Original ArticleThe additive prognostic value of perfusion and functional data assessed by quantitative gated SPECT in women
Introduction
Coronary artery disease (CAD) is the major cause of morbidity and mortality in the western countries. Increased mortality and reinfarction have been noted in women after myocardial infarction compared to men.1, 2, 3 The large proportion of atypical symptoms, higher incidence of associated disease (e.g., hypertension, diabetes mellitus), and the higher age at presentation may account for the worse outcome.3,4 Appropriate non-invasive diagnostic testing is important in the early diagnosis and the risk stratification of women with suspected CAD. Exercise ECG has a lower diagnostic and prognostic accuracy in women. It is influenced by multiple factors, i.e., exercise capacity and hormonal status.4,5 The increased age at presentation is often associated with lower exercise capacity and an inability to attain maximal stress.4,5 Myocardial perfusion imaging provides incremental prognostic information.4
The addition of regional left ventricular (LV) function parameters by gated single photon emission computed tomography (SPECT) improved the diagnostic accuracy and prognostic value of perfusion imaging, whereby LV function parameters have incremental prognostic value over perfusion data alone.6, 7, 8, 9, 10 Previous studies set normal functional data limits. However, some problems still have to be solved. First, most data on prognostic value of the parameters assessed by gated SPECT have been obtained in a mixed gender population and may not be applicable to women. Women often have smaller LV volumes. It has been shown that gender related differences in normal limits exist.11,12 However, a multicenter phantom study showed a wide range of results in different standard end-systolic and end-diastolic volume combinations. Moreover, the LV ejection fraction (LVEF) was overestimated and both the end-systolic volume (ESV) and end-diastolic volume (EDV) were underestimated. Especially, this is the case for small volumes. Cutoff values for LV functional parameters should be validated in each center.13
Second, most data on prognostic value of perfusion analyses by gated SPECT is obtained by a 20-segment model. However, recent guidelines on cardiac imaging suggest the use of a 17-segment model. Berman et al14 showed that a 17-segment model provides a more accurate prognostic categorization of individual patients with small abnormalities of the distal short axil and apical portions of the LV.
At present, few data exist on the prognostic value of gated SPECT in women. In this category of patients, little data are available on the value of LV function parameters to potentially improve risk stratification. Accordingly, the aim of the study was to assess the incremental prognostic value of technetium-99m tetrofosmin (Tc99m) gated SPECT imaging in women.
Section snippets
Study Population
We studied 453 consecutive women (median age 62 years [53 to 70 years, 25th to 75th percentiles]) who underwent rest/stress technetium-99m tetrofosmin myocardial perfusion gated SPECT imaging between October 1, 1999, and January 1, 2000, at the Leiden University Medical Center. Patients were followed up until the fixed census date May 1, 2000.
Stress Myocardial Perfusion Protocol
All patients were instructed to refrain from caffeine-containing products for 24 hours before the test. Beta-blocking agents, nitrates, calcium
Patient Characteristics
Four-hundred and fifty-three patients were followed. The patient baseline characteristics are shown in Table 1. Median age was 62 (53 to 70 years [25th to 75th percentiles]). One-hundred and fourteen (26%) patients had known CAD. Of those patients 67 (15%) had sustained a MI, 67 (15%) experienced one or more revascularization procedures, and none had a history of cardiac arrest.
Perfusion and Function
Perfusion and function data are shown in Table 2. Two-hundred and thirty-five patients (48%) had an abnormal perfusion
Discussion
Our results show that relatively young female patients with hard events had significantly larger LV volumes, increased defect sizes, and lower LVEFs than those without hard events. Also, patients with any cardiac event during follow-up had significantly larger LV volumes, increased defect sizes, and lower LVEFs than those without any cardiac events. Moreover, patients with any cardiac event had significantly larger ischemic defects. For hard events and cardiac death SSS, SRS, and all the
Conclusion
In women, perfusion and functional parameters derived from quantitative gated technetium-99m tetrofosmin SPECT imaging can adequately be used for cardiac risk assessment. Using quantitative gated SPECT, female patients with an LVEF < 52% or an SSS ≥ 22 are at increased risk for subsequent hard events. Women with an SSS ≥ 14 are at increased risk for any cardiac events.
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