Circulation, Vol 89, 615-622, Copyright © 1994 by American Heart Association
HG Stratmann, GA Williams, MD Wittry, BR Chaitman and DD Miller
BACKGROUND: This study was designed to evaluate the prognostic value of
symptom-limited maximal exercise treadmill testing with tomographic
technetium-99m sestamibi (MIBI) myocardial imaging in patients referred for
evaluation of stable angina. Exercise stress thallium-201 myocardial
imaging provides prognostic information in coronary artery disease subsets
including patients with stable chest pain. The prognostic value of exercise
technetium-99m MIBI myocardial tomography has not been established. METHODS
AND RESULTS: Of 548 consecutive patients with stable angina pectoris who
underwent maximal exercise treadmill stress testing in combination with a
same-day "rest-stress" tomographic technetium-99m MIBI myocardial imaging
protocol, 521 patients were followed for 13 +/- 5 months to determine the
univariate and multivariate variables associated with cardiac events and to
define their cardiac event-free survival. Ten patients were lost to
follow-up (98% complete), and 17 who had coronary revascularization within
6 months of testing were excluded. Major cardiac events occurred in 24
patients (9%)--nonfatal myocardial infarction in 11 and cardiac death in
13. Univariate Cox survival analysis demonstrated significant relative risk
(RR) and 95% confidence intervals (CI) for exercise ST segment depression
(RR = 2.3; 95% CI, 1.0 to 5.3), an abnormal MIBI scan (RR = 13.8; 95% CI,
1.9 to 102.3), and a reversible MIBI perfusion defect (RR = 3.2; 95% CI,
1.4 to 7.5). Multivariate models demonstrated that both exercise MIBI
perfusion abnormalities (RR = 11.9; 95% CI, 1.6 to 89.4) and reversible
MIBI perfusion defects (RR = 2.9; 95% CI, 1.2 to 7.0) had independent
predictive value. During 1 year of follow-up, cardiac events occurred in
only 0.5% of patients with normal MIBI scans compared with 7% of those with
abnormal MIBI scans (P < .001). One- year, cardiac event-free survival
was 92% in patients with reversible MIBI perfusion defects (P < .01
versus normal), 96% in patients with fixed defects (P < .01), and 93% in
patients with combined reversible and fixed MIBI myocardial perfusion
abnormalities (P < .02). CONCLUSIONS: As with exercise thallium-201
myocardial imaging, exercise stress technetium-99m MIBI myocardial
tomography provides significant independent information concerning the
subsequent risk of serious cardiac events (death, myocardial infarction) in
patients with stable angina pectoris. The identification of MIBI perfusion
abnormalities, in particular, the presence of reversible MIBI defects, was
associated with reduced 1-year, event-free survival. The recognized imaging
and radiotracer biokinetic differences between thallium-201 and MIBI do not
appear to modulate the prognostic value associated with scintigraphic
evidence of ischemic myocardial jeopardy in the stable angina population.
ARTICLES
Exercise technetium-99m sestamibi tomography for cardiac risk stratification of patients with stable chest pain
Division of Cardiology, St Louis Veterans Administration Medical Center, Mo.
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