SPECT myocardial perfusion versus fractional flow reserve for evaluation of functional ischemia: A meta analysis

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Abstract

Purpose

The present meta-analysis illustrates the accuracy of myocardial perfusion SPECT (MPS) to diagnose functional stenotic coronary artery disease (CAD) with fractional flow reserve (FFR) as standard reference.

Methods

All investigators screened and selected studies that compared MPS with FFR in symptomatic patients with suspected CAD. Patients and study characteristics were independently extracted by two investigators; differences were resolved by consensus.

Results

13 articles, including 1,017 patients, 699 vessels were included in the study. No significant publication bias was detected (P = 0.65). At the patient level, the summary sensitivity and specificity were 77% (95% confidence interval [CI], 70–83%) and 77% (95%CI, 67–84%) for MPS. Vessel-level pooled sensitivity was 66% (95%CI, 57–74%) and specificity was 81% (95%CI, 70–89%). The overall diagnostic performance of MPS was moderate. [The area under the summary receiver operating characteristic (sROC) curve was 0.83]. No study influenced the pooled results larger than 0.03.

Conclusions

The accuracy between FFR and MPS SPECT was moderate.

Introduction

Coronary artery disease (CAD) is one of the main causes of death in industrialized countries [1]. In order to avoid progression of irreversible myocardial damage, a reasonable treatment guided by precise diagnosis of ischemia is a critical problem. Therefore, efforts focusing on detection of ischemia are critical to prevent death of patients with CAD [2].

Myocardial perfusion single photon emission tomography (MPS) is widely used for assessment of ischemia in patients with CAD. It refers that the uptake of radiopharmaceutical is decreased in the area of serious coronary artery disease or in the situation of anomalous flow reserve. Relative differences can be assessed quantitatively or visually during the maximal vasodilatation generated by pharmacological pressure or exercise in the myocardial territory [3], [4]. Several meta analyses have confirmed the high accuracy to diagnose CAD, which, however, applied quantitative coronary angiography (QCA) as standard reference. Although QCA has a high accuracy to evaluate stenosis of coronary artery lumen, the myocardial ischemia could not be evaluated effectively by QCA [5].

Recently, FFR is used as new gold standard to diagnose ischemia. It is an invasive method conducted by pressure measurements in the progress of coronary angiography and has an important influence on guiding the settlement to carry out percutaneous coronary intervention (PCI) in the intermediately coronary stenosis of uncertain functional value. It is the ratio of the maximal achievable flow with a stenosis present divided by the theoretical maximal flow in the same vessel in the absence of stenosis,which has demonstrated its advantage to detect ischemia over QCA in evaluating myocardial ischemia by quantity of stenosis indirectly [6], [7]. FFR is therefore applied as a new superior index to guide revascularation [8].

The present meta-analysis illustrates the accuracy of MPS to diagnose functional stenotic coronary artery disease (CAD) with FFR as new standard reference.

Section snippets

Methods

We conducted this meta analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [9].

Study selection and characteristics

497 articles were firstly searched from PubMed, Embase and Cochrane. After screening by title and abstract, 96 full articles were retrieved. Based on the inclusion and exclusion criteria, 13 studies were finally included in the present study. The flow chart of articles research and selection process were demonstrated in Fig. 1. Baseline characteristics of the study are shown in Table 1.

Methodological quality

The methodological quality was assessed by the QUADAS tool. During which none fulfill all the items, 9 Studies

Discussion

Myocardial ischemia refers to the blood perfusion of the heart to reduce, causing abnormal myocardial energy metabolism. Precise diagnosis of ischemia is critical for reasonable treatment. MPS is one of noninvasive techniques to detect myocardial ischemia. Previous studies have demonstrated its high diagnostic accuracy to detect CAD, which, however, was evaluated with QCA as reference [sensitivity: 88% (95%CI: 88–89%) and specificity: 61% (95%CI: 59–62%)] [11]. As QCA is not a functional

Conclusions

The present meta-analysis illustrates the accuracy of MPS to diagnose functional stenotic coronary artery disease (CAD) with FFR as new standard reference. It is found that the accuracy between FFR and MPS SPECT was moderate.

Conflict of interest

The authors declare that they have no conflict of interest.

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    1

    These authors are first authors and they contributed equally to this work.

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