The prognosis of a normal stress-only Tc-99m myocardial perfusion imaging study

Duvall, W. Lane; Wijetunga, Melanie N.; Klein, Thomas M.; Razzouk, Louai; Godbold, J.; Croft, Lori B.; Henzlova, Milena J.

doi:10.1007/s12350-010-9210-x

Cited by 102 publications

(63 citation statements)

References 25 publications

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“…This study provides further confirmation that AC is an important requirement for the successful implementation of a stress-only imaging protocol in routine clinical practice. Our findings as well as those from previous studies 1,[5][6][7] demonstrate that normal AC stress-only imaging is associated with a very low incidence of short-term cardiac events ([11,722 patients in aggregate, including 1,247 from this study, Table 6) and suggests that such patients do not need to undergo additional rest imaging.…”

Section: Discussionsupporting

confidence: 86%

“…1,[5][6][7] This report emphasizes two important additional findings: first, the inherent value of AC which results in very few patients requiring additional rest imaging and second, the confidence of physicians in that if the stress image is abnormal, clinical decisions often can be made without an additional rest scan (high cardiac revascularization rate in patients with abnormal stress-only images). Reducing radiation exposure during imaging studies has been an ongoing issue.…”

Section: Discussionmentioning

confidence: 85%

“…3,4 The value of stress-only imaging with normal results has been confirmed by outcomes data from previous studies. 1,[5][6][7] While most of these studies utilized AC, there is insufficient information on the impact of this technique with stress-only imaging regarding post-test patient management (necessity for additional rest imaging) and cardiac risk stratification. Accordingly, the purpose of this study was to determine the clinical value of stressonly SPECT imaging with AC in a consecutive series of clinically referred patients with symptoms suggestive of myocardial ischemia.…”

Section: Introductionmentioning

confidence: 99%

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Clinical value of stress-only Tc-99m SPECT imaging: Importance of attenuation correction

Mathur

Heller

Bateman

et al. 2013

Journal of Nuclear Cardiology

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Background. In selected patients, stress-only SPECT imaging has been proposed as an alternative to rest-stress SPECT imaging to improve laboratory efficiency and reduce radiation exposure. The impact of attenuation correction (AC) upon interpretation, post-test patient management and cardiac risk stratification in relation to stress-only imaging is not well understood.Objectives. The purpose of this study was to determine the clinical value for laboratory throughput and predicting outcomes of normal and abnormal stress-only SPECT imaging with AC in a consecutive series of clinically referred patients.Methods. A retrospective analysis of 1,383 consecutive patients who were scheduled for stress-only SPECT imaging for symptom assessment of suspected myocardial ischemia was performed. All images had been interpreted and categorized using the standard 17-segment model without AC followed by AC. Follow-up data for 2.1 ± 1.3 years after SPECT imaging for the occurrence of cardiac events (non-fatal MI, cardiac death, and cardiac revascularization) previously collected by routine methods were reviewed.Results. Non-AC SPECT image interpretation revealed that 58% (802/1383) of patients had abnormal stress images. AC image interpretation of the abnormal non-AC images re-classified 83% (666/802) of these as normal. Among patients with abnormal stress images after AC (136/ 1383), 63% (86/136) returned for additional rest scans, while the remaining 37% (50/136) were clinically managed without further rest images. The incidence of cardiac death or non-fatal MI was very low in patients with normal stress-only scans (0.7%).Conclusion. A strategy of stress-only imaging with AC in symptomatic patients is an efficient method which appropriately identifies at risk and low-risk patients yielding a low percentage requiring rest imaging. Clinical decisions can be made based on abnormal stress-only imaging without further rest imaging if clinically appropriate. (J Nucl Cardiol 2013;20:27-37.)

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Section: Discussionsupporting

confidence: 86%

Section: Discussionmentioning

confidence: 85%

Section: Introductionmentioning

confidence: 99%

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Clinical value of stress-only Tc-99m SPECT imaging: Importance of attenuation correction

Mathur

Heller

Bateman

et al. 2013

Journal of Nuclear Cardiology

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“…6 There have been a number of recent improvements to traditional stress SPECT protocols including stress-only imaging that can decrease the length of the test and lower the radiation dose with a documented benign prognosis similar to that of a normal rest-stress study. [7][8][9][10] Additionally, new high-efficiency SPECT camera technology has also modernized MPI by allowing for shorter image acquisition and lower injected activity. [11][12][13] Several recent randomized studies and two metaanalyses have been published examining the diagnostic utility of CTA in evaluating patients in the ED with possible ACS.…”

Section: Introductionmentioning

confidence: 99%

A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department

Duvall

Savino

Levine

et al. 2014

Journal of Nuclear Cardiology

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Background. Recent studies have compared CTA to stress testing and MPI using older Na-I SPECT cameras and traditional rest-stress protocols, but are limited by often using optimized CTA protocols but suboptimal MPI methodology. We compared CTA to stress testing with modern SPECT MPI using high-efficiency CZT cameras and stress-first protocols in an ED population.Methods. In a retrospective, non-randomized study, all patients who underwent CTA or stress testing (ETT or Tc-99m sestamibi SPECT MPI) as part of their ED assessment in 2010-2011 driven by ED attending preference and equipment availability were evaluated for their disposition from the ED (admission vs discharge, length of time to disposition), subsequent visits to the ED and diagnostic testing (within 3 months), and radiation exposure. CTA was performed using a 64-slice scanner (GE Lightspeed VCT) and MPI was performed using a CZT SPECT camera (GE Discovery 530c). Data were obtained from prospectively acquired electronic medical records and effective doses were calculated from published conversion factors. A propensity-matched analysis was also used to compare outcomes in the two groups.Results. A total of 1,458 patients underwent testing in the ED with 192 CTAs and 1,266 stress tests (327 ETTs and 939 MPIs). The CTA patients were a lower-risk cohort based on age, risk factors, and known heart disease. A statistically similar proportion of patients was discharged directly from the ED in the stress testing group (82% vs 73%, P 5 .27), but their time to disposition was longer (11.0 ± 5 vs 20.5 ± 7 hours, P < .0001). There was no significant difference in cardiac return visits to the ED (5.7% CTA vs 4.3% stress testing, P 5 .50), but more patients had follow-up studies in the CTA cohort compared to stress testing (14% vs 7%, P 5 .001). The mean effective dose of 12.6 ± 8.6 mSv for the CTA group was higher (P < .0001) than 5.0 ± 4.1 mSv for the stress testing group (ETT and MPI). A propensity score-matched cohort showed similar results to the entire cohort.Conclusions. Stress testing with ETT, high-efficiency SPECT MPI, and stress-only protocols had a significantly lower patient radiation dose and less follow-up diagnostic testing than CTA with similar cardiac return visits. CTA had a shorter time to disposition, but there was a trend toward more revascularization than with stress testing. (J Nucl Cardiol 2014;21:305-18.)

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“…When a stressrest SPECT protocol is used, stress-only (SO) imaging can be performed with avoidance of the rest study if the stress study is normal (10,11). The use of SO imaging may optimize SPECT procedures by reducing time to diagnosis, LOS, radiation exposure, and cost.…”

mentioning

confidence: 99%

Optimizing Evaluation of Patients with Low-to-Intermediate-Risk Acute Chest Pain: A Randomized Study Comparing Stress Myocardial Perfusion Tomography Incorporating Stress-Only Imaging Versus Cardiac CT

et al. 2015

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The purpose of this study was to determine whether stress myocardial perfusion (SPECT) optimized with stress-only (SO) imaging is comparable to cardiac CT angiography (CTA) for evaluating patients with acute chest pain (ACP). Methods: This was a prospective randomized observational study in 598 ACP patients who underwent CTA versus SPECT. The primary endpoint was length of hospital stay, and secondary endpoints were test feasibility, time to diagnosis, diagnostic accuracy, radiation exposure, and overall cost. Median follow-up was 6.5 mo, with a 3.8% cardiac event rate defined as death or an acute coronary syndrome. Results: Of 2,994 patients screened, 1,703 (56.9%) were not candidates for CTA because of prior cardiac disease (41%) or imaging contraindications (16%). Time to diagnosis (8.1 ± 8.5 vs. 9.4 ± 7.4 h) and length of hospital stay (19.7 ± 27.8 vs. 23.5 ± 34.4 h) were significantly shorter with CTA than with SPECT (P 5 0.002). However, time to diagnosis (7.0 ± 6.2 vs. 6.8 ± 5.9 h, P 5 0.20), length of stay (15.5 ± 17.2 vs. 16.7 ± 15.3 h, P 5 0.36), and hospital costs ($4,242 ± $3,871 vs. $4,364 ± 1781, P 5 0.86) were comparable with CTA versus SO SPECT, respectively. SO was also superior to conventional SPECT regarding all of the above metrics and significantly reduced radiation exposure (5.5 ± 4.4 vs. 12.5 ± 2.7 mSv, P , 0.0001). Conclusion: Stress SPECT when optimized with SO imaging is similar to CTA in time to diagnosis, length of hospital stay, and cost, with improved prognostic accuracy and less radiation exposure. Our results emphasize the importance of SO imaging, particularly in low-intermediate-risk emergency room patients who are a population likely to have a normal test result.

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The prognosis of a normal stress-only Tc-99m myocardial perfusion imaging study

Abstract: A normal stress-only MPI has an excellent short-term prognosis (both for all-cause and cardiac mortality) comparable to that of a normal rest-stress MPI study.

Cited by 102 publications

References 25 publications

Clinical value of stress-only Tc-99m SPECT imaging: Importance of attenuation correction

Clinical value of stress-only Tc-99m SPECT imaging: Importance of attenuation correction

A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department

Optimizing Evaluation of Patients with Low-to-Intermediate-Risk Acute Chest Pain: A Randomized Study Comparing Stress Myocardial Perfusion Tomography Incorporating Stress-Only Imaging Versus Cardiac CT

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