title: Incremental value of prognostic testing in patients with known or suspected ischemic heart disease: a basis for optimal utilization of exercise technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography.
abstract: OBJECTIVE
  This study assessed the incremental prognostic implications of normal and equivocal exercise technetium-99m (Tc-99m) sestamibi single-photon emission computed tomography (SPECT) and sought to determine its incremental prognostic value, impact on patient management and cost implications.
  
  
  BACKGROUND
  The prognostic implications of Tc-99m sestamibi SPECT are not well defined, and risk stratification using this test has not been explored.
  
  
  METHODS
  We studied 1,702 patients referred for exercise Tc-99m sestamibi SPECT who were followed up for a mean (+/- SD) of 20 +/- 5 months. Patients with previous percutaneous transluminal coronary angioplasty or coronary artery bypass surgery were excluded. The SPECT studies were assessed using semiquantitative visual analysis. Cardiac death and myocardial infarction were considered "hard" events, and coronary angioplasty and bypass surgery > 60 days after testing were considered "soft" events.
  
  
  RESULTS
  Of the 1,702 patients studied, 1,131 had normal or equivocal scan results. A total of 10 events occurred in this group (1 cardiac death and 1 myocardial infarction [0.2% hard events]; 4 coronary angioplasty and 4 bypass surgery procedures [0.7% soft events]). The rates of hard events and referral to catheterization after SPECT were similarly low in patients with a low (< 0.15), intermediate (0.15 to 0.85) and high (> 0.85) post-exercise treadmill test (ETT) likelihood of coronary artery disease. With respect to scan type, patients with normal, probably normal or equivocal scan results had similarly low hard event rates. In the 571 patients with abnormal scan results, there were 43 hard events (7.5%) and 42 soft events (7.4%) (p < 0.001 vs. 1,131 patients with normal scan results for both). When the complete spectrum of scan responses was considered, SPECT provided incremental prognostic value in all patient subgroups analyzed. However, the nuclear scan was cost-effective only in patients with interpretable exercise ECG responses and an intermediate to high post-ETT likelihood of coronary artery disease and in those with uninterpretable exercise ECG responses and an intermediate to high pre-ETT likelihood of coronary artery disease.
  
  
  CONCLUSIONS
  Normal or equivocal exercise Tc-99m sestamibi study results are associated with a benign prognosis, even in patients with a high likelihood of coronary artery disease. Although incremental prognostic value is added by nuclear testing in all patient subgroups, a testing strategy incorporating nuclear testing proved to be cost-effective only in the groups with an intermediate to high likelihood of coronary artery disease before scanning.
authors.affiliation: Department of Imaging (Division of Nuclear Medicine), Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.
authors.forename: D S
authors.initials: DS
authors.lastname: Berman
authors.forename: R
authors.initials: R
authors.lastname: Hachamovitch
authors.forename: H
authors.initials: H
authors.lastname: Kiat
authors.forename: I
authors.initials: I
authors.lastname: Cohen
authors.forename: J A
authors.initials: JA
authors.lastname: Cabico
authors.forename: F P
authors.initials: FP
authors.lastname: Wang
authors.forename: J D
authors.initials: JD
authors.lastname: Friedman
authors.forename: G
authors.initials: G
authors.lastname: Germano
authors.forename: K
authors.initials: K
authors.lastname: Van Train
authors.forename: G A
authors.initials: GA
authors.lastname: Diamond
mesh_terms: D000368:Aged; D003365:Costs and Cost Analysis; D005080:Exercise Test / Q000191:economics / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006321:Heart / Q000000981:diagnostic imaging; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000000981:diagnostic imaging* / Q000191:economics / Q000453:epidemiology; D011379:Prognosis; D012307:Risk Factors; D017256:Technetium Tc 99m Sestamibi / Q000191:economics; D013794:Thallium Radioisotopes; D015899:Tomography, Emission-Computed, Single-Photon / Q000191:economics / Q000295:instrumentation / Q000379:methods* / Q000706:statistics & numerical data
chemical_list: D013794:Thallium Radioisotopes; D017256:Technetium Tc 99m Sestamibi