The clinical use of nuclear exercise tests

In the mid-1970s, after decades of clinical use, the utility of electrocardiographic exercise testing for the evaluation of patients with suspected ischemic heart disease was critically examined and questioned. Concurrent with this critique, two sophisticated, more expensive and powerful "nuclear" exercise tests were introduced sequentially for clinical use: myocardial perfusion imaging with thallium-201 and radionuclide ventriculography with technetium 99m. The published indications for the two tests are similar, and both have been shown to offer advantages over ECG stress testing in selected populations. However, few data are available regarding the comparative utility of thallium versus ventriculographic imaging. As part of a prospective study to assess the efficacy of cardiovascular nuclear medicine studies, we undertook the present analysis to assess the clinical evolution of these tests and to elucidate factors responsible for clinicians' choice for the often competing examinations. The study examined 213 consecutive patient referrals for thallium scintigraphy and 183 referrals for ventriculography, ranging from patients with no symptoms or highly non-specific chest pain syndromes (21% of referrals) to patients with proven coronary disease (28% of the referrals). Twenty-one percent of patients were referred to confirm the clinical impression that the patient did not have coronary disease, 40% to confirm its presence, and 37% to determine its severity. Analyses were undertaken to determine the factors that dictated a preference for thallium scintigraphy rather than ventriculography; only the physician's intent in testing and level of training were significant predictors for a particular nuclear test.