Myocardial perfusion assessment in patients with medium probability of coronary artery disease and no prior myocardial infarction: comparison of myocardial contrast echocardiography with 99mTc single-photon emission computed tomography

doi:10.1016/j.ahj.2003.12.030

American Heart Journal

Volume 147, Issue 6, June 2004, Pages 1100-1105

Presented in part at the 51st Annual Scientific Session of the American College of Cardiology, March 17–20, 2002, Atlanta, Ga.

https://doi.org/10.1016/j.ahj.2003.12.030 Get rights and content

Abstract

Background

No previous studies have compared myocardial contrast echocardiography (MCE) and single-photon emission computerized tomography (SPECT) for the detection of coronary artery disease (CAD) in patients with a medium likelihood of CAD. This study was developed to test the hypothesis that MCE is superior to SPECT for the detection of CAD.

Methods

Fifty-five patients with a medium probability of CAD and no previous myocardial infarction were recruited. Results of MCE and SPECT were compared to quantitative coronary arteriography, where CAD was defined as >50% stenosis. Each patient was examined for the anterior and posterior circulations.

Results

On a coronary circulation basis (n = 110), the sensitivity of MCE was significantly greater than that of SPECT for the detection of CAD (86% vs 43%, P < .0001). However, the specificities were similar (88% and 93%, P = .52). Both techniques were marginally more accurate in the anterior compared to the posterior circulation (88% vs 76%, P = .07 for MCE and 79% vs 63%, P = .19, for SPECT). On a patient basis (n = 55), MCE had a higher sensitivity than SPECT for the detection of CAD (83% vs 49%, P < .05). Although specificity tended to be higher for SPECT than MCE (92% vs 58%), it was not significant (P = .33). When CAD was defined as >40% coronary stenosis, the specificity of MCE increased to 83% without any change in sensitivity.

Conclusion

In this preliminary study, MCE was found to be superior to SPECT during dipyridamole stress for the diagnosis of CAD in patients with a medium pretest probability of CAD. Larger studies are required to confirm these findings.

Section snippets

Methods

Patient population and protocol

Adults with chest pain but without a history of prior myocardial infarction or resting regional dysfunction on echocardiography who were scheduled for diagnostic coronary angiography were recruited for this study from 3 centers in Europe. Exclusion criteria included previous coronary artery bypass surgery, valvular heart disease, cardiomyopathy, atrial fibrillation, and contraindications for dipyridamole administration. Patients were subjected to an analysis based

Results

A total of 55 patients with complete coronary angiographic data were recruited. The clinical characteristics of these patients and results of quantitative coronary angiography are listed in Table I. The pretest probability for this group of having CAD was 64% ± 26% (95% CI 57% –71%). For the assessment of perfusion, 110 coronary territories (equal number of anterior and posterior) were analyzed. Of these, 50 had CAD and 60 did not. Twelve patients had no CAD, while only 11 had multivessel CAD.

Discussion

This is the first study to examine the efficacy of both MCE and SPECT during dipyridamole stress in a patient population with medium probability of CAD who had no prior myocardial infarction or regional dysfunction on rest echocardiography. This is also the first study comparing both methods to quantitative coronary angiography. We found MCE to have a higher sensitivity than SPECT for the diagnosis of CAD on a patient as well as vascular territory basis. Although on a patient basis the

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We performed a meta-analysis to compare the diagnostic performance of conventional SPECT (C-SPECT) and cadmium-zinc-telluride (CZT)-SPECT systems in detecting angiographically proven coronary artery disease (CAD).
Studies published between January 2000 and February 2018 were identified by database search. We included studies assessing C-SPECT or CZT-SPECT as a diagnostic test to evaluate patients for the presence of CAD, defined as at least 50% diameter stenosis on invasive coronary angiography. A study was eligible regardless of whether patients were referred for suspected or known CAD.
We identified 40 eligible articles (25 C-SPECT and 15 CZT-SPECT studies) including 7334 patients (4997 in C-SPECT and 2337 in CZT-SPECT studies). The pooled sensitivity and specificity were 85% and 66% for C-SPECT and 89% and 69% for CZT-SPECT imaging studies. The area under the curve was slightly higher for CZT-SPECT (0.89) compared to C-SPECT (0.83); accordingly, the summary diagnostic OR was 17 for CZT-SPECT and 11 for C-SPECT. The accuracy of the two tests slightly differs between C-SPECT and CZT-SPECT (chi-square 11.28, P < .05). At meta-regression analysis, no significant association between both sensitivity and specificity and demographical and clinical variables considered was found for C-SPECT and CZT-SPECT studies.
C-SPECT and CZT-SPECT have good diagnostic performance in detecting angiographic proven CAD, with a slightly higher accuracy for CZT-SPECT. This result supports the use of the novel gamma cameras in clinical routine practices also considering the improvements in acquisition time and radiation exposure reduction.
Long-Term Association of Dipyridamole Stress Myocardial Contrast Echocardiography versus Single-Photon Emission Computed Tomography with Clinical Outcomes in Patients with Known or Suspected Coronary Artery Disease
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Citation Excerpt :
Several previous studies have indicated that stress MCE is more sensitive than SPECT for the detection of CAD.4,13,14,20 Three multicenter studies in which the results of MCE, SPECT, and coronary angiography were read blindly in core laboratories confirmed the superior sensitivity of MCE compared with SPECT for the detection of flow-limiting coronary stenosis.4,13,14 The lower specificity of MCE compared with SPECT for the detection of CAD may be explained by the higher prevalence of myocardial microvascular dysfunction in the patient population in which cardiovascular risk factors are highly prevalent.
Single-photon emission computed tomography (SPECT) is a well-established method to evaluate patients with coronary artery disease. Myocardial contrast echocardiography (MCE) is an imaging technique that allows the assessment of myocardial perfusion in real time. Previous research has shown that vasodilator MCE is superior to SPECT for the prediction of hard events. The aim of this study was to investigate the long-term association of SPECT and MCE with clinical outcomes in patients with known or suspected coronary artery disease.
Accordingly, 258 patients who underwent MCE and SPECT as part of multicenter studies performed prospectively were followed up for hard events (all-cause mortality and nonfatal myocardial infarction). The mean age was 63.4 ± 5.5 years, 186 (72.1%) were men, and 32 (12.4%) had left ventricular systolic dysfunction. We calculated the ratio of the number of abnormal segments (at rest and/or stress) to the total number of segments expressed as MCE and SPECT indices.
Over a mean follow-up period of 80.4 ± 6.1 months, 46 patients had hard events. MCE and SPECT indices were associated with all-cause mortality on univariate analysis (P = .008 and P = .035, respectively) but only MCE index was independently associated with hard events (hazard ratio, 4.24; 95% CI, 1.27–14.15; P = .019), beyond clinical data and left ventricular function, and independently associated with hard cardiac events (hazard ratio, 4.78; 95% CI, 1.06–21.59; P = .042).
MCE but not SPECT showed a long-term association with outcome. These results thus favor the routine use of MCE in the long-term assessment of patients with known or suspected coronary artery disease.
Clinical Applications of Ultrasonic Enhancing Agents in Echocardiography: 2018 American Society of Echocardiography Guidelines Update
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Reproducible Computer-Assisted Quantification of Myocardial Perfusion with Contrast-Enhanced Ultrasound
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Myocardial perfusion can be quantified by myocardial contrast echocardiography (MCE) and is used for the diagnosis of coronary artery disease (CAD). However, existing MCE quantification software is highly operator dependent and has poor reproducibility and ease of usage. The aim of this study was to develop robust and easy-to-use software that can perform MCE quantification accurately, reproducibly and rapidly. The developed software has the following features: (i) semi-automatic segmentation of the myocardium; (ii) automatic rejection of MCE data with poor image quality; (iii) automatic computation of perfusion parameters such as myocardial blood flow (MBF). MCE sequences of 18 individuals (9 normal, 9 with CAD) undergoing vasodilator stress with dipyridamole were analysed quantitatively using the software. When evaluated against coronary angiography, the software achieved a sensitivity of 71% and a specificity of 91% for hyperemic MBF. With the automatic rejection algorithm, the sensitivity and specificity further improved to 77% and 94%, respectively. For MBF reproducibility, the percentage agreement is 85% (κ = 0.65) for inter-observer variability and 88% (κ = 0.72) for intra-observer variability. The intra-class correlation coefficients are 0.94 (inter-observer) and 0.96 (intra-observer). The time taken to analyse one MCE sequence using the software is about 3 min on a PC. The software has exhibited good diagnostic performance and reproducibility for CAD detection and is rapid and user-friendly.
Prognostic value of qualitative and quantitative vasodilator stress myocardial perfusion echocardiography in patients with known or suspected coronary artery disease
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Quantification of myocardial blood flow reserve in patients with coronary artery disease using real-time myocardial perfusion echocardiography (RTMPE) has been demonstrated to further improve accuracy over the analysis of wall motion and qualitative analysis of myocardial perfusion. The aim of this study was to determine the prognostic value of qualitative and quantitative analyses obtained by RTMPE in patients with known or suspected coronary artery disease.
From March 2003 to December 2008, 227 consecutive patients with normal left ventricular function who underwent RTMPE were prospectively studied. Replenishment velocity reserve (β) and myocardial blood flow reserve were derived from RTMPE. Primary outcomes were cardiac death, myocardial infarction and unstable angina with need for urgent coronary revascularization, and secondary outcomes were coronary bypass graft surgery or angioplasty.
During a median follow-up period of 32 months (range, 5 days to 6.9 years), 19 major events (two deaths, six myocardial infarctions, and 11 episodes of unstable angina) and 46 total events occurred. Wall motion (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.4–5.6; P = .003) and qualitative myocardial perfusion analysis (HR, 4.3; 95% CI, 2.1–8.5; P < .001) were predictors of total events but not primary events. Abnormal myocardial blood flow reserve and abnormal β reserve were predictors of total events (HR, 8.1; 95% CI, 3–21; P < .001; and HR, 16.5; 95% CI, 5.5–49; P < .001) and primary events (HR, 3.8; 95% CI, 1–15; P = .048; and HR, 8.7; 95% CI, 1.8–40; P = .005). On multivariate analysis, only abnormal β reserve was an independent predictor of total (HR, 10.6; 95% CI, 2.5–43; P = .001) and primary (HR, 10.5; 95% CI, 1.5–6; P = .015) events. Abnormal β reserve added incremental value in predicting primary events (χ² = 2.0–13.2; P = .014).
Quantitative adenosine stress RTMPE added independent and additional prognostic information over wall motion and qualitative myocardial perfusion analysis in patients with known or suspected coronary artery disease and normal left ventricular function.

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^☆: Supported by a grant from Amersham Health, Amersham, UK, and in part by grants (RO1-HL48890 and RO1-HL66034) from the National Institutes of Health, Bethesda, Md.

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Clinical investigations: imaging and diagnostic testingMyocardial perfusion assessment in patients with medium probability of coronary artery disease and no prior myocardial infarction: comparison of myocardial contrast echocardiography with 99mTc single-photon emission computed tomography☆

Abstract

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Nucl Cardiol

Clinical epidemiology: the essentials

Mechanism of reversible 99mTc-sestamibi perfusion defects during pharmacologically induced coronary vasodilatation

Am J Physiol

Quantification of myocardial blood flow with ultrasound-induced destruction of microbubbles administered as a continuous infusion

Circulation

Noninvasive prediction of ultimate infarct size at the time of acute coronary occlusion based on the extent and magnitude of collateral-derived myocardial blood flow

Circulation

Clinical investigations: imaging and diagnostic testing
Myocardial perfusion assessment in patients with medium probability of coronary artery disease and no prior myocardial infarction: comparison of myocardial contrast echocardiography with ^99mTc single-photon emission computed tomography☆

Mechanism of reversible ^99mTc-sestamibi perfusion defects during pharmacologically induced coronary vasodilatation