Prognostic Value of Stress Myocardial Perfusion Positron Emission Tomography

Abstract

Objectives The primary objective of this multicenter registry was to study the prognostic value of PET MPI and the improved classification of risk in a large cohort of patients with suspected or known coronary artery disease (CAD). Background Limited prognostic data are available for myocardial perfusion imaging (MPI) with positron emission tomography (PET). Methods 7,061 patients from 4 centers underwent a clinically indicated rest/stress rubidium-82 PET MPI with a median follow-up of 2.2 years. The primary outcome of this study was cardiac-death (169 patients) and the secondary outcome was all-cause death (570 patients). Net reclassification improvement (NRI) and integrated discrimination (IDI) analyses were performed. Results Risk-adjusted hazard of cardiac-death increased with each 10% abnormal myocardium with mildly, moderately or severely abnormal stress PET [hazard ratio 2.3 (95% CI 1.4–3.8, P=0.001), 4.2 (95% CI 2.3–7.5, P<0.001), and 4.9 (95% CI 2.5–9.6, P <0.0001), respectively, normal MPI: referent]. Addition of %myocardium ischemic and scarred to clinical information (age, female sex, body mass index, history of hypertension, diabetes, dyslipidemia, smoking, angina, betablocker use, prior revascularization and rest heart rate) improved the model performance [C-statistic 0.805 (95% CI, 0.772–0.838) to 0.839 (95% CI, 0.809–0.869)] and risk reclassification for cardiac-death [NRI 0.116 (95% CI 0.021–0.210)] with smaller improvements in risk assessment for all-cause death. Conclusions In patients with known or suspected CAD, the extent and severity of ischemia and scar on PET MPI provide powerful and incremental risk estimates of cardiac-death and all-cause death compared to traditional coronary risk factors.

2013 Esc Guidelines on the Management of Stable Coronary Artery Disease

“…У таких пациентов следует рассмотреть проведение ранней коронарной артериографии. Протяженность и тяжесть ишемии или наличие рубца по данным перфузионной ПЭТ у пациентов с известной или подозреваемой ИБС также вносит дополнительный вклад в оценку риска сердечно-сосудистой смерти и смерти от любой причины, по сравнению с традиционными факторами коронар-ного риска [198]. Кроме того, дисфункция коронар-ной вазодилатации, выявленная с помощью ПЭТ, независимо коррелирует с сердечно-сосудистой смертностью как у пациентов с диабетом, так и лиц без этого заболевания [199].…”

The benefits of advanced risk reclassification

“…This approach has now been successfully applied in a number of prognostic analyses using nuclear imaging. [3][4][5][6][7][8][9] Although most reports quantifying the overall NRI have reported that nuclear variables add considerably to the ability to accurately detect low-and high-risk individuals, in this issue of the journal, Koh and colleagues 7 reported intriguing results from a relatively large, singlecenter database of 6702 patients referred for exercise myocardial perfusion imaging (MPI) for either suspected or known coronary artery disease (CAD). This report provided a unique approach by formulating three models including the base comparator of a clinical model which was then compared to a model adding the Duke Treadmill Score (DTS), and then a third model adding the summed difference score and a categorical post-stress left ventricular ejection fraction variables.…”

“…From the Multicenter PET Prognosis registry, Dorbala 5 formulated a clinical model that included 12 variables (including risk factors, symptoms, beta blocker use, and heart rate; to name a few). In the PET report, the NRI for inclusion of the percentage of ischemic and scarred myocardium on stress PET imaging for estimating cardiac death was 0.12 (or 12%).…”

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

“…10 In addition to its value as a diagnostic study, the independent and incremental value of myocardial perfusion PET has also been demonstrated in multiple studies, including a multicenter registry involving more than 7,000 patients. 11 PET possesses a greater discriminatory power than other non-invasive modalities with regards to cardiac events. 12 Furthermore, rubidium-82 perfusion PET is associated with a lower radiation burden and more rapid test performance, making this procedure an attractive test for the evaluation of known or suspect ischemic heart disease.…”

“…Positron emission tomography (PET) MPI has been shown to provide improved image quality, superior interpretative confidence, and higher diagnostic accuracy than SPECT [6][7][8][9][10][11][12] and has been considered by many to be a ''gold standard'' of non-invasive testing. 10 In addition to its value as a diagnostic study, the independent and incremental value of myocardial perfusion PET has also been demonstrated in multiple studies, including a multicenter registry involving more than 7,000 patients.…”