title: Added value of hybrid myocardial perfusion SPECT and CT coronary angiography in the diagnosis of coronary artery disease.
abstract: OBJECTIVE
  Hybrid single photon emission computed tomography (SPECT)/coronary computed tomography angiography (CCTA) has only been evaluated for its diagnostic accuracy as a single test in patients suspected of significant coronary artery disease (CAD). Added value of hybrid SPECT/CCTA beyond usual clinical work-up, or use of each of these tests separately, remains unclear. We evaluated the added value of hybrid myocardial perfusion SPECT (SPECT) and CCTA, beyond pre-test likelihood and exercise stress ECG (X-ECG), in the diagnosis of CAD.
  
  
  RESULTS
  Two hundred and five patients with stable angina pectoris and intermediate-to-high pre-test likelihood were prospectively included. All patients underwent clinical history and examination, X-ECG, stress and rest SPECT, coronary calcium scoring (CCS) and CCTA. Fractional flow reserve measurement <0.80 or a lesion >50% on coronary angiography (CA) served as reference standard for significant CAD. Multiple imputation was used to correct for missing test results (17-20%). Added value of hybrid SPECT/CCTA to the basic model of pre-test likelihood plus X-ECG was quantified using logistic regression analysis. Model differences were then assessed using differences in C-index and in net reclassification improvement (NRI). The basic model had a C-index of 0.73 (95%CI 0.66-0.80). This significantly increased to 0.85 (95%CI 0.80-0.91) by addition of only SPECT, to 0.90 (95%CI 0.85-0.94) when adding only CCTA, and to 0.96 (95%CI 0.92-0.99) when adding hybrid SPECT/CCTA. The accompanying NRIs were 0.82 (95%CI 0.62-1.02), 0.86 (95%CI 0.66-1.06) and 1.57 (95%CI 1.11-1.59) respectively.
  
  
  CONCLUSIONS
  Current analysis resembles clinical routine of layered testing and shows that hybrid SPECT/CCTA imaging has a substantially higher yield than standalone SPECT or CCTA in the diagnostic workup of patients suspected of significant CAD.
authors: Department of Cardiology, Amphia Hospital, PO Box 90158, 4800 RK, Breda, The Netherlands Department of Nuclear Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands jeroenschaap01@gmail.com.
authors: Jeroen
authors: J
authors: Schaap
authors: Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands.
authors: Joris A H
authors: JA
authors: de Groot
authors: Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors: Koen
authors: K
authors: Nieman
authors: Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors: W Bob
authors: WB
authors: Meijboom
authors: Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands.
authors: S Matthijs
authors: SM
authors: Boekholdt
authors: Department of Cardiology, Amphia Hospital, PO Box 90158, 4800 RK, Breda, The Netherlands.
authors: Robert M
authors: RM
authors: Kauling
authors: Department of Cardiology, Amphia Hospital, PO Box 90158, 4800 RK, Breda, The Netherlands.
authors: Martijn C
authors: MC
authors: Post
authors: Department of Cardiology, Amphia Hospital, PO Box 90158, 4800 RK, Breda, The Netherlands.
authors: Jan A
authors: JA
authors: Van der Heyden
authors: Department of Cardio-Thoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.
authors: Thom L
authors: TL
authors: de Kroon
authors: Department of Cardiology, Amphia Hospital, PO Box 90158, 4800 RK, Breda, The Netherlands.
authors: Benno J W M
authors: BJ
authors: Rensing
authors: Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands.
authors: Karel G M
authors: KG
authors: Moons
authors: Department of Nuclear Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands Department of Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands.
authors: J Fred
authors: JF
authors: Verzijlbergen
mesh_terms: D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging*; D003430:Cross-Sectional Studies; D004562:Electrocardiography; D005080:Exercise Test; D005260:Female; D053805:Fractional Flow Reserve, Myocardial; D006801:Humans; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging; D009426:Netherlands; D011446:Prospective Studies; D019275:Radiopharmaceuticals; D012307:Risk Factors; D017256:Technetium Tc 99m Sestamibi; D015899:Tomography, Emission-Computed, Single-Photon; D014057:Tomography, X-Ray Computed
chemical_list: D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi
keywords: Added value; Coronary computed tomography angiography; Hybrid imaging; Myocardial perfusion SPECT