Extent of Myocardial Ischemia on Positron Emission Tomography and Survival Benefit With Early Revascularization

Overview

Journal J Am Coll Cardiol

Specialty Cardiology & Vascular Diseases

Date 2019 Sep 28

PMID 31558246

Citations 32

Authors

Krishna K Patel

John A Spertus

Paul S Chan

Brett W Sperry

Randall C Thompson

Firas Al Badarin

Kevin F Kennedy

James A Case

Staci Courter

Ibrahim M Saeed

A Iain McGhie

Timothy M Bateman

Affiliations

Soon will be listed here.

Abstract

Background: Prior studies with single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) have shown a survival benefit with early revascularization in patients with >10% to 12.5% ischemic myocardium. The relationship among positron emission tomography (PET)-derived extent of ischemia, early revascularization, and survival is unknown.

Objectives: The purpose of this study was to evaluate the association among percent ischemia on PET MPI, revascularization, and survival.

Methods: A total of 16,029 unique consecutive patients who were undergoing Rubidium-82 rest-stress PET MPI from 2010 to 2016 were included. Patients with known cardiomyopathy and nondiagnostic perfusion results were excluded. Percent ischemic myocardium was estimated from a 17-segment model. Propensity scoring was used to account for nonrandomized referral to early revascularization (90 days of PET). A Cox model was developed, adjusting for propensity scores for early revascularization and percent ischemia, and an interaction between ischemia and early revascularization was tested.

Results: Median follow-up was 3.7 years. Overall, 1,277 (8%) patients underwent early revascularization and 2,493 (15.6%) died (738 cardiac). Nearly 37% of patients (n = 5,902) had ischemia, with 13.5% (n = 2,160) having ≥10%. In propensity-adjusted analyses, there was a significant interaction between ischemia and early revascularization (p < 0.001 for all-cause and cardiac death), such that patients with greater ischemia had improved survival with early revascularization, with a potential ischemia threshold at 5% (upper limit 95% confidence interval at 10%). There was no differential association between ischemia and early revascularization on death based on history of known coronary artery disease (interaction p = 0.72).

Conclusions: In a contemporary cohort of patients undergoing PET MPI, patients with greater ischemia had a survival benefit from early revascularization. On exploratory analyses, this threshold was lower than that previously reported for SPECT. These findings require future validation in prospective cohorts or trials.

Citing Articles

The Relationship Between Quantitative Ischemia, Early Revascularization, and Major Adverse Cardiovascular Events: A Multicenter Study.

Miller R, Bednarski B, Cui Y, Calsavara V, Patel K, Rozanski A JACC Adv. 2025; 4(1):101440.

PMID: 39759439 PMC: 11697767. DOI: 10.1016/j.jacadv.2024.101440.

Reassessing the Role of Ischemia Imaging: Insights from the ISCHEMIA Trial.

Nayfeh Jr M, Al-Mallah M Nucl Med Mol Imaging. 2024; 58(7):392-399.

PMID: 39635627 PMC: 11612102. DOI: 10.1007/s13139-023-00834-1.

Value of Ischemia and Coronary Anatomy in Prognosis and Guiding Revascularization Among Patients With Stable Ischemic Heart Disease.

Patel K, Peri-Okonny P, Giorgetti A, Shaw L, Gimelli A Circ Cardiovasc Imaging. 2024; 17(9):e016587.

PMID: 39247957 PMC: 11439561. DOI: 10.1161/CIRCIMAGING.123.016587.

[Should i treat a high risk chronic coronary syndrome invasively from the beginning? Yes, in most cases].

Ortiz Zegarra C, Custodio Sanchez P, Rojas De La Cuba P, Mori Pinedo G, Coloma Araniya R, Gonzales Alvarez B Arch Peru Cardiol Cir Cardiovasc. 2024; 1(4):222-228.

PMID: 38268509 PMC: 10804820. DOI: 10.47487/apcyccv.v1i4.86.

Chest Pain Evaluation: Diagnostic Testing.

Chow B, Galiwango P, Poulin A, Raggi P, Small G, Juneau D CJC Open. 2024; 5(12):891-903.

PMID: 38204849 PMC: 10774086. DOI: 10.1016/j.cjco.2023.09.001.

References

Shaw L, Weintraub W, Maron D, Hartigan P, Hachamovitch R, Min J . Baseline stress myocardial perfusion imaging results and outcomes in patients with stable ischemic heart disease randomized to optimal medical therapy with or without percutaneous coronary intervention. Am Heart J. 2012; 164(2):243-50. DOI: 10.1016/j.ahj.2012.05.018. View

Dorbala S, Di Carli M, Beanlands R, Merhige M, Williams B, Veledar E . Prognostic value of stress myocardial perfusion positron emission tomography: results from a multicenter observational registry. J Am Coll Cardiol. 2012; 61(2):176-84. PMC: 3549438. DOI: 10.1016/j.jacc.2012.09.043. View

Dorbala S, Hachamovitch R, Curillova Z, Thomas D, Vangala D, Kwong R . Incremental prognostic value of gated Rb-82 positron emission tomography myocardial perfusion imaging over clinical variables and rest LVEF. JACC Cardiovasc Imaging. 2009; 2(7):846-54. PMC: 3954510. DOI: 10.1016/j.jcmg.2009.04.009. View

Fihn S, Gardin J, Abrams J, Berra K, Blankenship J, Dallas A . 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on.... J Am Coll Cardiol. 2012; 60(24):2564-603. DOI: 10.1016/j.jacc.2012.07.012. View

Shaw L, Cerqueira M, Brooks M, Althouse A, Sansing V, Beller G . Impact of left ventricular function and the extent of ischemia and scar by stress myocardial perfusion imaging on prognosis and therapeutic risk reduction in diabetic patients with coronary artery disease: results from the Bypass Angioplasty.... J Nucl Cardiol. 2012; 19(4):658-69. PMC: 4135719. DOI: 10.1007/s12350-012-9548-3. View

Dilsizian V, Bacharach S, Beanlands R, Bergmann S, Delbeke D, Dorbala S . ASNC imaging guidelines/SNMMI procedure standard for positron emission tomography (PET) nuclear cardiology procedures. J Nucl Cardiol. 2016; 23(5):1187-1226. DOI: 10.1007/s12350-016-0522-3. View

Tonino P, De Bruyne B, Pijls N, Siebert U, Ikeno F, van t Veer M . Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009; 360(3):213-24. DOI: 10.1056/NEJMoa0807611. View

Boden W, ORourke R, Teo K, Hartigan P, Maron D, Kostuk W . Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007; 356(15):1503-16. DOI: 10.1056/NEJMoa070829. View

Sathiakumar N, Delzell E, Abdalla O . Using the National Death Index to obtain underlying cause of death codes. J Occup Environ Med. 1998; 40(9):808-13. DOI: 10.1097/00043764-199809000-00010. View

10.

Hachamovitch R . Does ischemia burden in stable coronary artery disease effectively identify revascularization candidates? Ischemia burden in stable coronary artery disease effectively identifies revascularization candidates. Circ Cardiovasc Imaging. 2015; 8(5):discussion p 8. DOI: 10.1161/CIRCIMAGING.113.000352. View

11.

Hachamovitch R, Rozanski A, Shaw L, Stone G, Thomson L, Friedman J . Impact of ischaemia and scar on the therapeutic benefit derived from myocardial revascularization vs. medical therapy among patients undergoing stress-rest myocardial perfusion scintigraphy. Eur Heart J. 2011; 32(8):1012-24. DOI: 10.1093/eurheartj/ehq500. View

12.

Frye R, August P, Brooks M, Hardison R, Kelsey S, MacGregor J . A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009; 360(24):2503-15. PMC: 2863990. DOI: 10.1056/NEJMoa0805796. View

13.

Doody M, Hayes H, Bilgrad R . Comparability of national death index plus and standard procedures for determining causes of death in epidemiologic studies. Ann Epidemiol. 2001; 11(1):46-50. DOI: 10.1016/s1047-2797(00)00177-0. View

14.

Hachamovitch R, Hayes S, Friedman J, Cohen I, Berman D . Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation. 2003; 107(23):2900-7. DOI: 10.1161/01.CIR.0000072790.23090.41. View

15.

Stergiopoulos K, Boden W, Hartigan P, Mobius-Winkler S, Hambrecht R, Hueb W . Percutaneous coronary intervention outcomes in patients with stable obstructive coronary artery disease and myocardial ischemia: a collaborative meta-analysis of contemporary randomized clinical trials. JAMA Intern Med. 2013; 174(2):232-40. DOI: 10.1001/jamainternmed.2013.12855. View

16.

Shaw L, Berman D, Maron D, Mancini G, Hayes S, Hartigan P . Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation. 2008; 117(10):1283-91. DOI: 10.1161/CIRCULATIONAHA.107.743963. View

17.

Goodney P, Woloshin S, Schwartz L . Fractional flow reserve-guided PCI in stable coronary disease. N Engl J Med. 2012; 367(24):2355. DOI: 10.1056/NEJMc1212344. View

18.

Dorbala S, Di Carli M . Cardiac PET perfusion: prognosis, risk stratification, and clinical management. Semin Nucl Med. 2014; 44(5):344-57. PMC: 4176813. DOI: 10.1053/j.semnuclmed.2014.05.003. View

19.

Bateman T, Dilsizian V, Beanlands R, DePuey E, Heller G, Wolinsky D . American Society of Nuclear Cardiology and Society of Nuclear Medicine and Molecular Imaging Joint Position Statement on the Clinical Indications for Myocardial Perfusion PET. J Nucl Med. 2016; 57(10):1654-1656. DOI: 10.2967/jnumed.116.180448. View

20.

De Bruyne B, Pijls N, Kalesan B, Barbato E, Tonino P, Piroth Z . Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med. 2012; 367(11):991-1001. DOI: 10.1056/NEJMoa1205361. View