Is There an Age When Myocardial Perfusion Imaging May No Longer Be Prognostically Useful?

Chest Pain Evaluation: Diagnostic Testing

Chest pain/discomfort (CP) is a common symptom and can be a diagnostic dilemma for many clinicians. The misdiagnosis of an acute or progressive chronic cardiac etiology may carry a significant risk of morbidity and mortality. This review summarizes the different options and modalities for establishing the diagnosis and severity of coronary artery disease. An effective test selection algorithm should be individually tailored to each patient to maximize diagnostic accuracy in a timely fashion, determine short- and long-term prognosis, and permit implementation of evidence-based treatments in a cost-effective manner. Through collaboration, a decision algorithm was developed (www.chowmd.ca/cadtesting) that could be adopted widely into clinical practice.

Cardiovascular Biomarkers and Imaging in Older Adults: JACC Council Perspectives

Whereas the burgeoning population of older adults is intrinsically vulnerable to cardiovascular disease, the utility of many management precepts that were validated in younger adults is often unclear. Whereas biomarker- and imaging-based tests are a major part of cardiovascular disease care, basic assumptions about their use and efficacy cannot be simply extrapolated to many older adults. Biology, physiology, and body composition change with aging, with important influences on cardiovascular disease testing procedures and their interpretation. Furthermore, clinical priorities of older adults are more heterogeneous, potentially undercutting the utility of testing data that are collected. The American College of Cardiology and the National Institutes on Aging, in collaboration with the American Geriatrics Society, convened, at the American College of Cardiology Heart House, a 2-day multidisciplinary workshop, "Diagnostic Testing in Older Adults with Cardiovascular Disease," to address these issues. This review summarizes key concepts, clinical limitations, and important opportunities for research.

Association between abnormal myocardial scintigraphy findings and long-term outcomes for elderly patients 85 years or older: a retrospective cohort study

Background

Normal findings of cardiac scintigraphy predict good outcomes. However, a paucity of the data exists for elderly patients 85 years or older. In the present study, we aimed to demonstrate the association between the abnormal findings of cardiac scintigraphy and the risk of all cause death in patients 85 years or older.

Methods

We enrolled 143 consecutive patients 85 years or older with known or suspected coronary artery disease who underwent stress scintigraphy under adenosine or an exercise test and a ^99mTechnetium (Tc)-labeled tracer or thallium 201 (²⁰¹Tl), dual tracer rest scintigraphy using ²⁰¹Tl and ¹²³I-β-methyl iodophenyl pentadecanoic acid (¹²³I-BMIPP), or ¹²³I-BMIPP single tracer scintigraphy. Ischemia was defined by an induced perfusion abnormality according to a provocation test with recovery at rest or decreased uptake of ¹²³I-BMIPP despite normal perfusion at rest. Infarction was defined by perfusion abnormalities assessed by images at rest on ²⁰¹Tl or ^99mTc-labeled tracer. We defined these findings as abnormal when at least one of these aforementioned characteristics was observed.

Results

Patients in the abnormal findings group (N = 62) were more likely to have undergone prior coronary angiography and to have decreased ejection fraction than those in the normal findings group (N = 81). The median follow-up duration was 797 days (interquartile range, 635–1045 days), with follow-up rates of 90% at 1 year and 73% at 2 years. The 2-year mortality rate were significantly higher in the abnormal findings group than in the normal findings group (26.8% vs. 10.9%; p = 0.01). The risk of abnormal findings relative to normal findings remained significant for the mortality (adjusted hazard ratio, 5.99; 95% CI, 1.37–42.8; P = 0.015).

Conclusion

Abnormal myocardial scintigraphy findings were associated with the increased risk for mortality, even for patients 85 years or older.

Diagnosis and Prognosis of Coronary Artery Disease with SPECT and PET

PURPOSE OF REVIEW

Radionuclide myocardial perfusion imaging (MPI) continues to be the most reliable modality for diagnosis of hemodynamically significant coronary artery disease (CAD). The application of radionuclide MPI using single photon emission computed tomography (SEPCT) and positron emission tomography (PET) for CAD is reviewed, with emphasis on diagnosis and risk stratification.

RECENT FINDINGS

Contemporary studies have reported the diagnostic and prognostic value of novel imaging protocols, employing stress-first or stress-only approach. In addition, the superior diagnostic value of PET has been established with a role of assessment of myocardial blood flow to improve risk stratification. The utility of MPI in special populations, such as the elderly, women, and diabetic patients has also been recently evaluated. Furthermore, multicenter studies have reported a similar diagnostic and prognostic value of radionuclide MPI compared with other functional and anatomical techniques for CAD. Radionuclide MPI with SPECT and PET are efficacious for diagnosis and prognosis of CAD. Its universal application in varied patient populations highlights its excellent clinical effectiveness.