Asnc Information Statement
The role of radionuclide myocardial perfusion imaging for asymptomatic individuals

https://doi.org/10.1007/s12350-010-9320-5Get rights and content

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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References (119)

  • GorayaTY et al.

    Coronary atherosclerosis in diabetes mellitus: A population based autopsy study

    J Am Coll Cardiol

    (2002)
  • BaxJJ et al.

    Global dialogue group for the evaluation of cardiovascular risk in patients with diabetes: The potential of myocardial perfusion scintigraphy for risk stratification of asymptomatic patients with type 2 diabetes

    J Am Coll Cardiol

    (2006)
  • RajagopalanN et al.

    Identifying high-risk asymptomatic diabetic patients who are candidates for screening stress single-photon emission computed tomography imaging

    J Am Coll Cardiol

    (2005)
  • RaggiP et al.

    Prognostic value of coronary artery calcium screening in subjects with and without diabetes

    J Am Coll Cardiol

    (2004)
  • ScholteAJ et al.

    Screening of asymptomatic patients with type 2 diabetes mellitus for silent coronary artery disease: Combined use of stress myocardial perfusion imaging and coronary calcium scoring

    J Nucl Cardiol

    (2006)
  • ChewKK et al.

    Erectile dysfunction as a predictor for subsequent atherosclerotic cardiovascular events: Findings from a linked-data study

    J Sex Med

    (2010)
  • GazzarusoC et al.

    Erectile dysfunction as a predictor of cardiovascular events and death in diabetic patients with angiographically proven asymptomatic coronary artery disease: A potential protective role for statins and 5-phosphodiesterase inhibitors

    J Am Coll Cardiol

    (2008)
  • AraujoAB et al.

    Erectile dysfunction and mortality

    J Sex Med

    (2009)
  • AraujoAB et al.

    Does erectile dysfunction contribute to cardiovascular disease risk prediction beyond the Framingham risk score?

    J Am Coll Cardiol

    (2010)
  • GuoW et al.

    Erectile dysfunction and risk of clinical cardiovascular events: A meta-analysis of seven cohort studies

    J Sex Med

    (2010)
  • WardRP et al.

    Comparison of findings on stress myocardial perfusion imaging in men with versus without erectile dysfunction and without prior heart disease

    Am J Cardiol

    (2008)
  • HiroseK et al.

    Prevalence of coronary heart disease in patients with aortic aneurysm and/or peripheral artery disease

    Am J Cardiol

    (2009)
  • ShawLJ et al.

    The value of estimated functional capacity in estimating outcome: Results from the NHBLI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE) Study

    J Am Coll Cardiol

    (2006)
  • ShawLJ et al.

    Prognostic value of gated myocardial perfusion SPECT

    J Nucl Cardiol

    (2004)
  • OkwuosaT et al.

    Coronary artery disease and nuclear imaging in renal failure

    J Nucl Cardiol

    (2006)
  • DahanM et al.

    Diagnostic accuracy and prognostic value of combined dipyridamole-exercise thallium imaging in hemodialysis patients

    Kidney Int

    (1998)
  • DussolB et al.

    Prognostic value of inducible myocardial ischemia in predicting cardiovascular events after renal transplantation

    Kidney Int

    (2004)
  • Catzin-KuhlmannA et al.

    Human immunodeficiency virus-infected subjects have no altered myocardial perfusion

    Int J Cardiol

    (2007)
  • WilsonPW

    Evidence of systemic inflammation and estimation of coronary artery disease risk: A population perspective

    Am J Med

    (2008)
  • BoucelmaM et al.

    Assessment of myocardial perfusion in systemic lupus erythematosus

    Rev Med Interne

    (2009)
  • LinCC et al.

    Usefulness of technetium-99 m sestamibi myocardial perfusion SPECT in detection of cardiovascular involvement in patients with systemic lupus erythematosus or systemic sclerosis

    Int J Cardiol

    (2003)
  • FusterV et al.

    ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation

    J Am Coll Cardiol

    (2006)
  • WardRP et al.

    American Society of Nuclear Cardiology review of the ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI)

    J Nucl Cardiol

    (2007)
  • ChangSM et al.

    The coronary artery calcium score and stress myocardial perfusion imaging provide independent and complementary prediction of cardiac risk

    J Am Coll Cardiol

    (2009)
  • BermanDS et al.

    Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography

    J Am Coll Cardiol

    (2004)
  • BlanksteinR et al.

    Adding calcium scoring to myocardial perfusion imaging: Does it alter physicians’ therapeutic decision making?

    J Nucl Cardiol

    (2010)
  • NambiV et al.

    Carotid intima-media thickness and presence or absence of plaque improves prediction of coronary heart disease risk: The ARIC (Atherosclerosis Risk In Communities) study

    J Am Coll Cardiol

    (2010)
  • HuntSA et al.

    2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation

    J Am Coll Cardiol

    (2009)
  • HachamovitchR 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)
  • CutlerBS et al.

    Dipyridamole thallium 201 scintigraphy to detect coronary artery disease before abdominal aortic surgery

    J Vasc Surg

    (1987)
  • FleisherLA et al.

    2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery

    J Am Coll Cardiol

    (2009)
  • EagleKA et al.

    ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary

    J Am Coll Cardiol

    (2002)
  • ShawLJ et al.

    Meta-analysis of intravenous dipyridamole-thallium-201 imaging (1985 to 1994) and dobutamine echocardiography (1991 to 1994) for risk stratification before vascular surgery

    J Am Coll Cardiol

    (1996)
  • PatelAD et al.

    Prognostic value of myocardial perfusion imaging in predicting outcomes after renal transplantation

    Am J Cardiol

    (2003)
  • WongCF et al.

    Technetium myocardial perfusion scanning in prerenal transplant evaluation in the United Kingdom

    Transplant Proc

    (2008)
  • KryzhanovskiVA et al.

    Usefulness of preoperative noninvasive radionuclide testing for detecting coronary artery disease in candidates for liver transplantation

    Am J Cardiol

    (1997)
  • ZoghbiGJ et al.

    Usefulness of preoperative stress perfusion imaging in predicting prognosis after liver transplantation

    Am J Cardiol

    (2003)
  • GuptaR et al.

    The renal patient with coronary artery disease: Current concepts and dilemmas

    J Am Coll Cardiol

    (2004)
  • LentineKL et al.

    Cardiovascular risk assessment among potential kidney transplant candidates: Approaches and controversies

    Am J Kidney Dis

    (2010)
  • BatsisJA et al.

    Cardiovascular risk assessment—from individual risk prediction to estimation of global risk and change in risk in the population

    BMC Med

    (2010)
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