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Seraphim A, Knott KD, Augusto JB, Menacho K, Tyebally S, Dowsing B, Bhattacharyya S, Menezes LJ, Jones DA, Uppal R, Moon JC, Manisty C. Non-invasive Ischaemia Testing in Patients With Prior Coronary Artery Bypass Graft Surgery: Technical Challenges, Limitations, and Future Directions. Front Cardiovasc Med 2022; 8:795195. [PMID: 35004905 PMCID: PMC8733203 DOI: 10.3389/fcvm.2021.795195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/25/2021] [Indexed: 01/09/2023] Open
Abstract
Coronary artery bypass graft (CABG) surgery effectively relieves symptoms and improves outcomes. However, patients undergoing CABG surgery typically have advanced coronary atherosclerotic disease and remain at high risk for symptom recurrence and adverse events. Functional non-invasive testing for ischaemia is commonly used as a gatekeeper for invasive coronary and graft angiography, and for guiding subsequent revascularisation decisions. However, performing and interpreting non-invasive ischaemia testing in patients post CABG is challenging, irrespective of the imaging modality used. Multiple factors including advanced multi-vessel native vessel disease, variability in coronary hemodynamics post-surgery, differences in graft lengths and vasomotor properties, and complex myocardial scar morphology are only some of the pathophysiological mechanisms that complicate ischaemia evaluation in this patient population. Systematic assessment of the impact of these challenges in relation to each imaging modality may help optimize diagnostic test selection by incorporating clinical information and individual patient characteristics. At the same time, recent technological advances in cardiac imaging including improvements in image quality, wider availability of quantitative techniques for measuring myocardial blood flow and the introduction of artificial intelligence-based approaches for image analysis offer the opportunity to re-evaluate the value of ischaemia testing, providing new insights into the pathophysiological processes that determine outcomes in this patient population.
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Affiliation(s)
- Andreas Seraphim
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Kristopher D Knott
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Joao B Augusto
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Katia Menacho
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Sara Tyebally
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom
| | - Benjamin Dowsing
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Sanjeev Bhattacharyya
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom
| | - Leon J Menezes
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom
| | - Daniel A Jones
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Rakesh Uppal
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - James C Moon
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Charlotte Manisty
- Department of Cardiac Imaging, Barts Health National Health System Trust, London, United Kingdom.,Institute of Cardiovascular Science, University College London, London, United Kingdom
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Martineau P, Slomka P, Goertzen A, Leslie WD. CRAX: A simple cardiovascular risk assessment tool to predict risk of acute myocardial infarction or death. J Nucl Cardiol 2020; 27:2365-2374. [PMID: 30535920 PMCID: PMC6565497 DOI: 10.1007/s12350-018-01556-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/21/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Determining the risk of cardiovascular events is essential to optimize patient management. METHODS AND RESULTS 5842 individuals underwent SPECT myocardial perfusion imaging (MPI) with 4.4 ± 1.2 years of follow-up. Models (the CRAX tool) were derived to predict the cumulative risk of death and acute myocardial infarction (AMI) at 1, 3, and 5 years using clinical and MPI variables. Predictors of AMI and death included age, number of hospitalizations in the 3 years preceding MPI, and left ventricular ejection fraction (LVEF). Additional predictors of death were the use of pharmacological stress, and global stress total perfusion deficit (sTPD), while transient ischemic dilation (TID), and ischemic total perfusion deficit (iTPD) change were predictive of AMI. CRAX predictions were significantly (P < .001) more accurate than clinical variables or MPI results alone, resulting in a significant net reclassification improvement (NRI, 7.5% for AMI, 14.5% death) compared to clinical variables alone. Accuracy for predicting major adverse cardiac events (MACE, comprising all-cause death, AMI, unstable angina, late revascularization) was comparable to that of AMI or death. CONCLUSIONS CRAX is a risk assessment tool that predicts the risk of AMI, death, or MACE, and improves prediction compared to clinical variables or MPI results alone.
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Affiliation(s)
- Patrick Martineau
- Department of Nuclear Medicine, University of Manitoba, 820 Sherbrook Street GC321, Winnipeg, MB, R3A 1R9, Canada
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Piotr Slomka
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew Goertzen
- Department of Nuclear Medicine, University of Manitoba, 820 Sherbrook Street GC321, Winnipeg, MB, R3A 1R9, Canada
| | - William D Leslie
- Department of Nuclear Medicine, University of Manitoba, 820 Sherbrook Street GC321, Winnipeg, MB, R3A 1R9, Canada.
- Department of Internal Medicine, University of Manitoba, C5121-409 Tache Ave, Winnipeg, MB, R2H 2A6, Canada.
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Ortiz F, Mbai M, Adabag S, Garcia S, Nguyen J, Goldman S, Ward HB, Kelly RF, Carlson S, Holman WL, McFalls EO. Utility of nuclear stress imaging in predicting long-term outcomes one-year post CABG Surgery. J Nucl Cardiol 2020; 27:1970-1978. [PMID: 30397864 DOI: 10.1007/s12350-018-01469-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 09/09/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Early MPI after CABG is currently considered rarely appropriate in asymptomatic patients. This study aimed to identify prognostic value of nuclear stress-imaging post-CABG. METHODS This was a single center prospective study looking at long-term outcomes post-CABG. Per protocol participants underwent SPECT-MPI stress testing and coronary angiogram on the same day, 1-year following CABG. Defect size was semi-quantified. The primary outcomes were the composite of death and congestive heart failure. RESULTS Eighty-four participants underwent nuclear stress-imaging and angiography, with a median follow-up of 11.1 years. Three separate stress findings predicted the primary outcome: inability to reach stage 3 of a Bruce protocol (OR 7.3, CI 2.4-22.1, P < 0.001), LVEF < 45% (OR 4.0, CI 1.1-15.3, P = 0.041) and a moderate-large stress defect size (HR 2.31, CI 1.1-1.5, P = 0.04). These findings appear to be additive and strongest among patients who underwent exercise stress testing (HR 10.6, CI 3.6-30.6, P < 0.001). Graft disease was identified in 39 (46%) patients and compared to those individuals with no graft disease, did not predict long-term adverse outcomes (P = 0.29). CONCLUSION In clinically stable patients early after revascularization with CABG, SPECT-MPI can identify patients at higher risk of heart failure and death.
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Affiliation(s)
| | - Mackenzi Mbai
- VA Medical Center Minneapolis, University of Minnesota, Minneapolis, MN, USA
| | - Selcuk Adabag
- VA Medical Center Minneapolis, University of Minnesota, Minneapolis, MN, USA
| | - Santiago Garcia
- VA Medical Center Minneapolis, University of Minnesota, Minneapolis, MN, USA
| | | | - Steven Goldman
- Southern Arizona VA Health Systems, University of Arizona, Tucson, AZ, USA
| | - Herbert B Ward
- VA Medical Center Minneapolis, University of Minnesota, Minneapolis, MN, USA
| | - Rosemary F Kelly
- VA Medical Center Minneapolis, University of Minnesota, Minneapolis, MN, USA
| | | | - William L Holman
- Birmingham VA Medical Center, University of Alabama Birmingham, Birmingham, AL, USA
| | - Edward O McFalls
- VA Medical Center Minneapolis, University of Minnesota, Minneapolis, MN, USA
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Mastrocola LE, Amorim BJ, Vitola JV, Brandão SCS, Grossman GB, Lima RDSL, Lopes RW, Chalela WA, Carreira LCTF, Araújo JRND, Mesquita CT, Meneghetti JC. Update of the Brazilian Guideline on Nuclear Cardiology - 2020. Arq Bras Cardiol 2020; 114:325-429. [PMID: 32215507 PMCID: PMC7077582 DOI: 10.36660/abc.20200087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
| | - Barbara Juarez Amorim
- Universidade Estadual de Campinas (Unicamp), Campinas, SP - Brazil
- Sociedade Brasileira de Medicina Nuclear (SBMN), São Paulo, SP - Brazil
| | | | | | - Gabriel Blacher Grossman
- Hospital Moinhos de Vento, Porto Alegre, RS - Brazil
- Clínica Cardionuclear, Porto Alegre, RS - Brazil
| | - Ronaldo de Souza Leão Lima
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brazil
- Fonte Imagem Medicina Diagnóstica, Rio de Janeiro, RJ - Brazil
- Clínica de Diagnóstico por Imagem (CDPI), Grupo DASA, Rio de Janeiro, RJ - Brazil
| | | | - William Azem Chalela
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brazil
| | | | | | | | - José Claudio Meneghetti
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brazil
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Ferreira MJV, Cerqueira MD. Clinical Applications of Nuclear Cardiology. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Maaniitty T, Jaakkola S, Saraste A, Knuuti J. Hybrid coronary computed tomography angiography and positron emission tomography myocardial perfusion imaging in evaluation of recurrent symptoms after coronary artery bypass grafting. Eur Heart J Cardiovasc Imaging 2018; 20:1298-1304. [DOI: 10.1093/ehjci/jey160] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 10/04/2018] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
Recurrent chest pain after coronary artery bypass grafting (CABG) poses a diagnostic challenge. We hypothesized that combining anatomy of bypass grafts and native coronary arteries with ischaemia detection by hybrid imaging could be used to gain valuable and complementary information in patients with recurrent symptoms after CABG.
Methods and results
We analysed 36 consecutive patients (67 ± 9 years, 81% male) who had undergone hybrid imaging using coronary computed tomography angiography (CCTA) and [15O]H2O positron emission tomography (PET) myocardial perfusion imaging due to recurrent symptoms after CABG. Coronary tree and left ventricular myocardium were divided into three main territories, yielding a total of 108 coronary territories in 36 patients. The presence of obstructive (≥50%) stenosis and the patency of grafts were evaluated by CCTA, while myocardial ischaemia was assessed by quantitative adenosine-stress PET. Altogether 28 (78%) of the 36 study patients presented with matched PET/CCTA abnormalities. Forty-one coronary territories were supplied by non-obstructed bypass grafts or native coronary arteries (protected territory). However, 12 (29%) of these presented with a perfusion defect. In six cases, the perfusion defect involved myocardium distal to the graft-coronary anastomosis, as interpreted on the PET/CCTA fusion images. In turn, in 48 coronary territories the supplying artery was obstructed on CCTA (unprotected territory). Of these, 41 (85%, P < 0.001 vs. protected) presented with abnormal perfusion, involving myocardium distal to the anastomosis in 29 cases.
Conclusion
Hybrid imaging provides complementary information on the presence and localization of atherosclerotic lesions and myocardial perfusion abnormalities in symptomatic patients with previous CABG.
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Affiliation(s)
- Teemu Maaniitty
- Turku PET Centre, University of Turku, Kiinamyllynkatu 4–8, Turku, Finland
| | - Samuli Jaakkola
- Heart Center, Turku University Hospital and University of Turku, Hämeentie 11, Turku, Finland
| | - Antti Saraste
- Turku PET Centre, University of Turku, Kiinamyllynkatu 4–8, Turku, Finland
- Heart Center, Turku University Hospital and University of Turku, Hämeentie 11, Turku, Finland
| | - Juhani Knuuti
- Turku PET Centre, University of Turku, Kiinamyllynkatu 4–8, Turku, Finland
- Department of Clinical physiology, nuclear medicine and PET, Turku University Hospital, Hämeentie 11, Turku, Finland
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Prognostic Value of “Routine” Cardiac Stress Imaging 5 Years After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2014; 7:615-21. [DOI: 10.1016/j.jcin.2014.01.161] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 12/30/2013] [Accepted: 01/02/2014] [Indexed: 11/20/2022]
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Harb SC, Marwick TH. Prognostic value of stress imaging after revascularization: a systematic review of stress echocardiography and stress nuclear imaging. Am Heart J 2014; 167:77-85. [PMID: 24332145 DOI: 10.1016/j.ahj.2013.07.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Accepted: 07/01/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Risk assessment may be important in patients being considered for repeat revascularization after prior coronary intervention or surgery. We sought the prognostic value of radionuclide stress myocardial perfusion imaging or echocardiography among patients with previous revascularization. METHODS Studies on the outcomes of stress imaging tests after revascularization were selected from an electronic search if they reported the odds or hazard ratio (HR) of an abnormal stress test in the prediction of mortality (cardiac or total), hard cardiac events (cardiac death and myocardial infarction [MI]), total hard events (total mortality and MI]), or overall events (cardiac death, MI, and repeat revascularization). RESULTS In 29 studies (12,874 patients, 63 ± 3 years, 80% men), an abnormal test result was associated with hard cardiac events (HR 1.2, 95% CI 1.1-1.3), cardiac mortality (HR 5.8, 95% CI 0.8-10.8), total mortality (HR 2.2, 95% CI 1.3-3.1), total hard events(HR 2.4, 95% CI 1.4-3.3), and overall events (HR 1.2, 95% CI 1.1-1.3). The nature of the end point was not associated with differences in the prediction of events, but the type of revascularization showed a significant association with outcome, with percutaneous intervention portending a worse outcome. Age and the timing of the stress imaging postrevascularization were inversely associated with survival. Gender, length of follow-up after testing, symptom status, past infarction, and risk factor status did not explain interstudy heterogeneity. CONCLUSIONS In patients with previous revascularization, abnormal results at stress echocardiography or radionuclide myocardial perfusion imaging are predictive of subsequent events, with age, type of revascularization, and the timing of the stress imaging after revascularization being important sources of heterogeneity between studies.
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Kawai H, Sarai M, Motoyama S, Ito H, Takada K, Harigaya H, Takahashi H, Hashimoto S, Takagi Y, Ando M, Anno H, Ishii J, Murohara T, Ozaki Y. A combination of anatomical and functional evaluations improves the prediction of cardiac event in patients with coronary artery bypass. BMJ Open 2013; 3:e003474. [PMID: 24220113 PMCID: PMC3831107 DOI: 10.1136/bmjopen-2013-003474] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To study the usefulness of combined risk stratification of coronary CT angiography (CTA) and myocardial perfusion imaging (MPI) in patients with previous coronary-artery-bypass grafting (CABG). DESIGN A retrospective, observational, single centre study. SETTING AND PATIENTS 204 patients (84.3% men, mean age 68.7±7.6) undergoing CTA and MPI. MAIN OUTCOME MEASURES CTA defined unprotected coronary territories (UCT; 0, 1, 2 or 3) by evaluating the number of significant stenoses which were defined as the left main trunk ≥50% diameter stenosis, other native vessel stenosis ≥70% or graft stenosis ≥70%. Using a cut-off value with receiver-operating characteristics analysis, all patients were divided into four groups: group A (UCT=0, summed stress score (SSS)<4), group B (UCT≥1, SSS<4), group C (UCT=0, SSS≥4) and group D (UCT≥1, SSS≥4). RESULTS Cardiac events, as a composite end point including cardiac death, non-fatal myocardial infarction, unstable angina requiring revascularisation and heart-failure hospitalisation, were observed in 27 patients for a median follow-up of 27.5 months. The annual event rates were 1.1%, 2%, 5.7% and 12.9% of patients in groups A, B, C and D, respectively (log rank p value <0.0001). Adding UCT or SSS to a model with significant clinical factors including left ventricular ejection fraction, time since CABG and Euro SCORE II improved the prediction of events, while adding UCT and SSS to the model improved it greatly with increasing C-index, net reclassification improvement and integrated discrimination improvement. CONCLUSIONS The combination of anatomical and functional evaluations non-invasively enhances the predictive accuracy of cardiac events in patients with CABG.
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Affiliation(s)
- Hideki Kawai
- Department of Cardiology, Fujita Health University, Toyoake, Japan
| | - Masayoshi Sarai
- Department of Cardiology, Fujita Health University, Toyoake, Japan
| | - Sadako Motoyama
- Department of Cardiology, Fujita Health University, Toyoake, Japan
| | - Hajime Ito
- Department of Cardiology, Fujita Health University, Toyoake, Japan
| | - Kayoko Takada
- Department of Cardiology, Fujita Health University, Toyoake, Japan
| | - Hiroto Harigaya
- Department of Cardiology, Fujita Health University, Toyoake, Japan
| | - Hiroshi Takahashi
- Departments of Medical Statistics, Fujita Health University, Toyoake, Japan
| | - Shuji Hashimoto
- Department of Hygiene, Fujita Health University, Toyoake, Japan
| | - Yasushi Takagi
- Department of Cardiovascular Surgery, Fujita Health University, Toyoake, Japan
| | - Motomi Ando
- Department of Cardiovascular Surgery, Fujita Health University, Toyoake, Japan
| | - Hirofumi Anno
- Departments of Radiology, Fujita Health University, Toyoake, Japan
| | - Junichi Ishii
- Department of Cardiology, Fujita Health University, Toyoake, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Fujita Health University, Toyoake, Japan
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University, Toyoake, Japan
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Schepis T, Benz K, Haldemann A, Kaufmann PA, Schmidhauser C, Frielingsdorf J. Prognostic value of stress-gated 99m-technetium SPECT myocardial perfusion imaging: risk stratification of patients with multivessel coronary artery disease and prior coronary revascularization. J Nucl Cardiol 2013; 20:755-62. [PMID: 23839243 DOI: 10.1007/s12350-013-9749-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 05/31/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND This study assessed the prognostic value of stress-gated 99mTc-sestamibi myocardial perfusion SPECT (MPS) in patients with multivessel coronary artery disease (CAD) and prior revascularization according to the presence and severity of ischemia. METHODS AND RESULTS We studied the outcome of 472 patients with multivessel CAD and prior revascularization (coronary angioplasty, 290 patients; bypass surgery, 182 patients), who underwent exercise or dipyridamole 99mTc-sestamibi MPS for evaluation of ischemia. Visual scoring of perfusion images used 20 segments and a 5-point scale. Gated post-stress EF was automatically calculated. Endpoints included hard events: cardiac death (CD) and nonfatal myocardial infarction (MI). During a mean follow-up of 3.0 ± 1.0 years, 37 hard events occurred, including CD in 15 (3%) and MI in 22 (5%) patients. In a risk-adjusted multivariable Cox model, a history of prior MI, diabetes, abnormal MPS, moderate-to-severe ischemia, and post-stress EF <35% were important predictors of cardiac events. Four-year risk-adjusted survival was 97.9% for normal MPS, 87.3% for abnormal MPS with ischemia, and 82.1% for moderate-to-severe ischemia. CONCLUSIONS Among patients with previous coronary revascularization, stress-gated 99mTc-sestamibi MPS provides prognostic information for the prediction of cardiac events. A normal perfusion scan confers an excellent prognosis and an exceedingly low hard event rate (<1%/year). The presence of moderate-to-severe ischemia or a post-stress EF <35% identifies patients at highest risk of subsequent cardiac events.
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Affiliation(s)
- Tiziano Schepis
- Clinic of Cardiology, Department of Internal Medicine, City Hospital Triemli, Zurich, Switzerland
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Askew JW, Miller TD, Greason KL, Schaff HV, McCully RB, Crusan DJ, Hodge DO, Gibbons RJ. Population-based study of the use of cardiac stress imaging and referral for coronary angiography and repeated revascularization after coronary artery bypass graft surgery. Mayo Clin Proc 2013; 88:345-53. [PMID: 23541009 DOI: 10.1016/j.mayocp.2012.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Revised: 11/20/2012] [Accepted: 12/04/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess stress single-photon emission computed tomography (SPECT) and stress echocardiography use after coronary artery bypass grafting (CABG) and their effect on referral for coronary angiography and revascularization. PATIENTS AND METHODS The referral, timing, and results of stress imaging after CABG; referral for coronary angiography and revascularization; and all-cause mortality were assessed in this longitudinal, population-based, retrospective study of 1138 Olmsted County, Minnesota, patients undergoing CABG between January 1, 1993, and December 31, 2003. RESULTS A total of 570 patients (50.1%) underwent a stress imaging study (341 SPECT and 229 echocardiography) during the study period. Of the 1138 patients, 372 (32.7%) were referred for coronary angiography, and 144 of those patients (12.7%) underwent repeated revascularization (132 percutaneous revascularization and 12 CABG). The median interval between CABG and the index stress imaging study was 3.0 years (25th-75th percentile, 1.2-5.7 years). The results of 75.7% (258 of 341) of the stress SPECT studies and 70.7% (162 of 229) of the stress echocardiograms were abnormal. Seventy-six of 570 patients (13.3%) referred for stress imaging underwent coronary angiography within 180 days after the stress test. Repeated coronary revascularization was performed in 25 patients (4.4%) who underwent a stress imaging study within the preceding 180 days. The 5- and 10-year survival rates in the entire study cohort (83.5% and 65.1%, respectively) were not significantly different than predicted for the age- and sex-matched Minnesota population. CONCLUSION Half of this community-based population of patients with CABG underwent stress SPECT or echocardiography during median follow-up of 8.9 years. Despite that approximately 75% of the results of stress imaging studies were abnormal, subsequent referral for coronary angiography within 180 days was low (13.3%), and the yield for repeated revascularization was very low (4.4%).
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Affiliation(s)
- J Wells Askew
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
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12
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Al Aloul B, Mbai M, Adabag S, Garcia S, Thai H, Goldman S, Holman W, Sethi G, Kelly R, Ward HB, McFalls EO. Utility of nuclear stress imaging for detecting coronary artery bypass graft disease. BMC Cardiovasc Disord 2012; 12:62. [PMID: 22862805 PMCID: PMC3469356 DOI: 10.1186/1471-2261-12-62] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 07/07/2012] [Indexed: 11/10/2022] Open
Abstract
Background The value of Single Photon Emission Computed Tomography stress myocardial perfusion imaging (SPECT-MPI) for detecting graft disease after coronary artery bypass surgery (CABG) has not been studied prospectively in an unselected cohort. Methods Radial Artery Versus Saphenous Vein Graft Study is a Veterans Affairs Cooperative Study to determine graft patency rates after CABG surgery. Seventy-nine participants agreed to SPECT-MPI within 24 hours of their coronary angiogram, one-year after CABG. The choice of the stress protocol was made at the discretion of the nuclear radiologist and was either a symptom-limited exercise test (n = 68) or an adenosine infusion (n = 11). The SPECT-MPI results were interpreted independent of the angiographic results and estimates of sensitivity, specificity and accuracy were based on the prediction of a graft stenosis of ≥70% on coronary angiogram. Results A significant stenosis was present in 38 (48%) of 79 patients and 56 (22%) of 251 grafts. In those stress tests with an optimal exercise heart rate response (>80% maximum predicted heart rate) (n = 26) sensitivity, specificity and accuracy of SPECT-MPI for predicting the graft stenosis was 77%, 69% and 73% respectively. With adenosine (n = 11) it was 75%, 57% and 64%, respectively. Among participants with a suboptimal exercise heart rate response, the sensitivity of SPECT-MPI for predicting a graft stenosis was <50%. The accuracy of SPECT-MPI for detecting graft disease did not vary significantly with ischemic territory. Conclusions Under optimal stress conditions, SPECT-MPI has a good sensitivity and accuracy for detecting graft disease in an unselected patient population 1 year post-CABG.
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13
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Takagi Y, Akita K, Kondo H, Ishida M, Kaneko K, Sato M, Ando M. Non-invasive evaluation of internal thoracic artery anastomosed to the left anterior descending artery with 320-detector row computed tomography and adenosine thallium-201 myocardial perfusion scintigraphy. Ann Thorac Cardiovasc Surg 2011; 18:24-30. [PMID: 21881340 DOI: 10.5761/atcs.oa.11.01684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE We evaluated the relationship between internal thoracic artery (ITA) stenosis anastomosed to the left anterior descending artery (LAD) and the degree of LAD stenosis using 320-detector row computed tomography (320-ADCT) and adenosine thallium-201 myocardial perfusion scintigraphy (Tl-201-MPS). METHODS We included 101 patients who underwent coronary artery bypass grafting (CABG) using ITA grafts; 320-ADCT and adenosine Tl-201-MPS were performed 2-3 months after CABG. Clinical parameters, degree of LAD stenosis, and regional myocardial ischemia of the LAD territory were compared between patients without ITA stenosis (Group A) and with ITA stenosis (Group B). RESULTS Thirty patients (30%) had ≤75% LAD stenosis, and 9 patients (30%) showed significant ITA stenosis. Regional ischemia was noted in 23 patients (23%). There were no differences in clinical parameters between the 2 groups. Twenty-two patients (24%) in Group A and 8 patients (89%) in Group B had ≤75% LAD stenosis (P <0.002). No Group B patients had regional myocardial ischemia of the LAD territory. CONCLUSION We concluded that ≤75% LAD stenosis significantly influences ITA stenosis, without associated regional myocardial ischemia of the LAD territory. Non-invasive 320-ADCT and adenosine Tl-201-MPS for ITA evaluation may be useful for long-term follow-up of patients after CABG.
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Affiliation(s)
- Yasushi Takagi
- Department of Cardiovascular Surgery, Fujita Health University, Dengakugakubo, Kutukake-cho, Toyoake, Aichi, Japan.
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14
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Weinstein H, Steingart R. Myocardial Perfusion Imaging for Preoperative Risk Stratification: TABLE 1. J Nucl Med 2011; 52:750-60. [DOI: 10.2967/jnumed.110.076158] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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15
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Cortigiani L, Bigi R, Sicari R, Landi P, Bovenzi F, Picano E. Stress echocardiography for the risk stratification of patients following coronary bypass surgery. Int J Cardiol 2010; 143:337-42. [DOI: 10.1016/j.ijcard.2009.03.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Revised: 01/08/2009] [Accepted: 03/10/2009] [Indexed: 10/21/2022]
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16
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Combining chronic kidney disease with 201thallium/123iodine β methyliodophenyl pentadecanoic acid dual myocardial single-photon emission computed tomography findings is useful for the evaluation of cardiac event risk. Nucl Med Commun 2009; 30:54-61. [DOI: 10.1097/mnm.0b013e328314b879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Cerqueira MD, Ferreira MJV. Heart. Clin Nucl Med 2008. [DOI: 10.1007/978-3-540-28026-2_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Askew JW, Miller TD, Araoz PA, Breen JF, Hodge DO, Gibbons RJ. Abnormal electron beam computed tomography results: the value of repeating myocardial perfusion single-photon emission computed tomography in the ongoing assessment of coronary artery disease. Mayo Clin Proc 2008; 83:17-22. [PMID: 18174005 DOI: 10.4065/83.1.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine whether asymptomatic patients with atherosclerosis, indicated by the presence of coronary artery calcium on electron beam computed tomography, are at enough risk for progression of disease to justify a repeated stress single-photon emission computed tomography (SPECT) examination after an initial normal to low-risk perfusion study. PATIENTS AND METHODS We retrospectively identified patients who had abnormal results on electron beam computed tomography (coronary artery calcium score > 0) and normal to low-risk results on SPECT (defined as a summed stress score of 0-3) within a 3-month period from January 1, 1995, to October 31, 2002. Of the 504 identified patients, 285 remained after exclusion criteria were applied. Of the 285 patients, 69 (mean +/- SD age, 58.2 +/- 7.6 years; 91% male) underwent at least 1 repeated myocardial perfusion SPECT imaging study within 4 years of their initial assessment as normal or at low risk without recurrence of symptoms. The value of repeated SPECT imaging was assessed by detection of a substantial change in the repeated SPECT study and by documentation of a clinical event (death, nonfatal myocardial infarction, or revascularization). Follow-up was 100% complete at a mean of 4.3 +/- 1.6 years. RESULTS Only 4 patients (6%) had a substantial progression in their SPECT risk category; substantial changes on the SPECT scans occurred only in patients with a coronary artery calcium score greater than 100. Three patients underwent revascularization, yielding a 5-year rate for survival free of revascularization of 94% (95% confidence interval, 88%-100%). No deaths or nonfatal myocardial infarctions were reported. CONCLUSION The principal findings of this study indicate that asymptomatic patients with initial normal or low-risk results from stress SPECT performed because of abnormal coronary artery calcium scores who remain asymptomatic are at low risk of death, myocardial infarction, or coronary revascularization. Three patients underwent revascularization by percutaneous coronary intervention despite the absence of symptoms. A substantial change in SPECT results (defined as progression from normal or low-risk summed stress score to intermediate- or high-risk summed stress score) affected 6% of patients and was not associated with any adverse hard events (nonfatal myocardial infarction or death).
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Affiliation(s)
- J Wells Askew
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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19
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Crusco F, Antoniella A, Papa V, Menzano R, Giovagnoni A. Evidence based medicine: role of multidetector CT in the follow-up of patients receiving coronary artery bypass graft. Radiol Med 2007; 112:509-25. [PMID: 17563851 DOI: 10.1007/s11547-007-0158-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2006] [Accepted: 08/07/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this study was to define the role of multidetector computed tomography (MDCT) in the follow-up assessment of patients undergoing coronary artery bypass grafting (CABG) using an evidence-based medicine (EBM) approach. MATERIALS AND METHODS We performed a literature search of the most reputable studies published in the period 1990-2005 on the clinical follow-up of patients after myocardial revascularisation by CABG. Relevant studies were ranked according to levels of evidence using EBM criteria. A similar search was also conducted on the Internet to identify and review the guidelines posted by the major international scientific societies. RESULTS A total of 29 papers meeting the basic reliability requirements of EBM were identified. The reported sensitivity and specificity for electrocardiogram (ECG) testing, stress echocardiography and radionuclide myocardial perfusion imaging were 45% and 82%, 86% and 90%, and 68% and 84%, respectively. All 16 CT studies (one retrospective, the remaining prospective) were validation studies comparing MDCT with conventional coronary angiography. The total number of patients and graft segments studied were 705 and 1,974, respectively. The total number of assessable graft segments were 62%-100%, with a sensitivity and specificity of 75%-100% and 76.9%-100%, respectively. CONCLUSIONS The applications of MDCT in the follow-up assessment of patients after CABG are derived from indirect evidence only. The efficacy of the method should be evaluated in randomised clinical trials comparing MDCT not only with conventional coronary angiography but also with other noninvasive stress imaging methods. On the basis of the clinical evidence reported in the literature, the indications for the use of MDCT are still limited. In our view, the completion of such randomised trials combined with the development of new-generation scanners is required to correctly define the role of MDCT in the follow-up assessment of patients who have undergone CABG.
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Affiliation(s)
- F Crusco
- Dipartimento Diagnostica per Immagini, AUSL 3 Umbria, Via Antica Vena n. 18, I-06087 Ospedale Foligno, Perugia, Italy.
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20
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Can L, Kayikçioğlu M, Halil H, Kültürsay H, Evrengül H, Kumanlioğlu K, Türkoglu C. The effect of myocardial surgical revascularization on left ventricular late potentials. Ann Noninvasive Electrocardiol 2006; 6:84-91. [PMID: 11333164 PMCID: PMC7027657 DOI: 10.1111/j.1542-474x.2001.tb00091.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The presence of ventricular late potentials (LP) is an important indicator for the development of ventricular tachyarrhythmias due to ischemic heart disease. The effect of myocardial revascularization on LP has remained controversial. The purpose of this study was to determine whether complete myocardial surgical revascularization (CABG) documented by myocardial perfusion scintigraphy might alter the substrate responsible for LP. METHODS Prospectively, enrolled patients undergoing elective CABG were evaluated with thallium-201 myocardial perfusion scintigraphy and signal- averaged ECG pre- and postoperatively. SAECG recordings were obtained serially: before, 48-72 hours and 3 months after CABG. LPS were defined as positive if SAECG met at least two of Gomes criteria. Scintigraphies were performed pre- and 3 months postoperatively for determination of the success of revascularization. Changes observed in SAECG recordings after CABG were compared between those with and without successful revascularization. RESULTS CABG resulted in successful revascularization in 23 patients and was unsuccessful in 17 (no change or deterioration of the perfusion defects). Preoperative SAECG values were not different between groups except for RMS values. The incidence of LP decreased significantly postoperatively in patients with improved myocardial perfusion, whereas there were no changes in patients who did not have postoperative perfusion improvement (McNemar test, P < 0.05). CONCLUSIONS LPs disappear following the elimination of myocardial ischemia by complete surgical revascularization. Persistence of ischemia following CABG usually results in the persistence of late potentials. The incidence of ventricular arrhythmias is expected to be unchanged in these patients and they should be reevaluated for reinterventions.
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Affiliation(s)
- L Can
- Department of Cardiology, Ege University School of Medicine, Izmir, Turkey.
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21
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Vernhet-Kovacsik H, Battistella P, Demaria R, Pasquie JL, Bousquet C, Dogas G, Leclercq F, Albat B, Senac JP. Early Postoperative Assessment of Coronary Artery Bypass Graft Patency and Anatomy: Value of Contrast-Enhanced 16-MDCT with Retrospectively ECG-Gated Reconstructions. AJR Am J Roentgenol 2006; 186:S395-400. [PMID: 16714615 DOI: 10.2214/ajr.04.1773] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of our study was to assess early postoperative patency and anatomy of off-pump coronary artery bypass grafts (CABGs) using retrospectively ECG-gated MDCT. CONCLUSION Retrospectively ECG-gated MDCT is a promising noninvasive technique with which to assess early postoperative patency and anatomy of CABGs.
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Affiliation(s)
- Hélène Vernhet-Kovacsik
- Department of Imaging, CHU Montpellier, 391 Avenue du Doyen Giraud, Montpellier 34295, France.
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22
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Eisenberg MJ, Wou K, Nguyen H, Duerr R, Del Core M, Fourchy D, Huynh T, Lader E, Rogers FJ, Chaudhry R, Okrainec K, Pilote L. Use of Stress Testing Early After Coronary Artery Bypass Graft Surgery. Am J Cardiol 2006; 97:810-6. [PMID: 16516581 DOI: 10.1016/j.amjcard.2005.09.130] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2005] [Revised: 09/22/2005] [Accepted: 09/22/2005] [Indexed: 11/26/2022]
Abstract
The American College of Cardiology/American Heart Association guidelines for exercise testing do not take a position regarding the utility of routine stress testing after coronary artery bypass grafting (CABG). Our purposes were (1) to document the patterns of use of stress testing after CABG and (2) to establish whether the choice of stress testing strategy is associated with clinical characteristics of patients. The Routine versus Selective Exercise Treadmill Testing after Coronary Artery Bypass Graft Surgery (ROSETTA-CABG) Registry is a prospective multicenter study that examined the use of stress testing after CABG among 395 patients at 16 clinical centers in 6 countries. During the 12 months after CABG, 37% of patients underwent stress testing (range across centers 0% to 100%). Among patients who underwent stress testing, 24% had a clinical indication and 76% had it as a routine follow-up. A total of 65% of stress tests involved exercise treadmill testing alone, 17% involved stress nuclear perfusion imaging, 13% involved stress echocardiographic imaging, and 5% involved other types of stress tests, such as positron emission tomographic scans. The first stress test was performed at a median of 13 weeks after CABG, with 20% of patients having second tests at a median of 28 weeks and 6% having additional tests at a median of 34 weeks. Univariate and multivariate analyses demonstrated that the chief determinant of using routine stress testing was the clinical center. In conclusion, these results suggest that there is little consensus on the appropriate use of stress testing soon after CABG. Practice patterns vary widely; poorly diagnostic tests are used routinely; and the clinical center at which the procedure is performed, rather than the clinical characteristics of the patient, determines the use of stress testing after CABG.
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23
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Adams GL, Ambati SR, Adams JM, Borges-Neto S. Role of nuclear imaging after coronary revascularization. J Nucl Cardiol 2006; 13:163-9. [PMID: 16580950 DOI: 10.1007/bf02971238] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- George L Adams
- Cardiology Division, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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24
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Liao L, Kong DF, Shaw LK, Sketch MH, Milano CA, Lee KL, Mark DB. A New Anatomic Score for Prognosis After Cardiac Catheterization in Patients with Previous Bypass Surgery. J Am Coll Cardiol 2005; 46:1684-92. [PMID: 16256869 DOI: 10.1016/j.jacc.2005.06.074] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2005] [Accepted: 06/09/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the value of a new anatomic score for prognosis after diagnostic catheterization in patients with previous coronary artery bypass grafting (CABG). BACKGROUND Previous CABG patients comprise a growing proportion of patients with coronary artery disease (CAD). Whereas prognostic scores are available to adjust for native CAD, there are no comparable scores for patients with previous CABG. METHODS We studied 3,178 previous CABG patients (2,729 in a training set) who underwent cardiac catheterization. With a Cox model to develop relative weights in the training set, we created a graft index that adjusted native anatomy for territories with grafts free of significant (> or =75%) stenoses. Scaling the regression coefficients by the maximum coefficient created an index ranging from 0 to 100, where 100 was three-vessel CAD with no patent grafts. RESULTS The graft index was significantly associated with all-cause death (chi-square = 121.9, p < 0.001). In combined models, the index was more strongly associated with all-cause death than either number of diseased vessels (chi-square = 68.0 and 1.7, respectively) or the Duke CAD index (chi-square = 54.3 and 9.5, respectively). In models for death using an independent validation set, the index was also associated more strongly than either native disease descriptors. In a model including other clinical variables, the graft index remained significantly associated with all-cause death (chi-square = 40.1, p < 0.001). CONCLUSIONS For previous CABG patients, the Duke graft index was significantly more associated with prognosis than native anatomy alone and quantifies the effect of patent grafts on survival. This tool has the potential to help determine prognosis and inform the referral of post-CABG patients to repeat revascularization procedures.
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25
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Valeti US, Miller TD, Hodge DO, Gibbons RJ. Exercise Single-Photon Emission Computed Tomography Provides Effective Risk Stratification of Elderly Men and Elderly Women. Circulation 2005; 111:1771-6. [PMID: 15809375 DOI: 10.1161/01.cir.0000160862.36124.8e] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
In a recent study, we reported that the Duke treadmill score was unable to effectively stratify elderly patients according to risk. The purpose of this study was to evaluate the prognostic value of exercise single-photon emission computed tomography (SPECT) in this same population and to examine results by gender.
Methods and Results—
A cohort of 247 elderly (age ≥75 years) patients (108 women, 139 men, age 77±3 years) who underwent exercise thallium-201 SPECT were followed up for a median duration of 6.4 years. SPECT variables were significantly associated with cardiac death: summed stress score (SSS) χ
2
=19.5,
P
<0.001; summed difference score χ
2
=12.3,
P
<0.001; increased lung uptake χ
2
=9.6,
P
=0.002; and left ventricular enlargement χ
2
=8.3,
P
=0.004. The Duke score was not significantly associated with cardiac death (χ
2
<1,
P
=NS). The SSS classified most patients as low risk (49%) or high risk (35%); the Duke score classified the majority (68%) as intermediate risk. Annual cardiac mortality rates for patients categorized by SSS as low risk and high risk were 0.8% and 5.8%, respectively. Cardiac survival rates according to SSS risk categories were significantly different for both women (
P
=0.012) and men (
P
=0.003).
Conclusions—
SPECT classified most elderly patients into clinically useful low- and high-risk categories and accurately predicted outcomes in both genders. If these results can be validated in future studies, exercise SPECT rather than standard treadmill testing may emerge as the initial noninvasive testing strategy in elderly patients who are able to exercise.
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Affiliation(s)
- Uma S Valeti
- Division of Cardiovascular Diseases and Department of Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA
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26
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Rajagopal V, Gurm HS, Brunken RC, Pothier CE, Bhatt DL, Lauer MS. Prediction of death or myocardial infarction by exercise single photon emission computed tomography perfusion scintigraphy in patients who have had recent coronary artery stenting. Am Heart J 2005; 149:534-40. [PMID: 15864244 DOI: 10.1016/j.ahj.2004.08.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although practice guidelines do not recommend routine exercise testing of patients after coronary stenting, several small studies have suggested that stress myocardial perfusion imaging can provide prognostic information about future adverse cardiac events. We sought to determine if exercise nuclear testing provides independent prognostic information in patients after coronary stenting. METHODS We analyzed the outcomes of 370 patients who underwent dual isotope exercise nuclear scintigraphy at least 1 month after coronary stenting and had testing between April 1996 and May 2002. Patients were classified according to presence or absence of any ischemia. The primary endpoint was all-cause mortality or myocardial infarction (MI) during a median of 30 months (range 6-59) of follow-up. RESULTS There were 86 patients (23%) who had ischemia. Major events--death or MI--occurred in 62 patients including 22 deaths. Among patients with no ischemia, the 30-month event rate was 9.1%, whereas among patients with ischemia, the event rate was 17.0% (P = .001). After adjusting for age, sex, standard cardiac risk factors, cardiac history, left ventricular ejection fraction, angiographic findings, procedural variables, exercise capacity, and heart-rate dynamics, the presence of scintigraphic evidence of ischemia predicted death or MI (adjusted hazard ratio 2.08, 95% CI 1.21-3.56, P = .008). The presence of ischemia similarly predicted events in asymptomatic patients (adjusted hazard ratio 2.19, 95% CI 1.17-4.11, P = .015). CONCLUSIONS In patients with recent coronary stent placement, reversible nuclear perfusion defects independently predicted risk of death or MI.
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Affiliation(s)
- Vivek Rajagopal
- Department of Cardiovascular, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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27
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Klocke FJ, Baird MG, Lorell BH, Bateman TM, Messer JV, Berman DS, O'Gara PT, Carabello BA, Russell RO, Cerqueira MD, St John Sutton MG, DeMaria AN, Udelson JE, Kennedy JW, Verani MS, Williams KA, Antman EM, Smith SC, Alpert JS, Gregoratos G, Anderson JL, Hiratzka LF, Faxon DP, Hunt SA, Fuster V, Jacobs AK, Gibbons RJ, Russell RO. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). J Am Coll Cardiol 2003; 42:1318-33. [PMID: 14522503 DOI: 10.1016/j.jacc.2003.08.011] [Citation(s) in RCA: 483] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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28
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Klocke FJ, Baird MG, Lorell BH, Bateman TM, Messer JV, Berman DS, O'Gara PT, Carabello BA, Russell RO, Cerqueira MD, St John Sutton MG, DeMaria AN, Udelson JE, Kennedy JW, Verani MS, Williams KA, Antman EM, Smith SC, Alpert JS, Gregoratos G, Anderson JL, Hiratzka LF, Faxon DP, Hunt SA, Fuster V, Jacobs AK, Gibbons RJ, Russell RO. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). Circulation 2003; 108:1404-18. [PMID: 12975245 DOI: 10.1161/01.cir.0000080946.42225.4d] [Citation(s) in RCA: 498] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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29
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Clinical trials report. Curr Cardiol Rep 2003. [DOI: 10.1007/s11886-003-0032-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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30
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Miller TD, Chaliki HP, Christian TF, Hodge DO, Gibbons RJ. Usefulness of worsening clinical status or exercise performance in predicting future events in patients with coronary artery disease. Am J Cardiol 2001; 88:1294-7. [PMID: 11728358 DOI: 10.1016/s0002-9149(01)02091-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- T D Miller
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA.
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31
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Krone RJ, Hardison RM, Chaitman BR, Gibbons RJ, Sopko G, Bach R, Detre KM. Risk stratification after successful coronary revascularization: the lack of a role for routine exercise testing. J Am Coll Cardiol 2001; 38:136-42. [PMID: 11451263 DOI: 10.1016/s0735-1097(01)01312-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for exercise testing (EXT) after successful coronary revascularization (CR) using the Bypass Angioplasty Revascularization Investigation experience. BACKGROUND The ACC/AHA guidelines state that EXT within three years of successful CR is not useful. METHODS The 1,678 patients randomized to CR by either angioplasty or bypass surgery were required to take symptom-limited treadmill tests one, three and five years after revascularization. RESULTS Patients who took the test at each specified time had a much lower subsequent two-year mortality than those who did not (1.9% vs. 9.4%, 3.5% vs. 12.6% and 3.3% vs. 11.0% at one, three and five years, respectively, after CR [p < 0.0001 for each]). Exercise parameters at the one- and three-year test did not improve a multivariable model of survival after including clinical parameters. Exercising to Bruce stage 3 or generating a Duke score >-6 were independently predictive of two-year survival after the five-year test. ST depression on the one-year test was associated with more revascularizations (relative risk = 1.6; p < 0.001). CONCLUSIONS Patients with stable multivessel coronary disease who took a protocol-mandated exercise test at one, three and five years after revascularization were at low risk for mortality in the two years subsequent to each test. Exercise parameters did not improve prediction of mortality in the two years after the one- and three-year tests. The ACC/AHA guidelines on exercise testing after CR (no value for routine testing in stable patients for three years after revascularization) are supported by these results.
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Affiliation(s)
- R J Krone
- Washington University School of Medicine, St Louis, Missouri, USA
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32
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Miller TD, Roger VL, Milavetz JJ, Hopfenspirger MR, Milavetz DL, Hodge DO, Gibbons RJ. Assessment of the exercise electrocardiogram in women versus men using tomographic myocardial perfusion imaging as the reference standard. Am J Cardiol 2001; 87:868-73. [PMID: 11274942 DOI: 10.1016/s0002-9149(00)01528-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The exercise electrocardiogram (ECG) is widely believed to be less accurate in women, primarily due to a high prevalence of false-positive tests. The purpose of this study was to examine the relative accuracy of the exercise ECG in women versus men in 8,671 patients (3,213 women, 5,458 men) using myocardial perfusion imaging as the reference standard. More women (14%) than men (10%) had a false-positive ECG (p <0.001), but the absolute difference was relatively small. The false-negative rate was considerably lower in women (17% vs 32%, p <0.001). Compared with men, women had lower test sensitivity (30% vs 42%, p <0.001) and positive predictive value (34% vs 70%, p <0.001) but higher specificity (82% vs 78%, p = 0.002), negative predictive value (78% vs 52%, p <0.001), and accuracy (69% vs 58%, p <0.001). In patients with a false-negative exercise ECG, "high-risk" scans were less prevalent in women (12% vs 19%, p <0.001). In the smaller subset of patients referred for coronary angiography (205 women, 838 men), the false-positive electrocardiographic rate was again higher in women (13% vs 7%, p = 0.003), but neither specificity (69% vs 74%, p = NS) nor accuracy (60% vs 66%, p = NS) was different between the sexes. Thus, the percentage of patients with a false-positive exercise ECG was higher in women than men but low in absolute terms (<15%) for both sexes. Test specificity was not lower in women. These results suggest that gender should not be a major determinant for selecting stress imaging over standard treadmill testing.
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Affiliation(s)
- T D Miller
- Division of Cardiovascular Disease, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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33
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Scarpinato L. Use of stress-testing modalities after angioplasty or bypass. Prim Care 2001; 28:209-18 ,viii-ix. [PMID: 11346506 DOI: 10.1016/s0095-4543(05)70015-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The use of stress-testing modalities after angioplasty or bypass has been an area of discussion and research since the advent of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG). Issues of when to do which test, and if any, in asymptomatic or symptomatic patients, are not resolved. Stress imaging ETT plays a larger role in this population, but task forces stop short of coming out with any frequency of testing. Cost-effective strategies have not been explored. This article attempts to summarize the results in the literature.
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Affiliation(s)
- L Scarpinato
- The Racine Family Practice Residency Program, The Medical College of Wisconsin, Racine, WI 53403, USA
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34
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Sarda L, Fuchs L, Lebtahi R, Faraggi M, Delahaye N, Hvass U, Le Guludec D. Prognostic value of 201Tl myocardial scintigraphy after coronary artery bypass grafting. Nucl Med Commun 2001; 22:189-96. [PMID: 11258406 DOI: 10.1097/00006231-200102000-00011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND 201Tl myocardial scintigraphy (201Tl SPECT) is of strong prognostic value in various populations with suspected or known coronary artery disease. However, its value in patients with coronary artery bypass grafting (CABG) is not fully assessed. METHODS We examined 115 consecutive patients to determine the relation between clinical data/stress 201Tl SPECT performed 5+/-3 years after CABG, and subsequent cardiac events. RESULTS Thirteen patients (11%) had stress-induced angina, 22 (19%) had electrical positivity, and 97 (84%) had abnormal scintigraphy, including 62 (54%) with reversible defects. During follow-up (35+/-22 months), there were nine cardiac deaths, seven myocardial infarctions, and 20 revascularization procedures. Multivariate Cox analysis identified the delay between CABG and scintigraphy (P<0.01, relative risk (RR) = 1.01), the extent of stress 201Tl defects (P = 0.04, RR = 1.18), and increased stress 201Tl lung uptake (P = 0.03, RR = 3.56) as significant predictors of cardiac deaths/infarctions. Delay between CABG and scintigraphy (P < 0.001, RR = 1.01), the extent of stress 201Tl defects (P = 0.03, RR = 1.15), and that of reversible defects (P = 0.05, RR = 1.13) were the only significant predictors of total events. CONCLUSIONS Besides the delay between CABG and scintigraphy, the scintigraphic parameters were the only significant and additive predictors of cardiac events in 115 patients with CABG.
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Affiliation(s)
- L Sarda
- Department of Nuclear Medicine, Bichat Hospital, Paris, France
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Zellweger MJ, Lewin HC, Lai S, Dubois EA, Friedman JD, Germano G, Kang X, Sharir T, Berman DS. When to stress patients after coronary artery bypass surgery? Risk stratification in patients early and late post-CABG using stress myocardial perfusion SPECT: implications of appropriate clinical strategies. J Am Coll Cardiol 2001; 37:144-52. [PMID: 11153729 DOI: 10.1016/s0735-1097(00)01104-9] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The study compared the prognostic significance of myocardial perfusion single-photon emission computed tomography (SPECT) (MPS) in patients early and late after coronary artery bypass graft surgery (CABG). BACKGROUND The long-term effectiveness of CABG is limited by graft stenosis. The greatest incidence of graft occlusion occurs between five and eight years after surgery. However, little is known regarding the appropriate time to stress patients post-CABG with respect to risk stratification. METHODS We identified 1,765 patients, who underwent MPS 7.1 +/- 5.0 years post-CABG. All patients underwent rest T1-201/stress Tc-99m sestamibi MPS and were followed up > or =1 year after testing. Patients with early CABG or PTCA (<60 days after MPS) were censored. The prognostic population consisted of 1,544 patients. A semiquantitative visual analysis employing a 20-segment model was used to define summed stress score (SSS), summed rest score (SRS), summed difference score (SDS), and the number of nonreversible segments (NRS). RESULTS During follow-up, 53 cardiac deaths (CD) occurred. There was a significant increase in annual CD rates as a function of SSS. A multivariate analysis identified age, ischemia (SDS), and infarct size (NRS) as independent predictors of CD. Nuclear variables added incremental value to prescan information. The annual CD rate was relatively low (1.3%) in patients < or =5 years post-CABG. In this subgroup only age and infarct size (NRS) were predictive of CD. CONCLUSION MPS is strongly predictive of subsequent CD in post-CABG patients and adds incremental value over clinical and treadmill test information. Our data suggest that symptomatic patients < or =5 years and all patients >5 years post-CABG may benefit from testing.
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Affiliation(s)
- M J Zellweger
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA
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Ho KT, Miller TD, Holmes DR, Hodge DO, Gibbons RJ. Long-term prognostic value of Duke treadmill score and exercise thallium-201 imaging performed one to three years after percutaneous transluminal coronary angioplasty. Am J Cardiol 1999; 84:1323-7. [PMID: 10614798 DOI: 10.1016/s0002-9149(99)00565-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The value of exercise nuclear perfusion imaging performed beyond the 6-month restenosis window for percutaneous transluminal coronary angioplasty (PTCA) has not been explored. This study evaluates the long-term prognostic value of exercise thallium (Tl)-201 imaging after PTCA. We studied the late outcome of a series of 211 patients with tomographic Tl-201 exercise studies performed between 1 to 3 years after PTCA. Follow-up was 96% complete at a median duration of 7.3 years. Most (73%) had 1- or 2-vessel coronary artery disease and normal left ventricular function and 193 (91%) had successful PTCA. Two thirds of the patients were symptomatic at the time of testing. The mean Duke score was 5+/-6 and 125 (60%) patients had a low-risk Duke score. Mean summed stress score was 50+/-9 and mean summed reversibility score was 3+/-4. The 5-year overall survival was 95%, yielding a low annual mortality rate of 1%/year. The summed stress score exhibited a significant association (p = 0.047) with the end point of cardiac death or myocardial infarction. The Duke score was predictive of the combination end point of hard and soft cardiac events (p = 0.002). This study demonstrates that exercise Tl-201 perfusion imaging performed 1 to 3 years after PTCA was predictive of cardiac events.
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Affiliation(s)
- K T Ho
- Department of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Abstract
Unidentified coronary artery disease remains a significant cause of premature death and morbidity during the prime of life. The availability of effective interventions for the management of ischemia has provoked new interest in screening for this condition in asymptomatic patients, in the hope of reducing the burden of this condition. Although widespread use of stress testing is ineffective, the use of imaging techniques may offer better accuracy for detection of ischemia. Other tests that identify evidence of atheroma in the peripheral or coronary circulation may be useful to identify patients at risk.
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Affiliation(s)
- T H Marwick
- Department of Medicine, University of Queensland, Australia.
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Verani MS. Stress myocardial perfusion imaging versus echocardiography for the diagnosis and risk stratification of patients with known or suspected coronary artery disease. Semin Nucl Med 1999; 29:319-29. [PMID: 10534234 DOI: 10.1016/s0001-2998(99)80019-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Stress perfusion imaging and stress echocardiography (ECHO) are both very useful for assessment of diagnosis and risk stratification of patients with coronary artery disease (CAD). Both techniques have been well validated during exercise and inotropic stress, but coronary vasodilation stress is better used in combination with perfusion imaging. The overall sensitivity for detection of CAD is slightly higher by single photon emission computed tomography (SPECT) than by two-dimensional (2D) ECHO during all stress modalities, whereas the specificity is slightly higher by ECHO, although the differences in general are not statistically significant. SPECT, however, appears to be superior to ECHO in the diagnosis of isolated circumflex stenosis, as well as for the correct identification of multivessel CAD. A substantially greater amount of information is available regarding risk stratification with SPECT than with 2D ECHO. Although the data suggest that both techniques are very useful for risk stratification of patients with stable CAD, after myocardial infarction, and for preoperative risk stratification, the risk for cardiac events is lower in the presence of a normal stress SPECT study than of a normal stress ECHO.
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Affiliation(s)
- M S Verani
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
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Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM, Grunwald MA, Levy D, Lytle BW, O'Rourke RA, Schafer WP, Williams SV, Ritchie JL, Cheitlin MD, Eagle KA, Gardner TJ, Garson A, Russell RO, Ryan TJ, Smith SC. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). J Am Coll Cardiol 1999; 33:2092-197. [PMID: 10362225 DOI: 10.1016/s0735-1097(99)00150-3] [Citation(s) in RCA: 367] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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