Key result
Abnormal stress SPECT-MPI prevalence drops ~79% between 1991 and 2009.
Why the study?
The frequency of inducible myocardial ischemia during cardiac stress testing over time had not been previously examined despite declines in cardiac death and clinical events.
Observational (n=39,515)
The frequency of abnormal stress SPECT-MPI studies has progressively decreased over two decades, suggesting a need for more cost-effective initial work-up strategies for low-risk patients.
Answers are grounded in this paper and cite their sources.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“From 1991 to 2009 there has been a marked progressive decline in the frequency of both abnormal SPECT-MPI studies as well as ischemic studies with the absolute prevalence of abnormal or ischemic tests accounting for <10% of all studies performed at a single academic center. These findings suggest that clinicians may need to reconsider whom they send for SPECT-MPI (and other methods of stress testing), and new approaches are needed to evaluate these low-risk patients.”
“A tremendous contrast compared to the 8.7% that has been described by investigators from Cedars Sinai in Los Angeles. In addition, at Cedars, they observed a progressive decrease in the abnormality rate from the 41% it was in early 1990s. This decline was such that these authors suggest considerations of more cost-effective strategies for the initial work up of these low probability patients than MPI-SPECT.”
May warrant updated pretest probabilities for stress testing; leaves open whether declines reflect true risk shifts or referral patterns.
OBJECTIVES: This study sought to assess whether the frequency of inducible myocardial ischemia during stress-rest single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has changed over time. BACKGROUND: The prevalence of cardiac death and other clinical cardiac events have declined in recent decades, but heretofore no study has examined if there has been a temporal change in the frequency of inducible myocardial ischemia during cardiac stress testing. METHODS: We assessed 39,515 diagnostic patients undergoing stress-rest MPI between 1991 and 2009. Patients were assessed for change in demographics, clinical symptoms, risk factors, and frequency of abnormal and ischemic SPECT-MPI. RESULTS: There was a marked progressive decline in the prevalence of abnormal SPECT studies, from 40.9% in 1991 to 8.7% in 2009 (p < 0.001). Similarly, the prevalence of ischemic SPECT-MPI declined, from 29.6% to 5.0% (p < 0.001), as did the prevalence of severe ischemia. The decline of SPECT-MPI abnormality occurred among all age and symptom subgroups, falling to only 2.9% among recent exercising patients without typical angina. We also noted a progressive trend toward performing more pharmacological rather than exercise stress in all age and weight groups, and pharmacological stress was more likely than exercise to be associated with SPECT-MPI abnormality (odds ratio: 1.43, 95% confidence interval: 1.3 to 1.5; p < 0.001). CONCLUSIONS: Over the past 2 decades, the frequency and severity of abnormal stress SPECT-MPI studies has progressively decreased. Notably, the frequency of abnormal SPECT-MPI is now very low among exercising patients without typical angina. These findings suggest the need for developing more cost-effective strategies for the initial work-up of patients who are presently at low risk for manifesting inducible myocardial ischemia during cardiac imaging procedures.
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Rozanski et al. (2013) conducted an observational in Patients undergoing stress-rest SPECT myocardial perfusion imaging (n=39,515). Later time period (2009) vs. Earlier time period (1991) was evaluated on Prevalence of abnormal SPECT studies (p=<0.001). The prevalence of abnormal stress SPECT-MPI studies progressively declined from 40.9% in 1991 to 8.7% in 2009.
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