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Diagnosis of Extensive Coronary Artery Disease: Intrinsic Value of Increased Lung ²⁰¹Tl Uptake with Exercise SPECT

Nuclear Medicine Department, Bichat University Hospital, Paris
Nuclear Medicine Department, Antoine Beclere Hospital, Clamart, France

Correspondence: For correspondence or reprints contact: Doumit Daou, MD, Nuclear Medicine Department, Bichat University Hospital, 46 rue Henri Huchard, 75877 Paris Cedex 18, France.

ABSTRACT

Exercise lung ²⁰¹Tl uptake calculated with planar imaging has an important diagnostic and prognostic value in patients with coronary artery disease (CAD). However, its value with SPECT imaging raises methodological concerns and is controversial. We studied its value for the discrimination between extensive (E) and limited (L) angiographic CAD with exercise SPECT. Methods: Four methods of lung-to-heart ratio quantification were calculated in patients with a low likelihood (< 5%) of CAD (n = 62). Their dependent variables were defined, and corresponding correction equations were derived. Receiver operating characteristic (ROC) analysis was performed in a pilot group (L-CAD, n = 49; E-CAD, n = 126) to define the optimal method of calculation of the lung-to-heart ratio. Its best threshold providing the best sensitivity for a specificity of 90% was defined. After correction for dependent variables, the 4 methods were also compared by ROC analysis and the optimal corrected method was compared with the optimal uncorrected method using ROC analysis and the best threshold. The consistency of these results in the validation group (L-CAD, n = 41; E-CAD, n = 122) and of the results of visual analysis of lung ²⁰¹Tl uptake were then verified. Results: On ROC analysis in the pilot group, the optimal method of calculation of the lung-to-heart ratio was the mean activity in a region of interest drawn at the base of the lungs to the mean activity over the heart (L_b/H). For the best threshold, L_b/H presented a sensitivity of 34%. Corrected L_b/H still remained the best method of calculation on ROC analysis compared with the other corrected methods. On ROC analysis, there was no difference between corrected and uncorrected L_b/H. For the best threshold, corrected L_b/H presented a similar sensitivity of 37% compared with uncorrected L_b/H. When applied to the validation group (L-CAD, n = 41; E-CAD, n = 122), the best-defined threshold in the pilot group for corrected L_b/H presented a diagnostic value similar to that in the pilot group (sensitivity, 41 %; specificity, 90%), but uncorrected L_b/H presented a higher sensitivity (47%; P < 0.04) and a slightly lower specificity (80%). Results of lung ²⁰¹Tl uptake visual analysis were inconsistent between pilot and validation groups (42% versus 58% sensitivity, P = 0.012; 86% versus 66% specificity, P = 0.023). Conclusion: For evaluation of E-CAD versus L-CAD, quantification of the exercise lung-to-heart ²⁰¹Tl uptake ratio with SPECT is feasible, reproducible, more discriminate than simple visual analysis, and best calculated as L_b/H. It presents an intrinsic diagnostic value even after correction for other clinically valuable dependent variables.

Key Words: ²⁰¹Tl • SPECT • exercise • coronary artery disease • radionuclide

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