title: Prognostic Utility of Calcium Scoring as an Adjunct to Stress Myocardial Perfusion Scintigraphy in End-Stage Renal Disease.
abstract: Coronary artery calcium score (CACS) is a strong predictor of adverse cardiovascular events in the general population. Recent data confirm the prognostic utility of single-photon emission computed tomographic (SPECT) imaging in end-stage renal disease, but whether performing CACS as part of hybrid imaging improves risk prediction in this population is unclear. Consecutive patients (n = 284) were identified after referral to a university hospital for cardiovascular risk stratification in assessment for renal transplantation. Participants underwent technetium-99m SPECT imaging after exercise or standard adenosine stress in those unable to achieve 85% maximal heart rate; multislice CACS was also performed (Siemens Symbia T16, Siemens, Erlangen, Germany). Subjects with known coronary artery disease (n = 88) and those who underwent early revascularization (n = 2) were excluded. The primary outcome was a composite of death or first myocardial infarction. An abnormal SPECT perfusion result was seen in 22% (43 of 194) of subjects, whereas 45% (87 of 194) had at least moderate CACS (>100 U). The frequency of abnormal perfusion (summed stress score ≥4) increased with increasing CACS severity (p = 0.049). There were a total of 15 events (8 deaths, and 7 myocardial infarctions) after a median duration of 18 months (maximum follow-up 3.4 years). Univariate analysis showed diabetes mellitus (Hazard ratio [HR] 3.30, 95% CI 1.14 to 9.54; p = 0.028), abnormal perfusion on SPECT (HR 5.32, 95% CI 1.84 to 15.35; p = 0.002), and moderate-to-severe CACS (HR 3.55, 95% CI 1.11 to 11.35; p = 0.032) were all associated with the primary outcome. In a multivariate model, abnormal perfusion on SPECT (HR 4.18, 95% CI 1.43 to 12.27; p = 0.009), but not moderate-to-severe CACS (HR 2.50, 95% CI 0.76 to 8.20; p = 0.130), independently predicted all-cause death or myocardial infarction. The prognostic value of CACS was not incremental to clinical and SPECT perfusion data (global chi-square change = 2.52, p = 0.112). In conclusion, a perfusion defect on SPECT is an independent predictor of adverse outcome in potential renal transplant candidates regardless of the CACS. The use of CACS as an adjunct to SPECT perfusion data does not provide incremental prognostic utility for the prediction of mortality and nonfatal myocardial infarction in end-stage renal disease.
authors.affiliation: Birmingham Cardio-Renal Group, Department of Cardiology, Institute of Cardiovascular Sciences, Nuffield House, Queen Elizabeth Hospital Birmingham, Edgbaston. Electronic address: william.moody@nhs.net.
authors.forename: William E
authors.initials: WE
authors.lastname: Moody
authors.affiliation: Birmingham Cardio-Renal Group, Department of Cardiology, Institute of Cardiovascular Sciences, Nuffield House, Queen Elizabeth Hospital Birmingham, Edgbaston.
authors.forename: Erica L S
authors.initials: EL
authors.lastname: Lin
authors.affiliation: Birmingham Cardio-Renal Group, Department of Cardiology, Institute of Cardiovascular Sciences, Nuffield House, Queen Elizabeth Hospital Birmingham, Edgbaston.
authors.forename: Matthew
authors.initials: M
authors.lastname: Stoodley
authors.affiliation: Birmingham Cardio-Renal Group, Department of Cardiology, Institute of Cardiovascular Sciences, Nuffield House, Queen Elizabeth Hospital Birmingham, Edgbaston.
authors.forename: David
authors.initials: D
authors.lastname: McNulty
authors.affiliation: Department of Cardiac Imaging and Nuclear Cardiology, S. Mark Taper Foundation Imaging Center Los Angeles, California.
authors.forename: Louise E
authors.initials: LE
authors.lastname: Thomson
authors.affiliation: Department of Cardiac Imaging and Nuclear Cardiology, S. Mark Taper Foundation Imaging Center Los Angeles, California.
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Berman
authors.affiliation: Birmingham Cardio-Renal Group, Department of Cardiology, Institute of Cardiovascular Sciences, Nuffield House, Queen Elizabeth Hospital Birmingham, Edgbaston.
authors.forename: Nicola C
authors.initials: NC
authors.lastname: Edwards
authors.affiliation: Birmingham Cardio-Renal Group, Department of Cardiology, Institute of Cardiovascular Sciences, Nuffield House, Queen Elizabeth Hospital Birmingham, Edgbaston.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Holloway
authors.affiliation: Birmingham Cardio-Renal Group, Department of Cardiology, Institute of Cardiovascular Sciences, Nuffield House, Queen Elizabeth Hospital Birmingham, Edgbaston.
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Ferro
authors.affiliation: Birmingham Cardio-Renal Group, Department of Cardiology, Institute of Cardiovascular Sciences, Nuffield House, Queen Elizabeth Hospital Birmingham, Edgbaston.
authors.forename: Jonathan N
authors.initials: JN
authors.lastname: Townend
authors.affiliation: Birmingham Cardio-Renal Group, Department of Cardiology, Institute of Cardiovascular Sciences, Nuffield House, Queen Elizabeth Hospital Birmingham, Edgbaston.
authors.forename: Richard P
authors.initials: RP
authors.lastname: Steeds
mesh_terms: D000328:Adult; D000368:Aged; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000401:mortality; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000000981:diagnostic imaging*; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging; D009203:Myocardial Infarction / Q000453:epidemiology*; D055414:Myocardial Perfusion Imaging; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D011859:Radiography; D018570:Risk Assessment; D012720:Severity of Illness Index; D015899:Tomography, Emission-Computed, Single-Photon; D061205:Vascular Calcification / Q000175:diagnosis* / Q000401:mortality