Impact of Appropriate Use on the Prognostic Value of Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging

Abstract

Background-Appropriate use criteria (AUC) have been developed to aid in the optimal use of single-photon emission computed tomography (SPECT)-myocardial perfusion imaging (MPI), a technique that is a mainstay of risk assessment for ischemic heart disease. The impact of appropriate use on the prognostic value of SPECT-MPI is unknown. Methods and Results-A prospective cohort study of 1511 consecutive patients undergoing outpatient, community-based SPECT-MPI was conducted. Subjects were stratified on the basis of the 2009 AUC for SPECT-MPI into an appropriate or uncertain appropriateness group and an inappropriate group. Patients were prospectively followed up for 27±10 months for major adverse cardiac events of death, death or myocardial infarction, and cardiac death or myocardial infarction. In the entire cohort, the 167 subjects (11%) with an abnormal scan experienced significantly higher rates of major adverse cardiac events and coronary revascularization than those with normal MPI. Among the 823 subjects (54.5%) whose MPIs were classified as appropriate (779, 51.6%) or uncertain (44, 2.9%), an abnormal scan predicted a multifold increase in the rates of death (9.2% versus 2.6%; hazard ratio, 3.1; P=0.004), death or myocardial infarction (11.8% versus 3.3%; hazard ratio, 3.3; P=0.001), cardiac death or myocardial infarction (6.7% versus 1.7%; hazard ratio, 3.7; P=0.006), and revascularization (24.7% versus 2.7%; hazard ratio, 11.4; P<0.001). Among the 688 subjects (45.5%) with MPI classified as inappropriate, an abnormal MPI failed to predict major adverse cardiac events, although it was associated with a high revascularization rate. Furthermore, appropriate MPI use provided incremental prognostic value beyond myocardial perfusion and ejection fraction data. Conclusions-When performed for appropriate indications, SPECT-MPI continues to demonstrate high prognostic value.However, inappropriate use lacks effectiveness for risk stratification, further emphasizing the need for optimal patient selection for cardiac testing. (Circulation. 2013;128:1634-1643.)

The value and appropriateness of positron emission tomography: An evolving tale

“…As shown in Table 2, these categorizations for PET appropriate use are similar to those found in the majority of reports with SPECT, [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] although there are some reports of SPECT MPI with higher frequency of inappropriate studies. 19,27 For evaluation of the scintigraphic findings and outcomes, the authors have combined ''appropriate'' with ''uncertain'' categories, which although somewhat controversial, is consistent with the intent of these AUC-''uncertain is assumed to not provide grounds for denial of reimbursement.''…”

Practice‐Level Variation in Outpatient Cardiac Care and Association With Outcomes

“…Several studies have documented high rates of inappropriate use based on published appropriate use criteria for these procedures in contemporary practice 23, 24, 25, 26, 27, 28, 29. Large, community‐based studies have documented inappropriate use rates of 45.5% for MPI23 and 34.6% for stress tests with imaging 28. Among 8996 patients undergoing diagnostic catheterization in New York, 24.9% were considered inappropriate with rates ranging from 8.6% to 48.8% across hospitals 26.…”

ASNC imaging guidelines for nuclear cardiology procedures

“…25 A significant body of literature demonstrated that appropriate MPI use enhances its acumen in risk stratification, reduces radiation risk, and improves its clinical value. [27][28][29][30][31][32][33] Physicians are faced with multiple, occasionally discordant, AUC from different organizations. For example, there is substantial discordance between the multimodality AUC for the detection and risk assessment of stable ischemic heart disease developed by the American College of Cardiology, ASNC, and several other societies and the Appropriateness Criteria set forth by the American College of Radiology (ACR).…”