Complete revascularization determined by myocardial perfusion imaging could improve the outcomes of patients with stable coronary artery disease, compared with incomplete revascularization and no revascularization

Utility of Noninvasive Testing Before Invasive Coronary Angiography in the Assessment for Revascularization

Objective

To examine the role of noninvasive testing (NIT) before invasive coronary angiography (ICA) by evaluating the association between a positive myocardial perfusion imaging (MPI) or computed tomography angiography (CTA) result and the decision to perform coronary revascularization.

Patients and Methods

We screened all patients who received ICA between August 1, 2015, and July 31, 2019, and identified those who received MPI or CTA within the preceding 12 months. We considered MPI to be a positive result if it found moderate or severe ischemia in a specific coronary territory and CTA to be a positive result if it identified a stenosis greater than 50% in any major coronary artery.

Results

Of the 17,181 individual procedures, 2183 were included. Positive CTA had an odds ratio (OR) of 2.68 (95% CI, 1.82-3.94) for revascularization and positive MPI an OR of 1.29 (95% CI, 1.07-1.56). Overall sensitivity for CTA in the prediction of revascularization was 80.4% (95% CI, 75.7%-84.6%), with vessel-level sensitivity ranging from 57.3% (95% CI, 47.5%-66.7%) to 71.8% (95% CI, 65.8%-77.4%). Overall sensitivity of MPI was 48.2% (95% CI, 44.7%-51.7%), with territory-specific sensitivity ranging from 33.7% (95% CI, 29.9%-37.7%) to 36.5% (95% CI, 32.6%-40.6%). Overall specificity for CTA was low, at 39.5% (32.9%-46.3%), but higher when evaluating at the vessel level, ranging from 60.3% (95% CI, 54.5%-66.0%) to 83.5% (95% CI, 79.6%-86.9%). Overall specificity for MPI was 58.1% (95% CI, 54.9%-61.3%), with territory-specific specificity ranging from 78.6% (95% CI, 76.1%-80.9%) to 78.9% (95% CI, 76.5%-81.3%).

Conclusion

In this population of patients referred for ICA, positive CTA was more closely associated with revascularization than MPI. Further studies are necessary to determine the role of NIT before ICA.

Prognostic value of the left ventricular ejection fraction reserve acquired by gated myocardial perfusion SPECT in patients with CAD and reduced stress LVEF

Purpose

Left ventricular ejection fraction (LVEF) strongly predicts cardiac events. However, conflicting findings exist regarding the prognostic value of the LVEF reserve (ΔLVEF) when measured by gated single-photon emission computed tomography myocardial perfusion imaging (SPECT G-MPI). In particular, data related to the prognostic value of ΔLVEF when measured by SPECT in patients with reduced LVEF are scarce. In this study, we aimed to evaluate the prognostic value of ΔLVEF when acquired by SPECT G-MPI in patients with coronary artery disease (CAD) and a LVEFStress < 60%.

Methods

We retrospectively recruited 260 consecutive patients diagnosed with CAD by coronary angiography (CAG) and a LVEFStress < 60%, as determined by SPECT G-MPI. These patients were followed up for 33.4 ± 7.6 months. The patients were divided into two groups (ΔLVEF > 0% and ΔLVEF ≤ 0%), and survival analyses were conducted. The primary endpoints were major adverse cardiac events (MACEs), a composite of all-cause death, nonfatal myocardial infarction, unplanned coronary revascularization, and hospitalization for unstable angina.

Results

We observed 69 MACEs (26.5%). The cumulative incidence of MACEs in patients with ΔLVEF ≤ 0% was significantly higher than in patients with ΔLVEF > 0% (P = 0.042). Multivariate Cox regression further revealed that a ΔLVEF ≤ 0% represented an independent predictor of MACEs (adjusted hazard ratio [HR]: 1.276; 95% confidence interval [CI]: (1.006, 1.618), P = 0.045). Adding a ΔLVEF ≤ 0% to traditional myocardial perfusion and function variables evaluated by MPI significantly improved the ability to predict MACEs (P = 0.044).

Conclusions

Determining ΔLVEF by SPECT G-MPI was associated with MACEs and improved risk stratification compared to prediction models based on traditional perfusion and functional parameters in CAD patients with left ventricular dysfunction, particularly those with no or mild myocardial ischemia.

Revascularization or medical therapy for stable coronary artery disease patients with different degrees of ischemia: a systematic review and meta-analysis of the role of myocardial perfusion

OBJECTIVE

This study explored the best treatment strategies for stable coronary artery disease (SCAD) patients with differing levels of ischemic severity.

METHODS

We conducted a comprehensive search of the PubMed, EMBASE, and Cochrane databases - searching for relevant articles through 4 February 2021. We selected studies comparing different treatments for patients with SCAD who had received ischemia assessments. The primary outcome was death. The secondary outcomes were major adverse cardiovascular events (MACEs) and myocardial infarction (MI).

RESULTS

A total of 11 studies, including 35,607 subjects, were selected for this meta-analysis. Results showed that, compared with medical therapy, revascularization could reduce MACE incidence (odds ratio (OR) 0.73, 95% confidence interval (CI): 0.57-0.94, p < 0.05) in SCAD patients with myocardial ischemia, but that it was not effective for patients without ischemia. For mild ischemia, the incidence of death (OR 0.78, 95% CI: 0.59-1.01, p = 0.063), MACE (OR 0.91, 95% CI: 0.48-1.70, p = 0.762), or MI (OR 1.44, 95% CI: 0.94-2.19, p = 0.093) was the same whether they were treated with revascularization or medical therapy. For moderate to severe ischemia, revascularization reduced the incidence of MACE (OR 0.59, 95% CI: 0.42-0.83, p < 0.05) and MI (OR 0.83, 95% CI: 0.71-0.98, p < 0.05), but the incidence of death (OR 0.73, 95% CI: 0.47-1.12, p = .145) was similar. For SCAD patients with severe ischemia, revascularization may confer survival benefits (OR 0.46, 95% CI: 0.21-1.00, p = 0.05).

CONCLUSION

For SCAD patients with moderate to severe ischemia, revascularization reduces the MACE and MI incidences, but does not change the incidence of death. Evaluation for myocardial ischemia is vital when selecting a therapeutic strategy.