title: Very high coronary artery calcium score with normal myocardial perfusion SPECT imaging is associated with a moderate incidence of severe coronary artery disease.
abstract: OBJECTIVE
  Myocardial perfusion imaging (MPI) has limitations in the presence of balanced multivessel disease (MVD) and left main (LM) coronary artery disease, occasionally resulting in false-normal results despite the high cardiovascular risk associated with this condition. The purpose of this study was to assess the incidence of severe coronary artery disease (CAD) in the presence of a very high Agatston coronary artery calcium (CAC) score (>1,000) in stable symptomatic patients without known CAD but with normal MPI results.
  
  
  METHODS
  A total of 2,659 prospectively acquired consecutive patients were referred for MPI and evaluation of CAC score by CT. Of this patient population, 8 % (222/2,659) had ischemia without myocardial infarction (MI) on MPIand 11 % (298/2,659) had abnormal MPI (MI and/or ischemia). On presentation 1 % of the patients (26/2,659) were symptomatic, had a CAC score >1,000 and normal MPI results. The definition of normal MPI was strict and included a normal hemodynamic response without ischemic ECG changes and normal imaging, particularly absence of transient ischemic dilation. All of these 26 patients with a CAC score >1,000 and normal MPI findings underwent cardiac catheterization.
  
  
  RESULTS
  Of these 26 patients, 58 % (15/26) had severe disease (≥70 % stenosis) leading to revascularization. Of this group, 47 % (7/15) underwent percutaneous intervention, and 53 % (8/15) underwent coronary artery bypass grafting. All of these 15 patients had either MVD (14/15) or LM coronary artery disease (1/15), and represented 0.6 % (15/2,659) of all referred patients (95 % CI 0.3 - 0.9 %). The majority, 90 % (8/9), had severe CAD with typical chest pain.
  
  
  CONCLUSIONS
  A very high CAC score (>1,000) with normal MPI in a small subset of symptomatically stable patients was associated with a moderate incidence of severe CAD (95 % CI 37 - 77 %). Larger studies and/or a meta-analysis of small studies are needed to more precisely estimate the incidence of CAD in this population. This study also supports the concept that a normal MPI result in patients with severe CAD may be due to balanced MVD.
authors.affiliation: Department of Nuclear Medicine, London Health Sciences Centre, 800 Commissioners Road East, PO Box 5010, London, ON, N6A 5W9, Canada.
authors.forename: Salem A
authors.initials: SA
authors.lastname: Yuoness
authors.forename: Ahmed M
authors.initials: AM
authors.lastname: Goha
authors.forename: Jonathan G
authors.initials: JG
authors.lastname: Romsa
authors.forename: Cigdem
authors.initials: C
authors.lastname: Akincioglu
authors.forename: James C
authors.initials: JC
authors.lastname: Warrington
authors.forename: Sudip
authors.initials: S
authors.lastname: Datta
authors.forename: David R
authors.initials: DR
authors.lastname: Massel
authors.forename: Rafael
authors.initials: R
authors.lastname: Martell
authors.forename: Sanjay
authors.initials: S
authors.lastname: Gambhir
authors.forename: Jean-Luc C
authors.initials: JL
authors.lastname: Urbain
authors.forename: William C
authors.initials: WC
authors.lastname: Vezina
mesh_terms: D000328:Adult; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D015984:Causality; D015897:Comorbidity; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000453:epidemiology*; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D055414:Myocardial Perfusion Imaging / Q000706:statistics & numerical data*; D009864:Ontario / Q000453:epidemiology; D015203:Reproducibility of Results; D012307:Risk Factors; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D017678:Sex Distribution; D015899:Tomography, Emission-Computed, Single-Photon / Q000706:statistics & numerical data*; D061205:Vascular Calcification / Q000000981:diagnostic imaging* / Q000453:epidemiology*