Exercise myocardial perfusion imaging in elderly patients

doi:10.1067/mnc.2002.127013

Journal of Nuclear Cardiology

Volume 9, Issue 6, November 2002, Pages 573-580

https://doi.org/10.1067/mnc.2002.127013 Get rights and content

Abstract

Background. Exercise myocardial perfusion imaging (MPI) has significant value for risk stratification, but most patients studied have been middle-aged. In particular, the value of exercise MPI in elderly patients with interpretable electrocardiographic (ECG) stress test results has not been well defined. Methods and Results. Clinical, ECG stress test, MPI, and follow-up data for 626 outpatients aged 65 years or older with interpretable electrocardiograms undergoing symptom-limited exercise MPI between 1992 and 1996 were analyzed. Follow-up was 97% complete after 4.4 ± 1.3 years. After exclusion of the 27 patients who underwent revascularization within 90 days of MPI, there were 361 men and 217 women, aged 70.7 ± 4.4 years. By univariate analysis, male sex, increasing age, an abnormal rest ECG result, lower exercise tolerance and lower peak exercise heart rates, exercise ST-segment depression, left ventricular dilatation, and the number of ischemic regions predicted death or myocardial infarction. By multivariable modeling, only increasing patient age, male sex, limitation of exercise tolerance, and the number of ischemic segments by MPI were predictive of subsequent death or myocardial infarction. Conclusions. In elderly patients referred for exercise MPI, age, sex, exercise tolerance, and MPI ischemia provide significant prognostic information. (J Nucl Cardiol 2002;9:573-80)

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Cited by (33)

Value of exercise ECG for risk stratification in suspected or known CAD in the era of advanced imaging technologies
2015, JACC: Cardiovascular Imaging
Citation Excerpt :
They are an important subgroup given their higher prevalence of CAD and cardiac events. Studies that have been performed in the elderly confirm the prognostic importance of exercise capacity (70,71). However, ST-segment depression did not predict cardiac events in a cohort of 514 elderly patients ≥65 years of age; the DTS did not have prognostic benefit in another elderly cohort (70,72).
Exercise stress electrocardiography (ExECG) is underutilized as the initial test modality in patients with interpretable electrocardiograms who are able to exercise. Although stress myocardial imaging techniques provide valuable diagnostic and prognostic information, variables derived from ExECG can yield substantial data for risk stratification, either supplementary to imaging variables or without concurrent imaging. In addition to exercise-induced ischemic ST-segment depression, such markers as ST-segment elevation in lead aVR, abnormal heart rate recovery post-exercise, failure to achieve target heart rate, and poor exercise capacity improve risk stratification of ExECG. For example, patients achieving ≥10 metabolic equivalents on ExECG have a very low prevalence of inducible ischemia and an excellent prognosis. In contrast, cardiac imaging techniques add diagnostic and prognostic value in higher-risk populations (e.g., poor functional capacity, diabetes, or chronic kidney disease). Optimal test selection for symptomatic patients with suspected coronary artery disease requires a patient-centered approach factoring in the risk/benefit ratio and cost-effectiveness.
Prognostic value of the Duke treadmill score in octogenarians undergoing myocardial perfusion imaging
2014, Atherosclerosis
Citation Excerpt :
If the MPI data were also unable to provide useful risk stratification data for the hard endpoint the observation of reduced prognostic value of the DTS in this population would have limited clinical importance, since for these patients treadmill exercise rather than application of the DTS would have been inappropriate. Previous studies addressing the issue of risk stratification in elderly patients able to exercise have used various age thresholds to define the elderly population, ranging from 65 to 80 years old and had a highly variable duration of follow-up [6,14,25–34]. Given the contemporary life expectancy rates in developed countries however [35], we believe that the truly elderly population for the new millennium should be defined as patients ≥ 75 years of age.
Although Duke treadmill score (DTS) is the most widely used risk stratification method in younger patients undergoing exercise treadmill test (ETT) its specific value in the elderly is not established.
137 patients aged ≥80 years who underwent ETT myocardial perfusion imaging (MPI) were studied. DTS and MPI (including summed stress scores, SSS) related data were registered per patient and follow up was performed to document cardiac death (CD), myocardial infarction (MI) and late (>3 months) revascularization (LR). Kaplan Meir and Cox regression survival analysis were employed to determine the prognostic value of DTS in relation to MPI data for these endpoints.
After a median follow up duration of 6.7 years 28 deaths, 7 CDs, 4 non fatal MIs and 12 LRs were observed. Incidence rates of CD/MI were significantly different only between low and high risk SSS categories (p = 0.044). Risk groups by DTS had no significant differences in survival free of CD/MI (p = 0.743) in contrast to risk groups according to SSS (p = 0.026), while both DTS and SSS based risk groups had significantly different survival free of CD/MI or LR. SSS was a significant univariate predictor of both CD/MI (HR 1.088, p = 0.019) and CD/MI or LR (HR 1.095, p < 0.001), but DTS only of the latter endpoint (HR 0.909, p = 0.003).
In octogenarians DTS was found to be a significant predictor of the LR related endpoint but not of the hard endpoint of CD/MI, in contrast to SSS which was a powerful predictor of both soft and hard cardiac endpoints.
Meta-analysis of optimal risk stratification in patients >65 years of age
2012, American Journal of Cardiology
Citation Excerpt :
Our meta-analysis event rates after normal or abnormal ETT results fall into an intermediate category of risk and cannot be distinguished prognostically. Although this pooled result of the primary end point represents only 2 series, it is consistent with other studies identified by our search strategy but excluded from meta-analysis because of different end points.30,31 Exercise testing reveals data about functional status, symptomatology, and effectiveness of treatment in addition to binary evidence of ischemia.
This meta-analysis evaluated the optimal noninvasive strategy for cardiac risk assessment of patients >65 years of age with known or suspected coronary artery disease using the available literature. Patients >65 years of age constitute a growing proportion of the population and have higher cardiovascular morbidity and mortality, but an optimal strategy to predict the risk of cardiac events in this group is unknown. A systematic search of MEDLINE was performed for cohort studies of ≥100 patients >65 years old with ≥12 months of follow-up that reported cardiac death and/or nonfatal myocardial infarction after any of stress myocardial perfusion imaging (MPI), stress echocardiography, or exercise tolerance testing (ETT) for known or suspected coronary artery disease. Pooled annualized event rates were calculated for each technique. Summary odds ratios (ORs) between normal and abnormal test results were calculated using a random-effects model. Seventeen studies (MPI 7, stress echocardiography 7, ETT 3) in 13,304 patients (mean age 75.5 years) were included. Abnormal compared to normal stress MPI (OR 11.8, 95% confidence interval [CI] 7.5 to 18.7) and stress echocardiography (OR 3.2, 95% CI 2.6 to 3.9) accurately stratified risk in patients. However, patients with abnormal and normal ETT results had similar cardiac event rates (OR 3.1, 95% CI 0.8 to 11.5). In conclusion, stress imaging with MPI or stress echocardiography effectively stratified risk in patients, whereas ETT alone did not.
Incremental prognostic value of combined perfusion and function assessment during myocardial gated SPECT in patients aged 75 years or older
2005, Journal of Nuclear Cardiology
Perfusion and functional data obtained during gated single photon emission computed tomography (SPECT) have proven prognostic value in the middle-aged patient population. The aim of this study was to investigate whether perfusion and functional cardiac gated SPECT data have prognostic value in patients aged 75 years or older.
We studied clinical and gated SPECT predictors of cardiac and all-cause death in 294 patients aged 75 years or older with known or suspected coronary artery disease who were referred for tetrofosmin cardiac gated SPECT imaging. Summed perfusion scores were calculated in a 17-segment model by use of commercially available software (4D-MSPECT). Left ventricular functional data were calculated by use of QGS gated SPECT software. The median age of the study population was 78 years (range, 75-91 years). There were 160 men (54%) and 134 women (46%). During a median follow-up of 25.9 months (range, 1.8-36 months), 47 patients (16%) died (27 cardiac deaths). In a multivariate Cox proportional hazards regression analysis, the summed rest score (χ² gain = 8.0, P = .009), transient ischemic dilatation index (χ² gain = 6.3, P = .012), and resting left ventricular ejection fraction (χ² gain = 7.0, P = .030) were independent predictors of all-cause death. The summed rest score (χ² gain = 8.2, P = .004) and resting end-systolic volume (χ² gain = 13.7, P = .005) were independent predictors of cardiac death.
This study showed that gated SPECT left ventricular functional data assessed during myocardial gated SPECT provide independent and incremental information above clinical and perfusion SPECT data for the prediction of cardiac and all-cause death in patients aged 75 years or older referred for myocardial SPECT imaging.
Prognostic value of stress myocardial perfusion imaging in octogenarian population
2005, Journal of Nuclear Cardiology
The prognostic value of myocardial perfusion imaging (MPI) in the very elderly population has not been addressed specifically. The aim of this study was to examine the characteristics of the octogenarian population referred for MPI and the prognostic value of the procedure in terms of patient gender.
The study sample consisted of 162 consecutive patients (61 women, 101 men) of mean age 83 ± 3 years (range, 80-90) who underwent stress MPI. The duration of follow-up was 45±12 months. Outcome measures were cardiac-related death, and nonfatal myocardial infarction (MI).
Thirty-one major cardiac events (19%) were recorded, including 26 cardiac deaths and 5 MI events, in 6 of the 61 women (10%) and 25 of the 101 men (25%) (p < 0.03). The univariate predictors of cardiac death or MI, except of known coronary artery disease (CAD), were MPI variables: left ventricular (LV) dilatation, increased lung uptake, abnormal scan, and the presence and extent of myocardial ischemia. However, the only predictors for major cardiac events were: LV dilatation (OR = 6.9, 95% CI 2.7-17.4, p < 0.0001) and ischemia by scan (OR = 2.75, 95% CI 1.09-6.96, p < 0.03). The Kaplan Meier curve demonstrated significant differences in survival between patients with or without LV dilatation and patients with or without ischemia.
LV dilatation and myocardial ischemia were useful predictors of cardiac death and MI in octogenarian patients with CAD or with suspicion of CAD.
Preoperative nuclear stress testing in the very old patient population
2020, World Journal of Cardiology

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Original ArticleExercise myocardial perfusion imaging in elderly patients

Abstract

Original Article
Exercise myocardial perfusion imaging in elderly patients