The use of nuclear cardiology in clinical decision making

https://doi.org/10.1053/j.semnuclmed.2004.09.005Get rights and content

Extensive data exist to support the role of myocardial perfusion single-photon emission computed tomography (MPS) in risk stratification. Normal MPS studies usually are associated with very low risk, and patient risk increase significantly as a function of MPS results. Ventricular function measurements from gated single-photon emission computed tomography further augment risk stratification, particularly with respect to identifying patients at risk of cardiac death. Ancillary findings are prognostically important, particularly in the setting of normal or near-normal MPS results. Recent data suggest that MPS results can identify which patients will benefit from revascularization versus medical therapy and have expanded the understanding of how stress MPS is helpful in the identification of risk, enhanced the means of identifying risk, and improved its use as a means to identify optimal posttest treatment.

Section snippets

Risk-based approach to patient care

A new paradigm in patient management is that of a risk-based approach to patients with suspected CAD without limiting symptoms.1 With a risk-based approach, the focus is not on predicting which patient has anatomic CAD but on identifying patients at risk for specific adverse events, ie, cardiac death or nonfatal myocardial infarction (MI), and on post-MPS management strategies that might reduce the risk of these outcomes. Catheterization and revascularization can be limited to those patients

Incremental prognostic value

Another concept underlying the prognostic use of stress MPS is that of incremental prognostic value.1 Given the constraints placed on physicians and the health care system to practice clinically effective and cost-effective medicine, it is generally accepted that all diagnostic modalities must be judged by the added or incremental information they contribute over that provided by the information known about the patient before the test. Hence, the clinical value of MPS for prognostic in CAD

Added value of gated single-photon emission computed tomography (SPECT)

Since gated SPECT has become routine only recently, there are few reports of its incremental value over perfusion imaging in assessing prognosis. Left ventricular ejection fraction (LVEF), when measured by other modalities, has been shown to risk-stratify patients for risk of subsequent cardiac death. Sharir and coworkers,11 demonstrated that poststress LVEF, as measured by gated SPECT, provided significant information over the extent and severity of perfusion defect in the prediction of

What is adequate risk stratification?

It is widely appreciated that although the concepts underlying incremental prognostic value are important, incremental prognostic value does not form the basis of daily application of MPS results. Physicians cannot make a patient management decision by knowing a χ2 value of a test. However, risk stratification is both conceptually important in its ability to ascertain the added value of testing and clinically important by providing a means by which the test results can be applied in daily

Risk of adverse events after a normal scan

There are extensive literature examining risk after a normal stress MPS with most studies reporting rates of hard events (cardiac death or nonfatal MI) of <1% per year of follow-up.1, 17 The American Society of Nuclear Cardiology published a position statement in 1997 stating that a normal MPS study predicts a very low likelihood (<1%) of adverse events such as cardiac death or myocardial infarction for at least 12 months and that this level of risk is independent of gender, age, symptom

Summed scores

To glean the full prognostic information from MPS, it is essential that scans not be simply interpreted as normal or abnormal but that the extent and severity of perfusion abnormalities be taken into account. We initially described a summed segmental scoring approach using 20 segments.3, 4 Recently, committees of the American College of Cardiology and the American Heart Association have recommended a 17-segment approach.26 Each segment is scored from 0 to 4, with 0 = normal, 1 = equivocal

Transient ischemic dilation (TID) of the left ventricle

TID is considered present when the LV cavity appears to be significantly larger in the poststress images than at rest36, 37 and may often represent apparent cavity dilation due to diffuse subendocardial ischemia (obscuring the endocardial border). TID is considered to represent severe and extensive ischemia and has been shown to be highly specific for critical stenosis (greater than 90% narrowing) in vessels that supply a large portion of the myocardium (ie, proximal left anterior descending or

Nonperfusion markers in the setting of pharmacologic stress

The clinical implementation of the results of pharmacologic stress MPS is challenging because of the absence or lowered accuracy of conventional markers of ischemia such as three times per day ischemic symptoms and ST segment response and exercise time.

Post-MPS patient management and its prognostic implications

Two important points must be made regarding abnormal scans. First, the relationship between scan results and physician action must be understood. Further, the subsequent impact on observed survival rates after MPS due to physician action, and their implications for future research, must also be considered.

Treatment algorithms based on risk

Until recently, post-MPS treatment recommendations were based on the extent and severity of stress perfusion defects—the SPECT data most predicative of adverse outcomes. The underlying principle of this approach was to manage patients on the basis of risk, with those patients at intermediate-to-high risk of cardiac death being referred to catheterization with possible revascularization, and those patients at low risk of cardiac death referred to medial management. As patients with normal MPS

Can we prognosticate in reports? a future direction of survival analyses

With the ongoing development of stress MPS, increasing numbers of variables are identified as being important prognosticators, and with the development of improving software, more information is being collected that may too be important for prognostication. The greatest challenge facing clinicians attempting to apply MPS results to patient care is to distill all information reported after MPS, eg, clinical, historical, stress test, perfusion, and function data, into an estimate of likelihood of

References (62)

  • G.V. Heller et al.

    Independent prognostic value of intravenous dipyridamole with technetium-99m sestamibi tomographic imaging in predicting cardiac events and cardiac-related hospital admissions

    J Am Coll Cardiol

    (1995)
  • L. Shaw et al.

    Prognostic value of dipyridamole thallium-201 imaging in elderly patients

    J Am Coll Cardiol

    (1992)
  • H.G. Stratmann et al.

    Prognostic value of dipyridamole technetium-99m sestamibi myocardial tomography in patients with stable chest pain who are unable to exercise

    Am J Cardiol

    (1994)
  • D.A. Calnon et al.

    Prognostic value of dobutamine stress technetium-99m-sestamibi single-photon emission computed tomography myocardial perfusion imagingstratification of a high-risk population

    J Am Coll Cardiol

    (2001)
  • X. Kang et al.

    Incremental prognostic value of myocardial perfusion single photon emission computed tomography in patients with diabetes mellitus

    Am Heart J

    (1999)
  • A.M. Amanullah et al.

    Adenosine technetium-99m sestamibi myocardial perfusion SPECT in womenDiagnostic efficacy in detection of coronary artery disease

    J Am Coll Cardiol

    (1996)
  • R. Hachamovitch et al.

    Determinants of risk and its temporal variation in patients with normal stress myocardial perfusion scansWhat is the warranty period of a normal scan?

    J Am Coll Cardiol

    (2003)
  • D.S. Berman et al.

    Prognostic validation of a 17-segment score derived from a 20-segment score for myocardial perfusion SPECT interpretation

    J Nucl Cardiol

    (2004)
  • R. Hachamovitch et al.

    Stress myocardial perfusion SPECT is clinically effective and cost-effective in risk-stratification of patients with a high likelihood of CAD but no known CAD

    J Am Coll Cardiol

    (2004)
  • D.S. Berman et al.

    Adenosine myocardial perfusion single-photon emission computed tomography in women compared with men. Impact of diabetes mellitus on incremental prognostic value and effect on patient management

    J Am Coll Cardiol

    (2003)
  • A. Abidov et al.

    Prognostic implications of myocardial perfusion SPECT in patients with chronic atrial fibrillation

    J Am Coll Cardiol

    (2004)
  • P.C. Albro et al.

    Noninvasive assessment of coronary stenoses by myocardial imaging during pharmacologic coronary vasodilatation

    Am J Cardiol

    (1978)
  • M. Mazzanti et al.

    Identification of severe and extensive coronary artery disease by automatic measurement of transient ischemic dilation of the left ventricle in dual-isotope myocardial perfusion SPECT

    J Am Coll Cardiol

    (1996)
  • P. Chouraqui et al.

    Significance of dipyridamole-induced transient dilation of the left ventricle during thallium-201 scintigraphy in suspected coronary artery disease

    Am J Cardiol

    (1990)
  • A. Abidov et al.

    Transient ischemic dilation of the left ventricle is a significant predictor of future cardiac events in patients with otherwise normal myocardial perfusion SPECT

    J Am Coll Cardiol

    (2003)
  • C.L. Hansen et al.

    Comparison of pulmonary uptake with transient cavity dilation after exercise thallium-201 perfusion imaging

    J Am Coll Cardiol

    (1999)
  • E.S. Marshall et al.

    Prognostic significance of ST-segment depression during adenosine perfusion imaging

    Am Heart J

    (1995)
  • R. Hachamovitch et al.

    Incremental prognostic value of adenosine stress myocardial perfusion single-photon emission computed tomography and impact on subsequent management in patients with or suspected of having myocardial ischemia

    Am J Cardiol

    (1997)
  • J. Lette et al.

    Long-term risk stratification with dipyridamole imaging

    Am Heart J

    (1995)
  • A.M. Amanullah et al.

    Incremental prognostic value of adenosine myocardial perfusion single-photon emission computed tomography in women with suspected coronary artery disease

    Am J Cardiol

    (1998)
  • H.G. Stratmann et al.

    Prognostic value of dipyridamole thallium-201 scintigraphy in patients with stable chest pain

    Am Heart J

    (1992)
  • Cited by (64)

    • Nuclear cardiology

      2017, Cardiology Secrets
    • The effect of relaxing music on heart rate and heart rate variability during ECG GATED-myocardial perfusion scintigraphy

      2015, Complementary Therapies in Clinical Practice
      Citation Excerpt :

      In recent years myocardial perfusion scintigraphy (MPS), frequently used in nuclear medical studies, has played an important role in researching coronary artery disease (CAD), in making clinical decisions and in monitoring patients. MPS is a non-invasive imaging method comparing two different scintigraphic studies, one after stress and the other at rest [1]. Imaging procedures where myocardial perfusion scintigraphy is synchronized with electrocardiography (ECG) are called GATED MPS.

    • Clinical characteristics, myocardial perfusion deficits, and clinical outcomes of patients with non-specific chest pain hospitalized for suspected acute coronary syndrome: A 4-year prospective cohort study

      2015, International Journal of Cardiology
      Citation Excerpt :

      Within four weeks following hospital discharge, patients underwent SPECT MPI. According to the stress part of a two-day protocol without attenuation correction [23], all patients firstly underwent an electrocardiographically gated stress imaging using pharmacological stress testing by adenosine infusion 0.140 mg·kg− 1·min− 1 for 6 min and injection of 10 MBq·kg− 1 (maximum 1100 MBq) of 99mTc-sestamibi between the third and the fourth minute of infusion, followed 30–60 min later by imaging using a dual-head gamma camera. The pharmacological stressor was chosen over physiological stress testing (bicycle ergometer) because of time constraints.

    • Nuclear Cardiology

      2013, Cardiology Secrets: Fourth Edition
    View all citing articles on Scopus
    View full text