title: Incremental diagnostic accuracy of hybrid SPECT/CT coronary angiography in a population with an intermediate to high pre-test likelihood of coronary artery disease.
abstract: OBJECTIVE
  Hybrid myocardial perfusion imaging with single photon emission computed tomography (SPECT) and CT coronary angiography (CCTA) has the potential to play a major role in patients with non-conclusive SPECT or CCTA results. We evaluated the performance of hybrid SPECT/CCTA vs. standalone SPECT and CCTA for the diagnosis of significant coronary artery disease (CAD) in patients with an intermediate to high pre-test likelihood of CAD.
  
  
  RESULTS
  In total, 98 patients (mean age 62.5 ± 10.1 years, 68.4% male) with stable anginal complaints and a median pre-test likelihood of 87% (range 22-95%) were prospectively included in this study. Hybrid SPECT/CCTA was performed prior to conventional coronary angiography (CA) including fractional flow reserve (FFR) measurements. Hybrid analysis was performed by combined interpretation of SPECT and CCTA images. The sensitivity, specificity, positive (PPV), and negative (NPV) predictive values were calculated for standalone SPECT, CCTA, and hybrid SPECT/CCTA on per patient level, using an FFR <0.80 as a reference for significant CAD. Significant CAD was demonstrated in 56 patients (57.9%). Non-conclusive SPECT or CCTA results were found in 32 (32.7%) patients. SPECT had a sensitivity of 93%, specificity 79%, PPV 85%, and NPV 89%. CCTA had a sensitivity of 98%, specificity 62%, PPV 77%, and NPV 96%. Hybrid analysis of SPECT and CCTA improved the overall performance: sensitivity, specificity, PPV, and NPV for the presence of significant CAD to 96, 95, 96, and 95%, respectively.
  
  
  CONCLUSIONS
  In > 40% of the patients with a high pre-test likelihood no significant CAD was demonstrated, emphasizing the value of accurate pre-treatment cardiovascular imaging. Hybrid SPECT/CCTA was able to accurately diagnose and exclude significant CAD surpassing standalone myocardial SPECT and CCTA, vs. a reference standard of FFR measurements.
authors.affiliation: Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands. jeroenschaap01@gmail.com
authors.forename: Jeroen
authors.initials: J
authors.lastname: Schaap
authors.forename: Robert M
authors.initials: RM
authors.lastname: Kauling
authors.forename: S Matthijs
authors.initials: SM
authors.lastname: Boekholdt
authors.forename: Koen
authors.initials: K
authors.lastname: Nieman
authors.forename: W Bob
authors.initials: WB
authors.lastname: Meijboom
authors.forename: Martijn C
authors.initials: MC
authors.lastname: Post
authors.forename: Jan A
authors.initials: JA
authors.lastname: Van der Heyden
authors.forename: Thom L
authors.initials: TL
authors.lastname: de Kroon
authors.forename: H Wouter
authors.initials: HW
authors.lastname: van Es
authors.forename: Benno J
authors.initials: BJ
authors.lastname: Rensing
authors.forename: J Fred
authors.initials: JF
authors.lastname: Verzijlbergen
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D016001:Confidence Intervals; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000000981:diagnostic imaging; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D016013:Likelihood Functions; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging; D055414:Myocardial Perfusion Imaging / Q000379:methods; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods*; D014057:Tomography, X-Ray Computed / Q000379:methods*
keywords: Coronary artery disease; Coronary computed tomography angiography; Hybrid imaging; Single photon emission computed tomography