Coronary revascularization guidance by myocardial perfusion imaging- retrospective real-life data from single center study

Background Myocardial perfusion imaging (MPI) is widely used for risk stratification and guidance of coronary revascularization in patients with suspected or known coronary artery disease. However, real-world concordance between MPI findings and invasive coronary intervention remains incompletely defined. Objective To evaluate the real-life concordance between positive myocardial perfusion imaging and subsequent coronary revascularization, and to assess the clinical implications of concordant versus discordant findings. Methods We conducted a retrospective single-center study including consecutive patients referred for invasive coronary angiography (CAG) following a positive MPI between January 2020 and October 2024. Patients with prior coronary artery bypass grafting were excluded. The primary endpoint was the degree of concordance between ischemic territories identified on MPI and the coronary vessels treated during angiography (full, partial, none, or “matching plus”). Secondary endpoints included repeat angiography within one year and characterization of recurrent procedures. Descriptive and comparative statistical analyses were performed. Results A total of 523 patients were included (mean age 69±11 years; 74% male). Of these, 313 (60%) underwent percutaneous coronary intervention (PCI), 35 (6.7%) underwent CABG, and 175 (33.3%) had no obstructive lesion requiring intervention. Among PCI patients, full concordance between MPI findings and the treated vessel was observed in 61.3%, partial concordance in 6.8%, no concordance in 14.4%, and “matching plus” in 17.6%. Notably, approximately one-third of patients with positive MPI had no target lesion identified at angiography, indicating a substantial false-positive rate. Lower double product (DP) values were observed in discordant and no-intervention groups, suggesting suboptimal stress intensity during MPI. One-year follow-up demonstrated low rates of missed revascularization and clinically driven repeat angiography across all groups. Conclusions In this real-world cohort, concordance between positive myocardial perfusion imaging and subsequent coronary revascularization was moderate, with a substantial proportion of false-positive results. Suboptimal stress intensity, reflected by low double product values, may partially explain diagnostic discordance. These findings highlight the importance of careful interpretation of MPI parameters—including stress adequacy, ischemia burden, and clinical/ECG correlation—before proceeding to invasive coronary angiography.