Asnc Information StatementThe role of radionuclide myocardial perfusion imaging for asymptomatic individuals
Introduction
Radionuclide myocardial perfusion imaging (RMPI) has served as a clinical mainstay in the management of patients with known or suspected coronary artery disease (CAD) for more than two decades. RMPI provides information beyond the mere detection of disease, delineating the extent, severity, and location of perfusion abnormalities. These data also have important prognostic implications and assist in providing reassurance to the clinician and patient or suggest the need for additional therapies. However, the role of RMPI among asymptomatic patients is less defined than among those with active symptoms. Furthermore, in keeping with the recent emphasis on improved resource utilization, cost-containment, and reduction of radiation exposure, the American Society of Nuclear Cardiology (ASNC) has commissioned a review of evidence for the use of RMPI specifically for asymptomatic individuals in an attempt to provide guidance for clinicians.
The notation of symptomatic status remains a challenge since this designation is largely given to patient exhibiting chest pain suggestive of myocardial ischemia. Other symptoms such as dyspnea or syncope are often assigned to those without symptoms (i.e., no chest pain). For these patients with atypical presentations, the symptom burden places them at an elevated risk and may require additional assessment even though they may not have chest pain. Additionally, ischemic-type abnormalities on a resting electrocardiogram (ECG) connote an increased risk of cardiac events. The most recent Appropriate Use Criteria for Cardiac Radionuclide Imaging1 document discriminates between asymptomatic patients and those with an ischemic equivalent, the latter including chest pain, anginal equivalents, or an abnormal ECG.
The goal of this Information Statement is to define instances when the additional evaluation of asymptomatic patients may offer useful clinical information. In contrast, the elimination of the use of RMPI in patient groups where no benefit may be garnered serves as an important means to reduce radiation exposure.2
Section snippets
Clinical Risk Assessment
Clinical risk assessment forms the basis for risk stratification and the intensity of medical management for asymptomatic patients.3,4 A number of global risk scores are available for use5, 6, 7, 8 with an aggregation of an array of traditional and novel risk factors into a composite score estimating major adverse cardiovascular events. In the United States, the Framingham risk score (FRS) is the most commonly applied index and renders an estimation of 10-year risk of cardiovascular death or
CHD Equivalents
Patients with medical conditions that portend a similar cardiovascular risk to those with established CHD represent an ideal asymptomatic population to discuss the role of RMPI. Conditions including diabetes mellitus, other atherosclerotic disease (e.g., peripheral arterial disease [PAD], abdominal aortic aneurysm, carotid artery disease), and a >20%, 10-year risk of CHD by Framingham projections have long been identified as CHD risk equivalents and accepted as indications to justify and
Unique Patient Populations
Several unique medical conditions are associated with an elevated risk for cardiovascular events and cardiac death. The detection of asymptomatic CAD in patients with these medical conditions may improve patient outcomes by identifying patients who may benefit from aggressive medical therapy and/or coronary revascularization. This section examines the currently available evidence for the clinical application of RMPI in asymptomatic individuals with these medical conditions.
Prior Test Results
Among asymptomatic patients with prior abnormal imaging results, RMPI may be used for both the diagnosis of ischemia and/or scar as well as to improve risk assessment (i.e., prognosis). However, serial (repeated test) and sequential or layered (additional test) testing may add substantial expense and risk, including radiation exposure. Thus, performing RMPI should provide incremental value to clinical information that is already available.
Asymptomatic patients without prior, known CAD may
Pre-Operative Evaluation
The systematic use of MPI in the preoperative evaluation of noncardiac surgery patients began more than two decades ago84,85 and has been recently updated by several national guidelines86,87 and appropriate use criteria.1 The incidence of serious cardiac events in this large population has driven the effort to appropriately risk stratify this group in an efficient and cost-effective manner.88 Patients may be asymptomatic for CAD but the standard clinical preoperative evaluation involves the
Asymptomatic Patients with Chronic CAD
RMPI has been shown to effectively risk stratify patients with chronic CAD and prior revascularization. Studies of the utility of MPI in this patient population have largely included patients with symptoms suggestive of CAD progression, and some asymptomatic patients.
Radiation Exposure
The current consensus, not supported by concrete data, is that even small amounts of radiation exposure increase lifetime risk of cancer.116 The increased risk is estimated to be approximately 0.05% for every 10 mSv of exposure. As such, both patient selection and the imaging protocol (i.e., equipment, radionuclides, doses) need to be carefully considered to keep exposure as low as reasonably achievable (ALARA).117 These considerations may be especially important for asymptomatic individuals,
Conclusions
There is robust medical evidence supporting the use of RMPI for the diagnostic evaluation and risk assessment of symptomatic patients with known or suspected ischemic heart disease. Yet, in general, similar literature is not available for asymptomatic individuals. However, the underlying physiologic assessment of coronary blood flow and its potential to impact on patient management should be similar.
Clinical risk assessment is key with regards to applying RMPI for the evaluation of asymptomatic
Disclosures
Robert C. Hendel, MD serves on the advisory board for Astellas Pharma US and UnitedHealth Group, serves on the speakers’ bureau for Astellas Pharma US, is a consultant for PGx Health, and receives research support from GE Healthcare and PGx Health. Brian G. Abbott, MD serves on the advisory Board for Astellas Pharma US. Dennis A. Calnon, MD is a consultant for PGx Health. Jamishid Maddahi, MD receives research support from Lantheus Medical Imaging, serves on the speakers’ bureau for Astellas
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Cited by (39)
Quality metrics for single-photon emission computed tomography myocardial perfusion imaging: an ASNC information statement
2023, Journal of Nuclear CardiologyACR Appropriateness Criteria® Asymptomatic Patient at Risk for Coronary Artery Disease: 2021 Update
2021, Journal of the American College of RadiologyCitation Excerpt :For a selected subgroup of asymptomatic patients with diabetes, data suggest routine use of SPECT as a screening test is likely to have a lower yield as well as limited effect on clinical outcomes [53]. However, the most recent ACC/AHA/ASNC Appropriate Use Criteria for SPECT MPI states SPECT would be useful when the calcium score is >400 or 100 to 400 if the patient is at high risk of CAD [38]. The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list.
Controversies in Diagnostic Imaging of Patients With Suspected Stable and Acute Chest Pain Syndromes
2019, JACC: Cardiovascular ImagingCitation Excerpt :In asymptomatic patients, these decisions remain controversial even within practice guidelines and more often than not, clinicians find little support towards justifying imaging of asymptomatic patients. Among the clinical high-risk cohort, a 15% to 60% increased risk of myocardial infarction (MI) and up to a 6-fold increased risk of coronary mortality have been reported (15). Up to one-half of all acute MI patients without previous CAD had no history of suggestive symptoms (16).
Collegial pressure and patient-centered shared-decision making: A case-based ethics discussion
2015, Journal of Nuclear CardiologyAnatomic versus physiologic assessment of coronary artery disease: Role of coronary flow reserve, fractional flow reserve, and positron emission tomography imaging in revascularization decision-making
2013, Journal of the American College of CardiologyCitation Excerpt :While FFR is an invasive pressure-derived relative CFR, noninvasive cardiac PET has been proven experimentally and clinically to measure absolute myocardial perfusion, absolute and relative CFR. Classic relative uptake PET images have powerfully advanced clinical imaging, even without absolute perfusion (22,26–29) due to attenuation correction, high resolution, and quantitative activity recovery. It has the additional advantage of measuring absolute myocardial perfusion, as proven by a substantial literature over the past 25 years, highlighted by recent useful reviews and reports (30–38,Online Refs. 50–81).
An appropriate use criterion is very important to reduce overuse for SPECT in coronary heart disease: Economic burden in time of crises
2013, International Journal of Cardiology