and prognostic application