Author + information
- Received July 5, 2016
- Revision received October 21, 2016
- Accepted October 27, 2016
- Published online November 6, 2017.
- Teemu Maaniitty, MDa,
- Iida Stenström, BMa,
- Jeroen J. Bax, MD, PhDb,
- Valtteri Uusitalo, MD, PhDa,
- Heikki Ukkonen, MD, PhDc,
- Sami Kajander, MD, PhDa,
- Maija Mäki, MD, PhDa,d,
- Antti Saraste, MD, PhDa,c and
- Juhani Knuuti, MD, PhDa,d,∗ ()
- aTurku PET Centre, University of Turku, Turku, Finland
- bDepartment of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
- cHeart Center, Turku University Hospital, Turku, Finland
- dDepartment of Clinical Physiology, Nuclear Medicine and PET, Turku University Hospital, Turku, Finland
- ↵∗Address for correspondence:
Dr. Juhani Knuuti, Turku PET Centre, Turku University Hospital, Kiinamyllynkatu 4-8, 20520 Turku, Finland.
Objectives The purpose of this study was to evaluate the prognostic value of sequential hybrid imaging strategy in which positron emission tomography (PET) perfusion imaging is performed selectively in patients with suspected obstructive coronary artery disease (CAD) on coronary computed tomography angiography (CTA).
Background Coronary CTA is an accurate diagnostic test for excluding obstructive CAD. However, the positive predictive value is suboptimal.
Methods We investigated 864 consecutive symptomatic patients with intermediate probability of CAD who adhered to the sequential imaging approach. PET myocardial perfusion imaging using 15O-labeled water during adenosine stress was performed when suspected obstructive stenosis was present on coronary CTA. The major adverse events (AEs) including all-cause mortality, myocardial infarction (MI), and unstable angina pectoris (UAP) were recorded.
Results During a median follow-up of 3.6 years, 16 deaths, 10 MIs, and 5 UAPs occurred. Obstructive CAD was excluded by coronary CTA in 462 (53%) patients who had significantly lower annual AE rate than did patients with suspected obstructive stenosis on coronary CTA (0.4% vs. 1.5%; p = 0.003). The latter underwent PET study, on which 195 (49%) had normal and 207 had abnormal perfusion. The annual rate of AEs was 5 times higher in those with abnormal perfusion than with normal perfusion (2.5% vs. 0.5%; p = 0.004). Patients with normal perfusion had AE rate comparable to patients without obstructive CAD on coronary CTA (p = 0.77).
Conclusions In patients with suspected CAD obstructive disease can be excluded in 53% of patients by coronary CTA, and these patients have good outcome. About one-half (49%) of the remaining patients have normal perfusion and event rate comparable to patients without obstructive CAD on coronary CTA while patients with ischemia have clearly worse outcome. Sequential approach utilizing anatomical imaging by coronary CTA followed by selective functional perfusion imaging is a feasible strategy to diagnose and risk-stratify patients with suspected CAD.
- computed tomography angiography
- coronary artery disease
- hybrid imaging
- myocardial perfusion
- positron emission tomography
The work was financially supported by the Academy of Finland Centre of Excellence on Cardiovascular and Metabolic Diseases, the Finnish Foundation for Cardiovascular Research, and the Turku University Hospital. Dr. Bax’s institution (Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands) has received unrestricted research grants from Medtronic, Biotronik, Boston Scientific, and Edwards Lifesciences. Dr. Saraste has received grant support from the Academy of Finland and the Finnish Foundation for Cardiovascular Research, during the conduct of the study; and personal fees from GE Healthcare, Novartis, Abbott, Actelion, Pfizer, and Lilly, outside the submitted work. Dr. Knuuti has received grant support from Cardirad; and personal fees from Lantheus Inc., outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 5, 2016.
- Revision received October 21, 2016.
- Accepted October 27, 2016.
- 2017 American College of Cardiology Foundation