title: Value of acute rest sestamibi perfusion imaging for evaluation of patients admitted to the emergency department with chest pain.
abstract: OBJECTIVE
  This study sought to determine the ability of early perfusion imaging using technetium-99m sestamibi to predict adverse cardiac outcomes in patients who present to the emergency department with possible cardiac ischemia and nondiagnostic electrocardiograms (ECGs).
  
  
  BACKGROUND
  Evaluation of patients presenting to the emergency department with possible acute coronary syndromes and nondiagnostic ECGs is problematic. Accurate risk stratification is necessary to prevent serious adverse outcomes. Initial results suggest that early perfusion imaging using technetium-99m sestamibi enables reliable risk stratification.
  
  
  METHODS
  Patients presenting to the emergency department with a low to moderate probability of acute coronary syndromes underwent rapid sestamibi injection with gated single-photon emission computed tomographic imaging. Studies showing perfusion defects with associated wall motion abnormalities were considered positive.
  
  
  RESULTS
  A total of 532 consecutive patients underwent serial myocardial marker analysis and rest perfusion imaging. Of these patients, perfusion imaging was positive in 171 (32%). Positive perfusion imaging was the only multivariate predictor of myocardial infarction (MI) (p < 0.0001, odds ratio [OR] 33, 95% confidence interval [CI] 7.7 to 141) and was the most important independent predictor of MI or revascularization (p < 0.0001, OR 14, 95% CI 7.3 to 25), followed by diabetes (p < 0.01, OR 2.8, 95% CI 1.5 to 5.1), typical angina (p = 0.01, OR 2.1, 95% CI 1.2 to 3.7) and male gender (p = 0.03, OR 1.9, 95% CI 1.1 to 3.5). The sensitivity of positive perfusion imaging for MI was 93% (95% CI 77% to 98%), and for MI or revascularization it was 81% (95% CI 71% to 88%), with negative predictive values of 99% (95% CI 98% to 100%) and 95% (95% CI 92% to 97%), respectively.
  
  
  CONCLUSIONS
  Positive rest perfusion imaging accurately identified patients at high risk for adverse cardiac outcomes, whereas negative perfusion imaging identified a low risk patient group. Early perfusion imaging allows for rapid and accurate risk stratification of emergency department patients with possible cardiac ischemia and nondiagnostic ECGs.
authors.affiliation: Medical College of Virginia/Virginia Commonwealth University, Richmond 23298-0128, USA. mkontos@gems.vcu.edu
authors.forename: M C
authors.initials: MC
authors.lastname: Kontos
authors.forename: R L
authors.initials: RL
authors.lastname: Jesse
authors.forename: K L
authors.initials: KL
authors.lastname: Schmidt
authors.forename: J P
authors.initials: JP
authors.lastname: Ornato
authors.forename: J L
authors.initials: JL
authors.lastname: Tatum
mesh_terms: D000368:Aged; D016022:Case-Control Studies; D002637:Chest Pain / Q000209:etiology*; D004562:Electrocardiography / Q000592:standards; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017202:Myocardial Ischemia / Q000150:complications* / Q000000981:diagnostic imaging*; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D015203:Reproducibility of Results; D012307:Risk Factors; D012680:Sensitivity and Specificity; D017256:Technetium Tc 99m Sestamibi
chemical_list: D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi