Value of Stress Myocardial Perfusion Single Photon Emission Computed Tomography in Patients With Normal Resting Electrocardiograms

Abstract

Background-The incremental value and cost-effectiveness of stress single photon emission computed tomography (SPECT) is of unclear added value over clinical and exercise treadmill testing data in patients with normal resting ECGs, a patient subset known to be at relatively lower risk. Methods and Results-We identified 3058 consecutive patients who underwent exercise dual isotope SPECT, who on follow-up (mean, 1.6Ϯ0.5 years; 3.6% lost to follow-up) were found to have 70 hard events (2.3% hard-event rate). Survival analysis used a Cox proportional hazards model, and cost-effectiveness was determined by the cost per hard event identified by strategies with versus without the use of SPECT. In this cohort, a normal study was associated with an exceedingly low hard-event rate (0.4% per year) that increased significantly as a function of the SPECT result. After adjusting for pre-SPECT information, exercise stress SPECT yielded incremental value for the prediction of hard events ( 2 52 to 85, PϽ0.001) and significantly stratified patients. In patients with intermediate to high likelihood of coronary artery disease after exercise treadmill testing, a cost-effectiveness ratio of $25 134 per hard event identified and a cost of $5417 per reclassification of patient risk were found. Subset analyses revealed similar prognostic, and cost results were present in men, women, and patients with and without prior histories of coronary artery disease. Conclusions-Stress SPECT yields incremental prognostic value and enhanced risk stratification in patients with normal resting ECGs in a cost-effective manner. These findings are opposite those of previous studies examining anatomic end points in this same population and thus, if confirmed, have significant implications for patient management.

Risk Assessment and Predictive Value of Coronary Artery Disease Testing

“…There is an abundance of economic literature on the comparative evaluation of stress nuclear imaging for patients with stable chest pain symptoms (51)(52)(53)56,(67)(68)(69)(70)(71). Several reports have noted that, compared with a direct angiographic approach, stress nuclear imaging can provide significant cost savings (;30%240%) for 2-3 y of follow-up cardiac care (52,53,56,69,70).…”

“…Several reports have noted that, compared with a direct angiographic approach, stress nuclear imaging can provide significant cost savings (;30%240%) for 2-3 y of follow-up cardiac care (52,53,56,69,70). Notably, the cost advantages of stress nuclear imaging are most prominent when it is applied to a population at intermediate risk of CAD.…”

Stress Single Photon Emission Computed Tomography in Patients With Normal Electrocardiograms

“…1 They share a misconception held by many regarding the use of single photon emission computed tomography (SPECT) in patients with normal resting electrocardiograms, which is that SPECT is neither useful nor costeffective in these patients. The primary conclusion of our study was that 50% or more of these patients will derive prognostic clinical value from SPECT in a cost-effective manner.…”

Seguimiento clínico en pacientes con buena capacidad metabólica en la prueba de esfuerzo con SPECT miocárdico

“…La tomografía computada de emisión de fotón único (SPECT) es superior a la PE para detección de EC 8 , con buen valor predictivo negativo; así un estudio normal tiene baja tasa de eventos mayores, en seguimiento a largo plazo 7 ; con ejercicio, en pacientes sin EC conocida, presenta tasa de mortalidad < 1% anual, desde 0,2% anual sin FRCV y hasta 1,7% anual con tres de ellos 9 . Un gran estudio que midió su impacto sobre muerte, infarto de miocardio (IM) y revascularización coronaria demostró que tiene implicancia pronós-tica con cualquier nivel de ejercicio y que aunque los defectos isquémicos fueron poco frecuentes sobre 10 METs estuvieron fuertemente asociados a eventos cardíacos 10 .…”