Coronary angiographic rates after stress single-photon emission computed tomographic scintigraphy

doi:10.1016/S1071-3581(05)80058-3

Journal of Nuclear Cardiology

Volume 2, Issue 3, May–June 1995, Pages 217-223

https://doi.org/10.1016/S1071-3581(05)80058-3 Get rights and content

Abstract

Background.

There is speculation that coronary angiography may be overused for the assessment of coronary artery disease. Because of its proved ability to differentiate high- and low-risk subsets of patients with coronary artery disease, myocardial perfusion scintigraphy should be an effective strategy in patient selection for angiography. This retrospective clinical study analyzed the relation between scintigraphic findings and subsequent angiography.

Methods and Results.

Coronary angiographic rates were determined by following up on all stress single-photon emission computed tomographic (SPECT) myocardial perfusion studies performed in a cardiology practice nuclear laboratory during a 26-month interval. All patients were followed up for at least 3 months; mean follow-up was 8.9 months. Subsequent angiography was determined from catheterization laboratory logs, medical records, and telephone contact. Scintigraphic studies were graded according to presence or absence of reversible perfusion defects, affected coronary territories, and lung uptake of ²⁰¹Tl. Scans were categorized high risk if more than two of the following three criteria were met: reversibility of left anterior descending or multivessel distributions or abnormal lung uptake of thallium. Of 4162 studies, 60% had reversible perfusion defects. Of such studies, 32% were followed up by angiography versus 3.5% without reversible defects. Among studies with reversible defects, the subsequent angiography rate was 60% for those showing high-risk reversibility, compared with 9% for all other studies demonstrating reversibility. Multivariate logistic regression identified high-risk reversibility (odds ratio 20.96) and any reversibility (odds ratio 8.22) as the strongest predictors of angiography. Other correlates of lesser statistical significance were angina and absence of prior infarction or coronary bypass.

Conclusions.

In this large retrospective study, the results of SPECT scintigraphy overpowered all other clinical and treadmill characteristics in determining the likelihood of subsequent coronary angiography. Only rarely were patients categorized as relatively low risk by scintigraphy referred for angiography. As such, SPECT scintigraphy as used in a private practice, self-referral environment appears to be effective in stratifying potential candidates for coronary angiography.

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Noninvasive cardiac imaging plays a pivotal role in the initial diagnostic evaluation of patients with suspected coronary artery disease (CAD). In patients with known or established CAD, they provide very powerful prognostic information and are useful for risk stratification, optimization of therapy, and long-term follow-up of these patients. A large portfolio of noninvasive imaging techniques, based on different imaging modalities is available for use in current clinical practice. Whereas, all of these modalities are based on the common principles of cardiac anatomy, pathophysiology, coronary vascular biology and hemodynamics, they differ from each other from imaging perspectives, which imparts a degree of uniqueness to each of these modalities. Therefore each modality has its strengths and weaknesses. The differences amongst different imaging modalities should be used to exploit their strengths so as to provide best possible care to the patients. Exercise electrocardiography, nuclear myocardial perfusion imaging, stress echocardiography, cardiac CT (computed tomography) imaging, and stress MR (magnetic resonance) imaging of heart are the noninvasive tests for diagnosing, risk-stratification and follow up of patients with known or suspected CAD. This chapter provides a brief review of these techniques and the recent advances in the respective fields.
Comparative definitions for moderate-severe ischemia in stress nuclear, echocardiography, and magnetic resonance imaging
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The relationship between perceived discrimination and coronary artery obstruction
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Chronic stressors such as perceived discrimination might underlie race disparities in cardiovascular disease. This study focused on the relationship between perceived discrimination and risk of severe coronary obstruction while also accounting for multiple psychosocial variables and clinical factors.
Data from 793 (629 white and 164 black) male veterans with positive nuclear imaging studies were analyzed. Participants were categorized as being at low/moderate or high risk for severe coronary obstruction based on results of their nuclear imaging studies. Hierarchical logistic regression models were tested separately for blacks and whites. The first step of the models included clinical factors. The second step included the psychosocial variables of optimism, religiosity, negative affect, and social support. The final step included perceived discrimination.
Perceived discrimination was positively related to risk of severe obstruction among blacks but not among whites after controlling for clinical and psychosocial variables. Similar results were found in patients who underwent coronary angiography (n = 311).
Perceived discrimination was associated with risk of severe coronary obstruction among black male veterans and could be an important target for future interventions.
Patient management after noninvasive cardiac imaging: Results from SPARC (Study of myocardial perfusion and coronary anatomy imaging roles in coronary artery disease)
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Citation Excerpt :
Thus, we cannot say with certainty whether the SPARC cohort and the findings reported in the current paper are unique or characteristic of widespread practice. Nonetheless, previous single-site studies report catheterization referral rates similar to those that we observed in the SPARC (5,10–13). Although randomized clinical trials enhance the validity of comparisons among imaging modalities, a prospective registry design enhanced our ability to observe patterns of care in daily clinical practice.
This study examined short-term cardiac catheterization rates and medication changes after cardiac imaging.
Noninvasive cardiac imaging is widely used in coronary artery disease, but its effects on subsequent patient management are unclear.
We assessed the 90-day post-test rates of catheterization and medication changes in a prospective registry of 1,703 patients without a documented history of coronary artery disease and an intermediate to high likelihood of coronary artery disease undergoing cardiac single-photon emission computed tomography, positron emission tomography, or 64-slice coronary computed tomography angiography.
Baseline medication use was relatively infrequent. At 90 days, 9.6% of patients underwent catheterization. The rates of catheterization and medication changes increased in proportion to test abnormality findings. Among patients with the most severe test result findings, 38% to 61% were not referred to catheterization, 20% to 30% were not receiving aspirin, 35% to 44% were not receiving a beta-blocker, and 20% to 25% were not receiving a lipid-lowering agent at 90 days after the index test. Risk-adjusted analyses revealed that compared with stress single-photon emission computed tomography or positron emission tomography, changes in aspirin and lipid-lowering agent use was greater after computed tomography angiography, as was the 90-day catheterization referral rate in the setting of normal/nonobstructive and mildly abnormal test results.
Overall, noninvasive testing had only a modest impact on clinical management of patients referred for clinical testing. Although post-imaging use of cardiac catheterization and medical therapy increased in proportion to the degree of abnormality findings, the frequency of catheterization and medication change suggests possible undertreatment of higher risk patients. Patients were more likely to undergo cardiac catheterization after computed tomography angiography than after single-photon emission computed tomography or positron emission tomography after normal/nonobstructive and mildly abnormal study findings. (Study of Perfusion and Anatomy's Role in Coronary Artery [CAD] [SPARC]; NCT00321399)
Is cardiac catheterization necessary before initial management of patients with stable ischemic heart disease? Results from a Web-based survey of cardiologists
2011, American Heart Journal
It is unknown whether preconceived beliefs regarding the need for cardiac catheterization and revascularization in patients with stable ischemic heart disease (SIHD) would preclude a study randomizing patients with significant ischemia to a conservative strategy. Given the widespread practice of performing revascularization in patients with SIHD, we assessed the feasibility of conducting a randomized trial comparing initial invasive and conservative strategies in patients with SIHD and moderate or severe ischemia.
An online survey to cardiologists queried their willingness to enroll a sample patient with frequent stable angina, >10% myocardial ischemia, and normal ejection fraction into a randomized trial with a 50% chance of being conservatively managed without cardiac catheterization.
Among 499 respondents, 57% (95% CI 53%-62%) were willing to enroll the patient. Among 207 cardiologists unwilling to enroll, 55% (95% CI 48%-61%) would be willing if they knew the patient did not have very high-risk features on stress imaging, yielding a total of 80% (95% CI 76%-83%) of cardiologists willing to enroll. No differences were observed among different types of cardiologists (interventional, invasive/noninterventional, and noninvasive). Seventy-one percent (95% CI 67%-75%) were more likely to try initial medical therapy after the publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial results.
Most surveyed cardiologists were willing to enroll SIHD patients with at least moderate ischemia into a trial with an initial noninvasive strategy arm. These findings support the feasibility of planning a large-scale trial to test the role of cardiac catheterization and revascularization in the initial management of SIHD patients with moderate or severe ischemia.
Prognostic implications of stress echocardiography and impact on patient outcomes: An effective gatekeeper for coronary angiography and revascularization
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Stress echocardiography is an established technique for diagnosis, risk stratification, and prognosis in patients with known or suspected coronary artery disease. The ability of stress echocardiography to predict clinical outcomes, such as coronary angiography and revascularization, has not been reported previously. The purpose of this study was to evaluate the clinical outcomes of coronary angiography, revascularization, and cardiac events in patients undergoing stress echocardiography.
A total of 3121 patients (mean age, 60 ± 13 years; 48% men) undergoing stress echocardiography (41% treadmill, 59% dobutamine) were assessed. Follow-up (mean, 2.8 ± 1.1 years) for subsequent coronary angiography, revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]), and confirmed hard events (nonfatal myocardial infarction or cardiac death) was obtained.
Stress echocardiographic results were normal (peak wall motion score index [pWMSI], 1.0) in 66% and abnormal (pWMSI > 1.0) in 34% of patients. The pWMSI effectively risk-stratified patients into low-risk (pWMSI, 1.0; 0.8% per year), intermediate-risk (pWMSI, 1.1-1.7; 2.6% per year), and high-risk (pWMSI >1.7; 5.5% per year) groups for future cardiac events (P < .0001). Early coronary angiography (30 days following stress echocardiography) was performed in only 35 patients (1.7%) with normal stress echocardiographic results and 267 patients (25.5%) with abnormal stress echocardiographic results (P < .0001). Late coronary revascularization (2 years following stress echocardiography) occurred in 80 patients (PCI, 2.8%; CABG, 1.1%) with pWMSI values of 1.0, 123 patients (PCI, 13.5%; CABG, 7.3%) with pWMSI values of 1.1 to 1.7, and 102 patients (PCI, 12.7%; CABG, 9.6%) with pWMSI values > 1.7. Multivariate logistic regression analysis identified pWMSI as a predictor of coronary angiography (relative risk, 2.04; 95% confidence interval, 1.67-2.5), revascularization (relative risk, 1.91; 95% confidence interval, 1.68-2.17), and cardiac events (relative risk, 2.45; 95% confidence interval, 2.09-2.88) (all P values < .0001). Patients with markedly abnormal stress echocardiographic results (pWMSI > 1.7) had a significantly higher cardiac event rate in those who did not undergo coronary revascularization (9.6% per year vs 2.9% per year, P < .05).
Stress echocardiography is an effective gatekeeper for coronary angiography and revascularization. Stress echocardiographic results influence clinical decision making in higher risk patients with significantly increased referral to coronary angiography and revascularization. Patients with markedly abnormal stress echocardiographic results (pWMSI > 1.7) were most likely to benefit from coronary revascularization.

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^*

Supported in part by research grants from Mallinckrodt Medical. Inc.

Presented at the Forty-first Annual Meeting of the Society of Nuclear Medicine, Orlando, Fla., June 1994.

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Original articleCoronary angiographic rates after stress single-photon emission computed tomographic scintigraphy*

Abstract

Background.

Methods and Results.

Conclusions.

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Cardiol Clin

J Am Coll Cardiol

J Am Coll Cardiol

Results of a second-opinion trial among patients recommended for coronary angiography

JAMA

The appropriateness of use of coronary angiography in New York state

JAMA

Nuclear cardiology

N Engl J Med

Prognostic value of thallium-201 myocardial perfusion imaging: a diagnostic tool comes of age

Circulation

Prognostic importance of thallium uptake by the lungs during exercise in coronary artery disease

N Engl J Med

Original article
Coronary angiographic rates after stress single-photon emission computed tomographic scintigraphy*