title: Nuclear scan strategy and outcomes in chest pain patients value of stress testing with dipyridamole or adenosine.
abstract: OBJECTIVE
  To update the prognostic value of scan strategy with pharmacological stress agent in chest pain (CP) patients presenting with normal electrocardiography (ECG) and troponin.
  
  
  METHODS
  Two consecutive nonrandomized series of patients with CP and negative first-line workup inclusive of serial ECG, serial troponin, and echocardiography underwent myocardial perfusion imaging single photon emission computed tomography (SPECT) in the emergency department. Of 170 patients enrolled, 52 patients underwent dipyridamole-SPECT and 118 adenosine-SPECT. Patients with perfusion defects underwent angiography, whereas the remaining patients were discharged and followed-up. Primary endpoint was the composite of nonfatal myocardial infarction, unstable angina, revascularization, and cardiovascular death at follow-up or the presence of coronary stenosis > 50% at angiography.
  
  
  RESULTS
  At multivariate analysis, the presence of perfusion defects or hypertension was independent predictor of the primary endpoint. Sensitivity and negative predictive value were higher in patients subjected to adenosine-SPECT (95% and 99%, respectively) versus dipyridamole-SPECT (56% and 89%; yield 70% and 11%, respectively; P < 0.03). Of note, sensitivity, negative, and positive predictive values were high in patients with hypertension (100%, 93%, and 60%, respectively) or nonischemic echocardiography alterations (100%, 100%, and 100%, respectively).
  
  
  CONCLUSIONS
  In CP patients, presenting with normal ECG and troponin, adenosine-SPECT adds incremental prognostic values to dipyridamole-SPECT. Costly scan strategy is more appropriate and avoids unnecessary angiograms in patients with hypertension or nonischemic echocardiography alterations.
authors.affiliation: Department of Critical Care Medicine and Surgery, Emergency Medicine, Careggi University Hospital, Florence, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Conti
authors.affiliation: Department of Critical Care Medicine and Surgery, Emergency Medicine, Careggi University Hospital, Florence, Italy.
authors.forename: Yuri
authors.initials: Y
authors.lastname: Mariannini
authors.affiliation: Department of Critical Care Medicine and Surgery, Emergency Medicine, Careggi University Hospital, Florence, Italy.
authors.forename: Erica
authors.initials: E
authors.lastname: Canuti
authors.affiliation: Department of Critical Care Medicine and Surgery, Emergency Medicine, Careggi University Hospital, Florence, Italy.
authors.forename: Tetyana
authors.initials: T
authors.lastname: Petrova
authors.affiliation: Department of Critical Care Medicine and Surgery, Emergency Medicine, Careggi University Hospital, Florence, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Innocenti
authors.affiliation: Department of Critical Care Medicine and Surgery, Emergency Medicine, Careggi University Hospital, Florence, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Zanobetti
authors.affiliation: Department of Nuclear Medicine, Careggi University Hospital, Florence, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Gallini
authors.affiliation: Department of Nuclear Medicine, Careggi University Hospital, Florence, Italy.
authors.forename: Egidio
authors.initials: E
authors.lastname: Costanzo
keywords: Chest pain; emergency medicine; myocardial ischemia; myocardial perfusion imaging; nuclear medicine; prognosis; risk assessment