Author + information
- Received February 24, 2020
- Revision received March 10, 2020
- Accepted March 13, 2020
- Published online June 17, 2020.
- Soroush Rouhani, BSca,
- Ali Al Shahrani, MD, MSca,b,
- Alomgir Hossain, PhDc,
- Yeung Yam, BSca,
- R. Glenn Wells, PhDa,
- Robert A. deKemp, PhDa,
- Rob S. Beanlands, MDa,d,
- Terrence D. Ruddy, MDa,d,
- Marcelo F. Di Carli, MDe,f,
- Michael E. Merhige, MDg,
- Brent A. Williams, PhDh,
- Emir Veledar, PhDi,
- Daniel S. Berman, MDj,
- Sharmila Dorbala, MD, MPHe,f and
- Benjamin J.W. Chow, MDa,d,∗ ()
- aDivision of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- bDepartment of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- cCardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- dDepartment of Radiology, University of Ottawa, Ottawa, Ontario, Canada
- eDivision of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- fDivision of Nuclear Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- gNiagara Falls Memorial Medical Center, Niagara Falls, New York
- hGeisinger Medical Center, Danville, Pennsylvania
- iBaptist Health South Florida, Miami, Florida
- jCedars-Sinai Medical Center, Los Angeles, California
- ↵∗Address for correspondence:
Dr. Benjamin Chow, University of Ottawa Heart Institute, Division of Cardiology, 40 Ruskin Street, Room 1220A, Ottawa, Ontario K1Y 4W7, Canada.
Objectives This study sought to develop a clinical model that identifies a lower-risk population for coronary artery disease that could benefit from stress-first myocardial perfusion imaging (MPI) protocols and that can be used at point of care to risk stratify patients.
Background There is an increasing interest in stress-first and stress-only imaging to reduce patient radiation exposure and improve patient workflow and experience.
Methods A secondary analysis was conducted on a single-center cohort of patients undergoing single-photon emission computed tomography (SPECT) and positron emission tomography (PET) studies. Normal MPI was defined by the absence of perfusion abnormalities and other ischemic markers and the presence of normal left ventricular wall motion and left ventricular ejection fraction. A model was derived using a cohort of 18,389 consecutive patients who underwent SPECT and was validated in a separate cohort of patients who underwent SPECT (n = 5,819), 1 internal cohort of patients who underwent PET (n=4,631), and 1 external PET cohort (n = 7,028).
Results Final models were made for men and women and consisted of 9 variables including age, smoking, hypertension, diabetes, dyslipidemia, typical angina, prior percutaneous coronary intervention, prior coronary artery bypass graft, and prior myocardial infarction. Patients with a score ≤1 were stratified as low risk. The model was robust with areas under the curve of 0.684 (95% confidence interval [CI]: 0.674 to 0.694) and 0.681 (95% CI: 0.666 to 0.696) in the derivation cohort, 0.745 (95% CI: 0.728 to 0.762) and 0.701 (95% CI: 0.673 to 0.728) in the SPECT validation cohort, 0.672 (95% CI: 0.649 to 0.696) and 0.686 (95% CI: 0.663 to 0.710) in the internal PET validation cohort, and 0.756 (95% CI: 0.740 to 0.772) and 0.737 (95% CI: 0.716 to 0.757) in the external PET validation cohort in men and women, respectively. Men and women who scored ≤1 had negative likelihood ratios of 0.48 and 0.52, respectively.
Conclusions A novel model, based on easily obtained clinical variables, is proposed to identify patients with low probability of having abnormal MPI results. This point-of-care tool may be used to identify a population that might qualify for stress-first MPI protocols.
- cardiac death
- computed tomography
- coronary angiography
- major adverse cardiac events
- myocardial infarction
Dr. Wells has received research grants from GE Healthcare and Advance Accelerator Applications. Dr. deKemp has received royalties from rubidium positron emission tomography technologies licensed to Jubilant DraxImage and from positron emission tomography analysis software licensed to INVIA Medical Solutions; and has received research support and honoraria from Jubilant DraxImage and GE Healthcare, Inc. Dr. Beanlands has received support from the Heart and Stroke Foundation of Ontario for service as a career investigator, the University of Ottawa for a Tier 1 Research Chair, and the University of Ottawa Heart Institute for the Vered Chair in Cardiology; and has received research support and honoraria from Lantheus Medical Imaging, Jubilant DraxImage, and GE Healthcare. Dr. Ruddy has received research grant support from GE Healthcare and Advanced Accelerator Applications. Dr. Di Carli has received research grants from Spectrum Dynamics and Gilead Sciences; has institutional research contracts with Xylocor and Alnylam; and has received consulting honoraria from Bayer and Janssen. Dr. Merhige has served as the Associate Medical Director of Cardionavix; and has served as a consultant for Bracco Diagnostics. Dr. Williams has received research support from Biosense Webster, Boehringer Ingelheim, Roche, Gilead, Janssen, Novo Nordisk, and Merck. Dr. Berman has received software royalties from Cedars-Sinai Medical Centre. Dr. Dorbala has received research support from Pfizer and GE Healthcare; has served as a consultant for Pfizer and GE Healthcare. Dr. Chow has held the Saul and Edna Goldfarb Chair in Cardiac Imaging Research; has received research support from TD Bank, CV Diagnostix, Ausculsciences, and Siemens; has received educational support from TeraRecon; and has equity interest in General Electric. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Cardiovascular Imaging author instructions page.
- Received February 24, 2020.
- Revision received March 10, 2020.
- Accepted March 13, 2020.
- 2020 American College of Cardiology Foundation
This article requires a subscription or purchase to view the full text. If you are a subscriber or member, click Login or the Subscribe link (top menu above) to access this article.