Temporal Trends of Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging in Patients With Coronary Artery Disease

Abstract

Background— There has been a gradual decline in the prevalence of abnormal stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging studies among patients without history of coronary artery disease (CAD). The trends of SPECT studies among patients with known CAD have not been evaluated previously. Methods and Results— We assessed the Mayo Clinic nuclear cardiology database for all stress SPECT tests performed between January 1991 and December 2012 in patients with history of CAD defined as having previous myocardial infarction, percutaneous coronary intervention, and coronary artery bypass grafting. The study cohort was divided into 5 time periods: 1991 to 1995, 1996 to 2000, 2001 to 2005, 2006 to 2010, and 2011 to 2012. There were 19 373 patients with a history of CAD who underwent SPECT between 1991 and 2012 (mean age, 66.2±10.9 years; 75.4% men). Annual utilization of SPECT in these patients increased from an average of 495 tests per year in 1991 to 1995 to 1425 in 2003 and then decreased to 552 tests in 2012 without evidence for substitution with other stress modalities. Asymptomatic patients initially increased until 2006 and then decreased. Patients with typical angina decreased, whereas patients with dyspnea and atypical angina increased. High-risk SPECT tests significantly decreased, and the percentage of low-risk SPECT tests increased despite decreased SPECT utilization between 2003 and 2012. Almost 80% of all tests performed in 2012 had a low-risk summed stress score compared with 29% in 1991 ( P <0.001). Conclusions— In Mayo Clinic, Rochester, annual SPECT utilization in patients with previous CAD increased between 1992 and 2003, but then decreased after 2003. High-risk SPECT tests declined, whereas low-risk tests increased markedly. Our results suggest that among patients with a history of CAD, SPECT was being increasingly utilized in patients with milder CAD. This trend parallels reduced utilization of other stress modalities, coronary angiography, reduced smoking, and greater utilization of optimal medical therapy for prevention and treatment of CAD.

Changing epidemiology of CAD: Why should we pay attention?

“…17 The epidemic of cardiometabolic disease has been associated with an anatomic phenotype dominated by 'diffuse atherosclerosis' and 'microvascular remodeling'. 18 Reprint Fourth, the observed temporal decline in the rate of abnormal SPECT MPI studies 4 with a marked reduction in the proportion of high-risk scans and a proportional increase in apparently 'low-risk' tests 3 appear to be in line with all secular changes described above. It is not surprising that an anatomic phenotype characterized by diffuse nonobstructive atherosclerosis and microvascular disease would be relatively invisible for our traditional radionuclide semi-quantitative MPI approach designed to uncover focal obstructive CAD.…”

“…Indeed, over the last two decades, diagnostic yields for invasive coronary angiography, 1,2 and noninvasive stress testing have fallen. 3,4 In one large registry of patients with angina referred for coronary angiography, the rate of nonobstructive atherosclerosis as the principal underlying angiographic phenotype increased by 20% to 40% over a 10-year period in both women and men. 1 Recent data from Olmstead County, MN have also documented a steady decline in angiographically obstructive CAD over the last two decades.…”

Coronary Revascularization in Patients With Stable Coronary Artery Disease: The Role of Imaging

“…In the last decades, the prevalence of obstructive coronary artery disease (CAD) and significant myocardial ischemia has been progressively decreasing in stable patients (1)(2)(3)(4). As a result of the lower prevalence of disease, the accuracy of most of the currently available diagnostic strategies for the evaluation of patients with chronic coronary syndromes (CCS) has been steadily decreasing.…”

SPECT and PET MPI: The future has arrived but it is unevenly distributed

“…2,3 These advances led to widespread utilization (and perhaps overutilization) of exercise nuclear testing, peaking in approximately 2003. 4,5 . Since then, however, centers across the country have seen a progressive decline in testing.…”

“…Analysis of the temporal trends in population being referred for myocardial perfusion imaging time reveals progressively fewer asymptomatic patients as well as fewer patients with traditional angina are undergoing SPECT testing. 5 Over a similar time-frame, more patients are also being evaluated via a pharmacologic stress rather than exercise testing, losing out on critical prognostic information. This shift in practice patterns likely reflects the advances in both medical management of atherosclerosis and percutaneous revascularization techniques, with at-risk asymptomatic patients being preferentially managed medically without further imaging and high-risk patients being referred for diagnostic angiography and possible intervention.…”