ABSTRACT
The impact of coronary artery calcium (CAC) scoring on subsequent changes in cardiovascular medication use in symptomatic patients with normal myocardial perfusion imaging (MPI) findings is not well established. The aim of the current study was to evaluate changes in aspirin and statin use in patients suspected for coronary artery disease after CAC scoring and normal single photon emission computed tomography (SPECT) MPI. METHODS: In the current study, 1,033 stable symptomatic patients without a known history of coronary artery disease with normal SPECT MPI who underwent concomitant CAC scoring were included. All patients had a clinical indication for imaging, mainly atypical chest pain and dyspnea, and were referred from the outpatient clinic of our hospital. Data regarding posttest medication change (either starting or discontinuation of aspirin and statin therapy at the subsequent outpatient visit) were retrospectively collected. Patients were categorized into 4 groups based on their CAC score. RESULTS: Mean age of the patients was 61±11 years and 39% were male. At baseline, 35% of the patients used aspirin and 39% used statin. In patients with CAC scores 0, 1-99, 100-399, and ≥400, aspirin was started in 1%, 4%, 9%, and 9%, respectively, and statin was started in 0%, 7%, 18%, and 24% of the patients, respectively (P<.001). Aspirin was discontinued in 19%, 11%, 7%, and 1% and statin was discontinued in 8%, 6%, 2%, and 0% (P<.001) of the patients in these respective CAC score categories. After correction for differences in risk factors and baseline medication use, increased CAC was independently associated with posttest aspirin (odds ratio 4.6, 11.2, and 27.1 for CAC scores 1-99, 100-399, and ≥400, respectively; P<.001) and statin use (odds ratio 4.4, 19.4, and 60.9 for CAC scores 1-99, 100-399, and ≥400, respectively; P<.001). CONCLUSIONS: Higher CAC scores are associated with the initiation of aspirin and statin therapy in patients with normal SPECT MPI. In patients with lower CAC scores, discontinuation of cardioprotective medication is more likely. CAC score is independently associated with posttest statin and aspirin use.
Subject(s)
Calcinosis/diagnostic imaging , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/drug therapy , Coronary Vessels/diagnostic imaging , Aspirin/therapeutic use , Female , Fibrinolytic Agents/therapeutic use , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Male , Middle Aged , Retrospective Studies , Tomography, Emission-Computed, Single-PhotonABSTRACT
The prognostic value of myocardial perfusion imaging (MPI) with the cadmium-zinc-telluride (CZT) SPECT camera is not well established. Therefore, the aim of the current study was to evaluate the prognostic value of MPI performed with a CZT SPECT camera in a large cohort of patients suspected of having coronary artery disease. Methods: Consecutive symptomatic stable patients (n = 4,057) without a history of coronary artery disease underwent CZT SPECT MPI. During a median follow-up of 2.4 y (25th-75th percentile, 1.7-3.4), patients were monitored for primary (nonfatal myocardial infarction and cardiac mortality) and secondary outcomes (late revascularization [>90 d after scanning] and primary outcome). Results: Patients with normal perfusion demonstrated low annual event rates (primary outcome, 0.2%; secondary outcome, 0.6%). Annual event rates increased with the extent of abnormality of myocardial perfusion. In patients with small ischemic perfusion defects, annual event rates were 0.7% and 2.8% for the primary and secondary outcome, respectively. In patients with moderate or large ischemic perfusion defects, these event rates were 1.2% and 4.3%, respectively. After multivariate analysis, the risk for events was significantly associated with the extent of ischemia (hazard ratio for small ischemic defects: 2.2, 95% confidence interval [CI], 0.9-5.9 and 4.6, 95% CI, 2.8-7.6, for primary and secondary outcomes, respectively; hazard ratio for moderate or large ischemic defects: 4.0, 95% CI, 1.5-10.5 and 12.1, 95% CI, 7.2-20.2, for primary and secondary outcomes, respectively). Conclusion: Our findings show that MPI acquired with a CZT SPECT camera provides excellent prognostic information, with low event rates in patients with normal myocardial perfusion. In patients with abnormal SPECT MPI, the extent of abnormality is independently associated with an increased risk of events.
Subject(s)
Cadmium , Coronary Artery Disease/diagnostic imaging , Gamma Cameras , Myocardial Perfusion Imaging/instrumentation , Tellurium , Tomography, Emission-Computed, Single-Photon/instrumentation , Zinc , Female , Follow-Up Studies , Humans , Male , Middle Aged , PrognosisABSTRACT
BACKGROUND: Performing both single photon emission computerized tomography (SPECT) and coronary computed tomography angiography (CCTA) in patients suspected for coronary artery disease (CAD) leads to increased radiation exposure. We evaluated the need for additional imaging and following implications for radiation exposure of a sequential SPECT/computed tomography (CT) algorithm. METHODS AND RESULTS: 5018 consecutive patients without history of CAD were referred for stress-first SPECT and coronary artery calcium (CAC) scoring. If stress SPECT was abnormal, additional rest SPECT and, if feasible, CCTA were acquired. Stress SPECT was normal in 2617 patients (52%). CCTA was not performed in 1289 of the 2401 patients referred for additional imaging (54%), mainly because of severe CAC (47%) or fast/irregular heart rate (22%). 642 patients with abnormal SPECT underwent CCTA, which excluded significant CAD in 378 patients (59%). Mean radiation dose was 4.5 ± 0.3 mSv for stress-only imaging and 13.2 ± 3.3 mSv for additional imaging (P < 0.001). CONCLUSIONS: Half of the patients do not require additional imaging in our sequential SPECT/CT algorithm, which is accompanied with low radiation exposure. CCTA cannot be performed in half of the patients who undergo additional imaging because of (relative) contra-indications. CCTA is able to correct for false-positive SPECT findings in our algorithm.
Subject(s)
Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/epidemiology , Medical Overuse/statistics & numerical data , Radiation Exposure/prevention & control , Radiation Exposure/statistics & numerical data , Referral and Consultation/statistics & numerical data , Single Photon Emission Computed Tomography Computed Tomography/statistics & numerical data , Disease Progression , Female , Humans , Longitudinal Studies , Male , Middle Aged , Needs Assessment , Netherlands/epidemiology , Prevalence , Risk Factors , Subtraction Technique/statistics & numerical data , Utilization ReviewABSTRACT
OBJECTIVES: To investigate the impact of left bundle branch block (LBBB) on sequential single photon emission computed tomography (SPECT)/ CT imaging starting with stress-first SPECT. METHODS: Consecutive symptomatic low- to intermediate-risk patients without a history of coronary artery disease (CAD) referred for SPECT/CT were included from an observational registry. If stress SPECT was abnormal, additional rest SPECT and, if feasible, coronary CT angiography (CCTA) were acquired. RESULTS: Of the 5,018 patients, 218 (4.3 %) demonstrated LBBB. Patients with LBBB were slightly older than patients without LBBB (65±12 vs. 61±11 years, p<0.001). Stress SPECT was more frequently abnormal in patients with LBBB (82 % vs. 46 %, p<0.001). After reviewing stress and rest images, SPECT was normal in 43 % of the patients with LBBB, compared to 77 % of the patients without LBBB (p<0.001). Sixty-four of the 124 patients with LBBB and abnormal stress-rest SPECT underwent CCTA (52 %), which could exclude obstructive CAD in 46 of the patients (72 %). CONCLUSIONS: Sequential SPECT/CT imaging starting with stress SPECT is not the optimal imaging protocol in patients with LBBB, as the majority of these patients have potentially false-positive stress SPECT. First-line testing using CCTA may be more appropriate in low- to intermediate-risk patients with LBBB. KEY POINTS: ⢠Stress-first SPECT imaging is attractive if many patients demonstrate normal stress perfusion. ⢠The majority of left bundle branch block patients have abnormal stress-first SPECT. ⢠Coronary CT excluded obstructive CAD in many LBBB patients with abnormal SPECT. ⢠Stress-first SPECT imaging is not the optimal imaging protocol in LBBB patients. ⢠In LBBB patients imaging with initial coronary CT may be more appropriate.
Subject(s)
Bundle-Branch Block/diagnosis , Coronary Artery Disease/complications , Coronary Vessels/diagnostic imaging , Tomography, Emission-Computed, Single-Photon/methods , Aged , Bundle-Branch Block/etiology , Bundle-Branch Block/physiopathology , Coronary Angiography , Coronary Artery Disease/diagnosis , Exercise Test , Feasibility Studies , Female , Humans , Male , Middle Aged , Prospective StudiesABSTRACT
The coronary artery calcium (CAC) score provides independent prognostic value on top of single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). We sought to determine whether the prognostic value of the CAC score in patients with normal SPECT MPI is gender specific. We studied 3,705 consecutive symptomatic patients without a history of coronary artery disease with normal SPECT MPI. All patients underwent concomitant CAC scoring, which was categorized as CAC score 0, 1 to 99, 100 to 399, 400 to 999, or ≥1,000. Major adverse cardiac events were defined as revascularization, nonfatal myocardial infarction, or all-cause mortality. The median CAC score was 9 in women (interquartile range 0 to 113) and 47 in men (interquartile range 1 to 307, p <0.001). The annual event rate was lower in women than in men (1.6% and 2.7%, respectively, p <0.001). When stratified by CAC score, annual event rates were similar (for women and men, respectively: CAC score 0, 0.6% and 0.5%, p = 0.95; CAC score 1 to 99, 0.9% and 1.2%, p = 0.45; CAC score 100 to 399, 2.7% and 3.8%, p = 0.23; CAC score 400 to 999, 3.8% and 5.3%, p = 0.34; CAC score ≥1,000, 8.4% and 8.7%, p = 0.99). The CAC score was an independent predictor of major adverse cardiac events in both genders (CAC score ≥1,000: hazard ratio for women 8.5, 95% confidence interval 4.0 to 18.1; hazard ratio for men 14.8, 95% confidence interval 5.3 to 41.1). In conclusion, risk for events is similar for both genders when stratified by CAC score, wherein a high CAC score carries a high risk for events despite normal SPECT MPI. Our findings do not reveal a gender-specific prognostic value of the CAC score.
Subject(s)
Calcinosis/epidemiology , Calcium/metabolism , Coronary Artery Disease/epidemiology , Coronary Vessels/diagnostic imaging , Myocardial Perfusion Imaging/methods , Tomography, Emission-Computed, Single-Photon/methods , Age Factors , Calcinosis/diagnosis , Coronary Artery Disease/diagnosis , Coronary Vessels/metabolism , Female , Follow-Up Studies , Humans , Incidence , Male , Middle Aged , Netherlands/epidemiology , Prognosis , Prospective Studies , Risk FactorsABSTRACT
OBJECTIVES: This study compared the prevalence of angiographic underestimation of left anterior descending artery (LAD) lesions with non-LAD lesions. BACKGROUND: Coronary angiography cannot assess the functional severity of a coronary stenosis. Previous studies suggested that lesions of the LAD are more often angiographically underestimated, but evidence is limited. MATERIALS AND METHODS: Fractional flow reserve (FFR) was performed in 335 coronary lesions (187 LAD lesions and 148 non-LAD lesions). A visually estimated diameter stenosis of at least 70% was considered functionally significant. An FFR value of up to 0.80 was considered significant. Multivariable analyses were carried out. RESULTS: Angiographically, LAD lesions as well as non-LAD lesions were considered functionally significant in 29% (P=0.94). FFR showed significant stenosis of the LAD in 52% compared with 24% in non-LAD lesions (P<0.001). Underestimation was observed in 30% of LAD lesions compared with 11% in non-LAD lesions (P<0.001). The adjusted odds ratio for underestimation in LAD lesions in comparison with non-LAD lesions was 3.48 (95% confidence interval 1.89-6.41; P<0.001). CONCLUSION: Underestimation of the functional severity of a coronary stenosis is more common in LAD lesions. FFR should be performed more often for intermediate stenosis of the LAD.
Subject(s)
Cardiac Catheterization , Coronary Angiography , Coronary Stenosis/diagnosis , Coronary Vessels/diagnostic imaging , Coronary Vessels/physiopathology , Fractional Flow Reserve, Myocardial , Aged , Coronary Stenosis/diagnostic imaging , Coronary Stenosis/physiopathology , Female , Humans , Male , Middle Aged , Netherlands , Predictive Value of Tests , Reproducibility of Results , Retrospective Studies , Severity of Illness IndexABSTRACT
BACKGROUND: The prognostic value of coronary artery calcium (CAC) scoring on top of myocardial perfusion imaging with single-photon emission computed tomography (SPECT) in patients suspected for coronary artery disease is not well established. METHODS AND RESULTS: Four thousand eight hundred ninety-seven symptomatic patients without a history of coronary artery disease referred for SPECT and CAC scoring were included. Major adverse cardiac events (MACEs) were defined as late revascularization (>90 days after scanning), nonfatal myocardial infarction, and all-cause mortality. The frequency of abnormal SPECT increased with higher CAC scores, from 12% in patients with CAC scores of 0 to 19%, 32%, 37%, and 50% among those with CAC scores 1 to 99, 100 to 399, 400 to 999, and ≥1000, respectively (P<0.001). During a median follow-up of 940 days (25th to 75th percentile, 581-1377), a total of 278 MACEs were observed. Overall incidence of MACE was 2.3% per year. A stepwise increase of MACE was present with increasing CAC scores, both in patients with normal SPECT (annual event rate CAC score 0: 0.6%; CAC score ≥1000: 5.5%) and abnormal SPECT (annual event rate CAC score 0: 0.4%; CAC score ≥1000: 7.6%). After multivariate analysis, both SPECT and CAC score were independent predictors of MACE (CAC score ≥1000: hazard ratio, 7.7; P<0.001 and large perfusion defect on SPECT: hazard ratio, 3.7; P<0.001). CONCLUSIONS: CAC score and SPECT are independent predictors of MACE in patients suspected for coronary artery disease. Our findings strongly support performing a CAC score in addition to SPECT in symptomatic patients to better define the risk of events during follow-up.