title: Impact of appropriate use on the prognostic value of single-photon emission computed tomography myocardial perfusion imaging.
abstract: BACKGROUND
  Appropriate use criteria (AUC) have been developed to aid in the optimal use of single-photon emission computed tomography (SPECT)-myocardial perfusion imaging (MPI), a technique that is a mainstay of risk assessment for ischemic heart disease. The impact of appropriate use on the prognostic value of SPECT-MPI is unknown.
  
  
  RESULTS
  A prospective cohort study of 1511 consecutive patients undergoing outpatient, community-based SPECT-MPI was conducted. Subjects were stratified on the basis of the 2009 AUC for SPECT-MPI into an appropriate or uncertain appropriateness group and an inappropriate group. Patients were prospectively followed up for 27±10 months for major adverse cardiac events of death, death or myocardial infarction, and cardiac death or myocardial infarction. In the entire cohort, the 167 subjects (11%) with an abnormal scan experienced significantly higher rates of major adverse cardiac events and coronary revascularization than those with normal MPI. Among the 823 subjects (54.5%) whose MPIs were classified as appropriate (779, 51.6%) or uncertain (44, 2.9%), an abnormal scan predicted a multifold increase in the rates of death (9.2% versus 2.6%; hazard ratio, 3.1; P=0.004), death or myocardial infarction (11.8% versus 3.3%; hazard ratio, 3.3; P=0.001), cardiac death or myocardial infarction (6.7% versus 1.7%; hazard ratio, 3.7; P=0.006), and revascularization (24.7% versus 2.7%; hazard ratio, 11.4; P<0.001). Among the 688 subjects (45.5%) with MPI classified as inappropriate, an abnormal MPI failed to predict major adverse cardiac events, although it was associated with a high revascularization rate. Furthermore, appropriate MPI use provided incremental prognostic value beyond myocardial perfusion and ejection fraction data.
  
  
  CONCLUSIONS
  When performed for appropriate indications, SPECT-MPI continues to demonstrate high prognostic value. However, inappropriate use lacks effectiveness for risk stratification, further emphasizing the need for optimal patient selection for cardiac testing.
authors.affiliation: Division of Cardiology, Rush University Medical Center, Chicago, IL (R.D., K.H., N.F., M.O.R.); Division of Adult Cardiology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL (R.D., Y.G.); Department of Medicine, Iowa Methodist Medical Center, Des Moines (G.B.); Division of Hospitalist Medicine, Rockford Memorial Hospital, Rockford, IL (V.S.D.); Division of Cardiology, Mount Sinai Hospital, Chicago, IL (E.G.-S.); and Cardiovascular Division, University of Miami, Miller School of Medicine, Miami, FL (R.C.H.).
authors.forename: Rami
authors.initials: R
authors.lastname: Doukky
authors.forename: Kathleen
authors.initials: K
authors.lastname: Hayes
authors.forename: Nathan
authors.initials: N
authors.lastname: Frogge
authors.forename: Gautam
authors.initials: G
authors.lastname: Balakrishnan
authors.forename: Venkata Satish
authors.initials: VS
authors.lastname: Dontaraju
authors.forename: Maria O
authors.initials: MO
authors.lastname: Rangel
authors.forename: Yasmeen
authors.initials: Y
authors.lastname: Golzar
authors.forename: Enrique
authors.initials: E
authors.lastname: Garcia-Sayan
authors.forename: Robert C
authors.initials: RC
authors.lastname: Hendel
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D003643:Death; D005080:Exercise Test / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000000981:diagnostic imaging* / Q000401:mortality* / Q000628:therapy; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D010043:Outcome and Process Assessment, Health Care; D010824:Physicians' Offices; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods*
keywords: myocardial perfusion imaging; outcome assessment (health care); prognosis; tomography, emission-computed, single-photon