Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Journal of Nuclear Cardiology
Published in: Journal of Nuclear Cardiology 1/2017

01-02-2017 | Original Article

Sequential SPECT/CT imaging for detection of coronary artery disease in a large cohort: evaluation of the need for additional imaging and radiation exposure

Authors: Elsemiek M. Engbers, MD, Jorik R. Timmer, MD, PhD, Jan Paul Ottervanger, MD, PhD, Mohamed Mouden, MD, PhD, Ad. H. J. Oostdijk, MD, Siert Knollema, MD, PhD, Pieter L. Jager, MD, PhD

Published in: Journal of Nuclear Cardiology | Issue 1/2017

Login to get access

Abstract

Background

Performing both single photon emission computerized tomography (SPECT) and coronary computed tomography angiography (CCTA) in patients suspected for coronary artery disease (CAD) leads to increased radiation exposure. We evaluated the need for additional imaging and following implications for radiation exposure of a sequential SPECT/computed tomography (CT) algorithm.

Methods and Results

5018 consecutive patients without history of CAD were referred for stress-first SPECT and coronary artery calcium (CAC) scoring. If stress SPECT was abnormal, additional rest SPECT and, if feasible, CCTA were acquired. Stress SPECT was normal in 2617 patients (52%). CCTA was not performed in 1289 of the 2401 patients referred for additional imaging (54%), mainly because of severe CAC (47%) or fast/irregular heart rate (22%). 642 patients with abnormal SPECT underwent CCTA, which excluded significant CAD in 378 patients (59%). Mean radiation dose was 4.5 ± 0.3 mSv for stress-only imaging and 13.2 ± 3.3 mSv for additional imaging (P < 0.001).

Conclusions

Half of the patients do not require additional imaging in our sequential SPECT/CT algorithm, which is accompanied with low radiation exposure. CCTA cannot be performed in half of the patients who undergo additional imaging because of (relative) contra-indications. CCTA is able to correct for false-positive SPECT findings in our algorithm.
Literature
1.
Budoff MJ, Dowe D, Jollis JG, Gitter M, Sutherland J, Halamert E, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: Results from the prospective multicenter ACCURACY (assessment by coronary computed tomographic angiography of individuals undergoing invasive coronary angiography) trial. J Am Coll Cardiol 2008;52:1724-32.CrossRefPubMed
2.
Hacker M, Jakobs T, Hack N, Nikolaou K, Becker C, von Ziegler F, et al. Sixty-four slice spiral CT angiography does not predict the functional relevance of coronary artery stenoses in patients with stable angina. Eur J Nucl Med Mol Imaging 2007;34:4-10.CrossRefPubMed
3.
Gaemperli O, Schepis T, Koepfli P, Valenta I, Soyka J, Leschka S, et al. Accuracy of 64-slice CT angiography for the detection of functionally relevant coronary stenoses as assessed with myocardial perfusion SPECT. Eur J Nucl Med Mol Imaging 2007;34:1162-71.CrossRefPubMed
4.
Arbab-Zadeh A, Miller JM, Rochitte CE, Dewey M, Niinuma H, Gottlieb I, et al. Diagnostic accuracy of computed tomography coronary angiography according to pre-test probability of coronary artery disease and severity of coronary arterial calcification. The CORE-64 (coronary artery evaluation using 64-row multidetector computed tomography angiography) international multicenter study. J Am Coll Cardiol 2012;59:379-87.CrossRefPubMedPubMedCentral
5.
Buechel RR, Husmann L, Herzog BA, Pazhenkottil AP, Nkoulou R, Ghadri JR, et al. Low-dose computed tomography coronary angiography with prospective electrocardiogram triggering: Feasibility in a large population. J Am Coll Cardiol 2011;57:332-6.CrossRefPubMed
6.
Rispler S, Keidar Z, Ghersin E, Roguin A, Soil A, Dragu R, et al. Integrated single-photon emission computed tomography and computed tomography coronary angiography for the assessment of hemodynamically significant coronary artery lesions. J Am Coll Cardiol 2007;49:1059-67.CrossRefPubMed
7.
van Werkhoven JM, Schuijf JD, Gaemperli O, Jukema JW, Boersma E, Wijns W, et al. Prognostic value of multislice computed tomography and gated single-photon emission computed tomography in patients with suspected coronary artery disease. J Am Coll Cardiol 2009;53:623-32.CrossRefPubMed
8.
Sato A, Nozato T, Hikita H, Miyazaki S, Takahashi Y, Kuwahara T, et al. Incremental value of combining 64-slice computed tomography angiography with stress nuclear myocardial perfusion imaging to improve noninvasive detection of coronary artery disease. J Nucl Cardiol 2010;17:19-26.CrossRefPubMed
9.
Slart RH, Tio RA, Zijlstra F, Dierckx RA. Diagnostic pathway of integrated SPECT/CT for coronary artery disease. Eur J Nucl Med Mol Imaging 2009;36:1829-34.CrossRefPubMed
10.
Pazhenkottil AP, Herzog BA, Husmann L, Buechel RR, Burger IA, Valenta I, et al. Non-invasive assessment of coronary artery disease with CT coronary angiography and SPECT: A novel dose-saving fast-track algorithm. Eur J Nucl Med Mol Imaging 2010;37:522-7.CrossRefPubMed
11.
von Ziegler F, Brendel M, Uebleis C, Helbig S, Greif M, Ruemmler J, et al. SPECT myocardial perfusion imaging as an adjunct to coronary calcium score for the detection of hemodynamically significant coronary artery stenosis. BMC Cardiovasc Disord 2012;12:116.CrossRef
12.
Flotats A, Knuuti J, Gutberlet M, Marcassa C, Bengel FM, Kaufmann PA, et al. Hybrid cardiac imaging: SPECT/CT and PET/CT. A joint position statement by the european association of nuclear medicine (EANM), the european society of cardiac radiology (ESCR) and the european council of nuclear cardiology (ECNC). Eur J Nucl Med Mol Imaging 2011;38:201-12.CrossRefPubMed
13.
Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979;300:1350-8.CrossRefPubMed
14.
Gowd BM, Heller GV, Parker MW. Stress-only SPECT myocardial perfusion imaging: A review. J Nucl Cardiol 2014;21:1200-12.CrossRefPubMed
15.
Henzlova MJ, Cerqueira MD, Mahmarian JJ, Yao SS. Quality Assurance Committee of the American Society of Nuclear Cardiology. Stress protocols and tracers. J Nucl Cardiol 2006;13:e80-90.CrossRefPubMed
16.
Mouden M, Timmer JR, Ottervanger JP, Reiffers S, Oostdijk AH, Knollema S, et al. Impact of a new ultrafast CZT SPECT camera for myocardial perfusion imaging: Fewer equivocal results and lower radiation dose. Eur J Nucl Med Mol Imaging 2012;39:1048-55.CrossRefPubMed
17.
Herzog BA, Buechel RR, Katz R, Brueckner M, Husmann L, Burger IA, et al. Nuclear myocardial perfusion imaging with a cadmium-zinc-telluride detector technique: Optimized protocol for scan time reduction. J Nucl Med 2010;51:46-51.CrossRefPubMed
18.
Mouden M, Ottervanger JP, Timmer JR, Reiffers S, Oostdijk AH, Knollema S, et al. Myocardial perfusion imaging in stable symptomatic patients with extensive coronary atherosclerosis. Eur J Nucl Med Mol Imaging 2014;41:136-43.CrossRefPubMed
19.
Berman DS, Abidov A, Kang X, Hayes SW, Friedman JD, Sciammarella MG, et al. Prognostic validation of a 17-segment score derived from a 20-segment score for myocardial perfusion SPECT interpretation. J Nucl Cardiol 2004;11:414-23.CrossRefPubMed
20.
Berman DS, Hachamovitch R, Kiat H, Cohen I, Cabico JA, Wang FP, et al. Incremental value of prognostic testing in patients with known or suspected ischemic heart disease: A basis for optimal utilization of exercise technetium-99 m sestamibi myocardial perfusion single-photon emission computed tomography. J Am Coll Cardiol 1995;26:639-47.CrossRefPubMed
21.
Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M Jr, Detrano R. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 1990;15:827-32.CrossRefPubMed
22.
Abbara S, Arbab-Zadeh A, Callister TQ, Desai MY, Mamuya W, Thomson L, et al. SCCT guidelines for performance of coronary computed tomographic angiography: A report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr 2009;3:190-204.CrossRefPubMed
23.
Austen WG, Edwards JE, Frye RL, Gensini GG, Gott VL, Griffith LS, et al. A reporting system on patients evaluated for coronary artery disease. report of the Ad Hoc Committee for grading of coronary artery disease, Council on Cardiovascular Surgery, American Heart Association. Circulation 1975;51:5-40.CrossRefPubMed
24.
Raff GL, Abidov A, Achenbach S, Berman DS, Boxt LM, Budoff MJ, et al. SCCT guidelines for the interpretation and reporting of coronary computed tomographic angiography. J Cardiovasc Comput Tomogr 2009;3:122-36.CrossRefPubMed
25.
Valentin J. Radiation dose to patients from radiopharmaceuticals (addendum 2 to ICRP publication 53). Ann ICRP 1998;28:1-126.CrossRef
26.
Einstein AJ, Moser KW, Thompson RC, Cerqueira MD, Henzlova MJ. Radiation dose to patients from cardiac diagnostic imaging. Circulation 2007;116:1290-305.CrossRefPubMed
27.
Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol 2012;60:1581-98.CrossRefPubMed
28.
Beller GA, Zaret BL. Contributions of nuclear cardiology to diagnosis and prognosis of patients with coronary artery disease. Circulation 2000;101:1465-78.CrossRefPubMed
29.
Schaap J, Kauling RM, Boekholdt SM, Nieman K, Meijboom WB, Post MC, et al. Incremental diagnostic accuracy of hybrid SPECT/CT coronary angiography in a population with an intermediate to high pre-test likelihood of coronary artery disease. Eur Heart J Cardiovasc Imaging 2013;14:642-9.CrossRefPubMed
30.
Underwood SR, Anagnostopoulos C, Cerqueira M, Ell PJ, Flint EJ, Harbinson M, et al. Myocardial perfusion scintigraphy: The evidence. Eur J Nucl Med Mol Imaging 2004;31:261-91.CrossRefPubMed
31.
Mouden M, Ottervanger JP, Timmer JR, Reiffers S, Oostdijk AH, Knollema S, et al. The influence of coronary calcium score on the interpretation of myocardial perfusion imaging. J Nucl Cardiol 2014;21:368-74.CrossRefPubMed
32.
Uretsky S, Cohen R, Argulian E, Balasundaram K, Supariwala A, Subero M, et al. Combining stress-only myocardial perfusion imaging with coronary calcium scanning as a new paradigm for initial patient work-up: An exploratory analysis. J Nucl Cardiol 2014;22:89-97.CrossRefPubMed
33.
Villines TC, Hulten EA, Shaw LJ, Goyal M, Dunning A, Achenbach S, et al. Prevalence and severity of coronary artery disease and adverse events among symptomatic patients with coronary artery calcification scores of zero undergoing coronary computed tomography angiography: Results from the CONFIRM (coronary CT angiography evaluation for clinical outcomes: An international multicenter) registry. J Am Coll Cardiol 2011;58:2533-40.CrossRefPubMed
34.
Ghadri JR, Pazhenkottil AP, Nkoulou RN, Goetti R, Buechel RR, Husmann L, et al. Very high coronary calcium score unmasks obstructive coronary artery disease in patients with normal SPECT MPI. Heart 2011;97:998-1003.CrossRefPubMed
35.
Chang SM, Nabi F, Xu J, Raza U, Mahmarian JJ. Normal stress-only versus standard stress/rest myocardial perfusion imaging: Similar patient mortality with reduced radiation exposure. J Am Coll Cardiol 2010;55:221-30.CrossRefPubMed
36.
Duvall WL, Wijetunga MN, Klein TM, Razzouk L, Godbold J, Croft LB, et al. The prognosis of a normal stress-only tc-99 m myocardial perfusion imaging study. J Nucl Cardiol 2010;17:370-7.CrossRefPubMed
37.
Ueyama T, Takehana K, Maeba H, Iwasaka T. Prognostic value of normal stress-only technetium-99 m myocardial perfusion imaging protocol. Comparison with standard stress-rest protocol. Circ J 2012;76:2386-91.CrossRefPubMed
38.
Edenbrandt L, Ohlsson M, Tragardh E. Prognosis of patients without perfusion defects with and without rest study in myocardial perfusion scintigraphy. EJNMMI Res 2013;3:58. 219X-3-58. eCollection 2013.CrossRefPubMedPubMedCentral
39.
Ferreira MJ, Cunha MJ, Albuquerque A, Moreira AP, Ramos D, Costa G, et al. Prognosis of normal stress-only gated-SPECT myocardial perfusion imaging: A single center study. Int J Cardiovasc Imaging 2013;29:1639-44.CrossRefPubMed
40.
Chang SM, Nabi F, Xu J, Peterson LE, Achari A, Pratt CM, et al. The coronary artery calcium score and stress myocardial perfusion imaging provide independent and complementary prediction of cardiac risk. J Am Coll Cardiol 2009;54:1872-82.CrossRefPubMed
41.
Ramakrishna G, Miller TD, Breen JF, Araoz PA, Hodge DO, Gibbons RJ. Relationship and prognostic value of coronary artery calcification by electron beam computed tomography to stress-induced ischemia by single photon emission computed tomography. Am Heart J 2007;153:807-14.CrossRefPubMed
42.
Dewey M, Vavere AL, Arbab-Zadeh A, Miller JM, Sara L, Cox C, et al. Patient characteristics as predictors of image quality and diagnostic accuracy of MDCT compared with conventional coronary angiography for detecting coronary artery stenoses: CORE-64 multicenter international trial. AJR Am J Roentgenol 2010;194:93-102.CrossRefPubMedPubMedCentral
43.
Patel N, Pal RS, Flores F, Budoff M. Utility of cardiac computed tomography angiography to exclude clinically significant obstructive coronary artery disease in patients after myocardial perfusion imaging. Am J Cardiol 2012;109:165-8.CrossRefPubMed
44.
Klocke FJ, Baird MG, Lorell BH, Bateman TM, Messer JV, Berman DS, et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging-executive summary: A report of the american college of Cardiology/American heart association task force on practice guidelines (ACC/AHA/ASNC committee to revise the 1995 guidelines for the clinical use of cardiac radionuclide imaging). Circulation 2003;108:1404-18.CrossRefPubMed
45.
Arad Y, Spadaro LA, Goodman K, Newstein D, Guerci AD. Prediction of coronary events with electron beam computed tomography. J Am Coll Cardiol 2000;36:1253-60.CrossRefPubMed
46.
Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004;351:1296-305.CrossRefPubMed
47.
Schuijf JD, Wijns W, Jukema JW, Atsma DE, de Roos A, Lamb HJ, et al. Relationship between noninvasive coronary angiography with multi-slice computed tomography and myocardial perfusion imaging. J Am Coll Cardiol 2006;48:2508-14.CrossRefPubMed
48.
Pazhenkottil AP, Nkoulou RN, Ghadri JR, Herzog BA, Buechel RR, Kuest SM, et al. Prognostic value of cardiac hybrid imaging integrating single-photon emission computed tomography with coronary computed tomography angiography. Eur Heart J 2011;32:1465–71.CrossRefPubMed
49.
Schepis T, Gaemperli O, Koepfli P, Namdar M, Valenta I, Scheffel H, et al. Added value of coronary artery calcium score as an adjunct to gated SPECT for the evaluation of coronary artery disease in an intermediate-risk population. J Nucl Med 2007;48:1424-30.CrossRefPubMed
50.
Berman DS, Wong ND, Gransar H, Miranda-Peats R, Dahlbeck J, Hayes SW, et al. Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography. J Am Coll Cardiol 2004;44:923-30.CrossRefPubMed
51.
Hayat SA, Dwivedi G, Jacobsen A, Lim TK, Kinsey C, Senior R. Effects of left bundle-branch block on cardiac structure, function, perfusion, and perfusion reserve: Implications for myocardial contrast echocardiography versus radionuclide perfusion imaging for the detection of coronary artery disease. Circulation 2008;117:1832-41.CrossRefPubMed
52.
Tandogan I, Yetkin E, Ileri M, Ortapamuk H, Yanik A, Cehreli S, et al. Diagnosis of coronary artery disease with tl-201 SPECT in patients with left bundle branch block: Importance of alternative interpretation approaches for left anterior descending coronary lesions. Angiology 2001;52:103-8.CrossRefPubMed
53.
Depuey EG, Mahmarian JJ, Miller TD, Einstein AJ, Hansen CL, Holly TA, et al. Patient-centered imaging. J Nucl Cardiol 2012;19:185-215.CrossRefPubMed
54.
Cerqueira MD, Allman KC, Ficaro EP, Hansen CL, Nichols KJ, Thompson RC, et al. Recommendations for reducing radiation exposure in myocardial perfusion imaging. J Nucl Cardiol 2010;17:709-18.CrossRefPubMed
55.
Raman V, McWilliams ET, Holmberg SR, Miles K. Economic analysis of the use of coronary calcium scoring as an alternative to stress ECG in the non-invasive diagnosis of coronary artery disease. Eur Radiol 2012;22:579-87.CrossRefPubMed
56.
Sarwar A, Shaw LJ, Shapiro MD, Blankstein R, Hoffmann U, Cury RC, et al. Diagnostic and prognostic value of absence of coronary artery calcification. JACC Cardiovasc Imaging 2009;2:675-88.CrossRefPubMed
57.
Mouden M, Timmer JR, Reiffers S, Oostdijk AH, Knollema S, Ottervanger JP, et al. Coronary artery calcium scoring to exclude flow-limiting coronary artery disease in symptomatic stable patients at low or intermediate risk. Radiology 2013;269:77-83.CrossRefPubMed
Metadata
Title
Sequential SPECT/CT imaging for detection of coronary artery disease in a large cohort: evaluation of the need for additional imaging and radiation exposure
Authors
Elsemiek M. Engbers, MD
Jorik R. Timmer, MD, PhD
Jan Paul Ottervanger, MD, PhD
Mohamed Mouden, MD, PhD
Ad. H. J. Oostdijk, MD
Siert Knollema, MD, PhD
Pieter L. Jager, MD, PhD
Publication date
01-02-2017
Publisher
Springer US
Published in
Journal of Nuclear Cardiology / Issue 1/2017
Print ISSN: 1071-3581
Electronic ISSN: 1532-6551
DOI
https://doi.org/10.1007/s12350-015-0243-z

Other articles of this Issue 1/2017

Journal of Nuclear Cardiology 1/2017 Go to the issue

Original Article

Measurement of absolute myocardial blood flow in humans using dynamic cardiac SPECT and 99mTc-tetrofosmin: Method and validation

JOURNAL OF NUCLEAR CARDIOLOGY NEWS UPDATE

Purposeful Imaging: Goals for ASNC in 2017

Editorial

Predicting cardiac events using ventricular dyssynchrony in patients who received implantable cardioverter defibrillators: Are more treatment options required?

International Corner

Current status of nuclear cardiology practice in Latin America and the Caribbean

Abstracts/Proceedings

Multimodality Imaging: Bird’s-Eye View from the 65th Annual Scientific Sessions of the American College of Cardiology, Chicago, Ill, April 2–4, 2016

Review of the Literature

Nuclear cardiology in the literature: A selection of recent, original research papers

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Heart Failure Video

Watch this official video from ACC.24. Dr. Biykem Bozkurt discusses last year's major advances in heart failure and cardiomyopathies.

Watch now

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits