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Identifying Coronary Artery Calcification on Non-gated Computed Tomography Scans
Published on: August 28, 2018
Improved near-term coronary artery disease risk classification with gated stress myocardial perfusion SPECT
Leslee J Shaw1, Peter W F Wilson, Rory Hachamovitch
1Emory University School of Medicine, Atlanta, Georgia, USA. leslee.shaw@emory.edu
Insights
Myocardial perfusion single-photon emission computed tomography (MPS) effectively estimates coronary artery disease (CAD) outcomes. Analytical methods, particularly those assessing ischemia, significantly improve risk reclassification for better patient prognosis.
Area of Science:
- Cardiology
- Nuclear Medicine
- Medical Imaging
Background:
- Stress myocardial perfusion scintigraphy (MPS) markers of regional ischemia are established prognostic indicators.
- Existing evidence lacks comparative analyses of analytical methods to quantify the added value of stress MPS in risk classification.
Purpose of the Study:
- To compare analytical approaches for estimating the incremental value of myocardial perfusion scintigraphy (MPS) variables in predicting coronary artery disease (CAD) outcomes.
- To define a clinically meaningful method for assessing the improved risk classification provided by stress MPS.
Main Methods:
- Prospective enrollment of 4,575 patients in the Myoview Prognosis Registry.
- Utilization of multivariable Cox proportional hazards models to assess CAD death or myocardial infarction (MI).
- Calculation of risk reclassification metrics, including net reclassification improvement (NRI).
Main Results:
- Stress MPS ischemia, rest, and post-stress left ventricular ejection fraction (LVEF) were significant predictors of CAD death or MI (p < 0.0001).
- MPS ischemia contributed 34% to the model chi-square.
- Adding MPS ischemia to models incorporating pre-test likelihood and Duke Treadmill Score (DTS) resulted in a substantial net reclassification improvement (NRI = 0.358).
Conclusions:
- Stress-induced ischemia is an independent predictor of near-term CAD outcomes.
- Risk reclassification methods offer a valuable approach for quantifying the benefits of stress MPS.
- These analytical strategies can serve as quality metrics for evaluating improved health outcomes and comparing imaging modalities.
Objectives:
We compared analytical approaches to estimate the added value of myocardial perfusion single-photon emission computed tomography (MPS) variables in estimating coronary artery disease (CAD) outcomes.
Background:
Stress MPS markers of regional ischemia are strong estimators of prognosis. Evidence published to date has not compared analytical methods to establish the added value of stress MPS and to define a clinically meaningful approach to detect improve classification of risk.
Methods:
A total of 4,575 patients were consecutively and prospectively enrolled in the Myoview Prognosis Registry. Multivariable Cox proportional hazards model were employed to estimate CAD death or myocardial infarction (MI). Risk reclassification methods were also calculated.
Results:
In risk-adjusted models (including age, sex, presenting symptoms, stress type, CAD history, and risk factors), stress MPS ischemia, rest and post-stress left ventricular ejection fraction (LVEF) (all p < 0.0001) were all significant estimators of CAD death or MI. In this multivariable model, 34% of the model chi-square was contributed by MPS ischemia. In receiver-operating characteristic curve analysis, the area under the curve increased from 0.61 to 0.66 when rest and post-stress LVEF were combined with pre-test CAD likelihood (p < 0.0001), increasing to 0.69 for MPS ischemia (p < 0.0001). The net reclassification improvement (NRI) by adding the Duke Treadmill Score (DTS) to a model including pre-test CAD likelihood was 0.112. The cost per NRI was $57 for the exercise test as compared with an office visit for risk stratification purposes. Further, the NRI by adding MPS ischemia to a model with the DTS and pre-test CAD likelihood was 0.358. The cost per NRI was $615 for the stress MPS as compared with an exercise test.
Conclusions:
Stress-induced ischemia is independently predictive of near-term CAD outcomes. Analytical approaches that establish the reclassification of events provide a unique approach and may serve as a quality imaging metric for estimation of improved health outcomes for stress MPS as well as for comparison to other imaging modalities.
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