Author + information
- Received January 20, 1995
- Revision received April 7, 1995
- Accepted April 12, 1995
- Published online September 1, 1995.
- Daniel S. Berman, MD, FACC*,
- Rory Hachamovitch, MD,
- Hosen Kiat, MD, FACC,
- Ishac Cohen, PHD,
- J. Arthur Cabico, BS,
- Fan Ping Wang, MD,
- John D. Friedman, MD, FACC,
- Guido Germano, PHD,
- Kenneth Van Train, BS and
- George A. Diamond, MD, FACC
- ↵*Address for correspondence: Dr. Daniel S. Berman, Department of Imaging, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Room A042, North Tower, Lower Level, Los Angeles, California 90048.
Objectives This study assessed the incremental prognostic implications of normal and equivocal exercise technetium-99m (Tc-99m) sestamibi single-photon emission computed tomography (SPECT) and sought to determine its incremental prognostic value, impact on patient management and cost implications.
Background The prognostic implications of Tc-99m sestamibi SPECT are not well defined, and risk stratification using this test has not been explored.
Methods We studied 1,702 patients referred for exercise Tc99m sestamibi SPECT who were followed up for a mean (±SD) of 20 ± 5 months. Patients with previous percutaneous transluminal coronary angioplasty or coronary artery bypass surgery were excluded. The SPECT studies were assessed using semiquantitative visual analysis. Cardiac death and myocardial infarction were considered “hard” events, and coronary angioplasty and bypass surgery >60 days after testing were considered “soft” events.
Results Of the 1,702 patients studied, 1,131 had normal or equivocal scan results. A total of 10 events occurred in this group (1 cardiac death and 1 myocardial infarction [0.2% hard events]; 4 coronary angioplasty and 4 bypass surgery procedures [0.7% soft events]). The rates of hard events and referral to catheterization after SPECT were similarly low in patients with a low (< 0.15), intermediate (0.15 to 0.85) and high (>0.85) post-exercise treadmill test (ETT) likelihood of coronary artery disease. With respect to scan type, patients with normal, probably normal or equivocal scan results had similarly low hard event rates. In the 571 patients with abnormal scan results, there were 43 hard events (7.5%) and 42 soft events (7.4%) (p < 0.001 vs. 1,131 patients with normal scan results for both). When the complete spectrum of scan responses was considered, SPECT provided incremental prognostic value in all patient subgroups analyzed. However, the nuclear scan was cost-effective only in patients with interpretable exercise ECG responses and an intermediate to high post-ETT likelihood of coronary artery disease and in those with uninterpretable exercise ECG responses and an intermediate to high pre-ETT likelihood of coronary artery disease.
Conclusions Normal or equivocal exercise Tc-99m sestamibi study results are associated with a benign prognosis, even in patients with a high likelihood of coronary artery disease. Although incremental prognostic value is added by nuclear testing in all patient subgroups, a testing strategy incorporating nuclear testing proved to be cost-effective only in the groups with an intermediate to high likelihood of coronary artery disease before scanning.
This study was presented in part at the 43rd Annual Scientific Session of the American College of Cardiology, Atlanta, Georgia, March 1994 and was supported in part by a grant from Dupont Pharma, Billerica, Massachusetts.
- Received January 20, 1995.
- Revision received April 7, 1995.
- Accepted April 12, 1995.
- American College of Cardiology