Key result
Among patients with appropriate indications for SPECT-MPI, an abnormal scan strongly predicted death compared to a normal scan (9.2% vs 2.6%; HR 3.1; P=0.004).
Why the study?
The impact of appropriate use criteria on the prognostic value of SPECT-MPI for ischemic heart disease risk assessment was unknown.
Does adherence to appropriate use criteria impact the prognostic value of SPECT-MPI for predicting major adverse cardiac events in outpatients?
Cohort (n=1,511)
Does adherence to appropriate use criteria impact the prognostic value of SPECT-MPI for predicting major adverse cardiac events in outpatients?
SPECT-MPI provides significant prognostic value for major adverse cardiac events when performed for appropriate indications, but lacks risk stratification effectiveness when ordered inappropriately.
SPECT-MPI prognostic value appears confined to appropriate indications; supports AUC but leaves open whether enforcement improves outcomes.
BACKGROUND: Appropriate use criteria (AUC) have been developed to aid in the optimal use of single-photon emission computed tomography (SPECT)-myocardial perfusion imaging (MPI), a technique that is a mainstay of risk assessment for ischemic heart disease. The impact of appropriate use on the prognostic value of SPECT-MPI is unknown. METHODS AND RESULTS: A prospective cohort study of 1511 consecutive patients undergoing outpatient, community-based SPECT-MPI was conducted. Subjects were stratified on the basis of the 2009 AUC for SPECT-MPI into an appropriate or uncertain appropriateness group and an inappropriate group. Patients were prospectively followed up for 27±10 months for major adverse cardiac events of death, death or myocardial infarction, and cardiac death or myocardial infarction. In the entire cohort, the 167 subjects (11%) with an abnormal scan experienced significantly higher rates of major adverse cardiac events and coronary revascularization than those with normal MPI. Among the 823 subjects (54.5%) whose MPIs were classified as appropriate (779, 51.6%) or uncertain (44, 2.9%), an abnormal scan predicted a multifold increase in the rates of death (9.2% versus 2.6%; hazard ratio, 3.1; P=0.004), death or myocardial infarction (11.8% versus 3.3%; hazard ratio, 3.3; P=0.001), cardiac death or myocardial infarction (6.7% versus 1.7%; hazard ratio, 3.7; P=0.006), and revascularization (24.7% versus 2.7%; hazard ratio, 11.4; P<0.001). Among the 688 subjects (45.5%) with MPI classified as inappropriate, an abnormal MPI failed to predict major adverse cardiac events, although it was associated with a high revascularization rate. Furthermore, appropriate MPI use provided incremental prognostic value beyond myocardial perfusion and ejection fraction data. CONCLUSIONS: When performed for appropriate indications, SPECT-MPI continues to demonstrate high prognostic value. However, inappropriate use lacks effectiveness for risk stratification, further emphasizing the need for optimal patient selection for cardiac testing.
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Doukky et al. (2013) conducted a cohort in Ischemic heart disease risk assessment (n=1,511). Abnormal SPECT-MPI scan (in patients with appropriate indications) vs. Normal SPECT-MPI scan was evaluated on Death (HR 3.1, p=0.004). Among patients with appropriate indications for SPECT-MPI, an abnormal scan strongly predicted death compared to a normal scan (9.2% vs 2.6%; HR 3.1; P=0.004).
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