The use of nuclear cardiology in clinical decision making
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
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2015, Complementary Therapies in Clinical PracticeCitation 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.
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2015, International Journal of CardiologyCitation 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.
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