HYPOTHESIS: stress-rest Tc-99m tetrofosmin myocardial perfusion imaging can provide useful information in regards to who will benefit from coronary revascularization using percutaneous coronary intervention (PCI).

BACKGROUND: Since the Courage Trial, there remains uncertainty over which patients should undergo coronary revascularization using percutaneous coronary intervention. In patients with stable angina, PCI has not been shown to be associated with a survival gain over optimum medical therapy. Furthermore, complications from PCI are associated with a risk of morbidity of about 0.25% and risk of mortality of about 0.20%.

RESEARCH OBJECTIVE: Stress-rest myocardial perfusion scintigraphy has important prognostic ability to predict mortality, but can it also help predict just who will show the greatest benefit from PCI? Does MPS help forecast who will show an improved exercise capacity after PCI? In the UK, what is the prevalence of inducible ischemia in those patients who undergo a PCI procedure?

PATIENTS: The patient population studied was selected from consecutive patients that were previously scheduled for an elective PCI after having a positive diagnostic angiogram. On average, the patients were 65 years-old, with the majority being male (86%) with stable angina (63%). About 25% of the patients also had diabetes mellitus.

METHODS: Research patients all underwent a stress-rest myocardial perfusion scan using a single-day, single-isotope protocol utilizing Tc-99m tetrofosmin. The nuclear scan was done within a month prior to the PCI procedure. As much as possible, treadmill stress testing rather than pharmacologic stress testing was performed. Their New York Heart Association functional status was assessed. Patients also filled out the Seattle Angina Questionnaire. All of the physicians doing the PCI procedures where unaware of the results of the stress-rest myocardial perfusion scan.

At about 6 months following the revascularization procedure, patients were re-evaluated. Functional status and clinical symptoms were assessed once again using the New York Heart Association scale and the Seattle Angina Questionnaire. A repeat treadmill stress ECG test was done if the patient had undergone a baseline treadmill stress test. The same protocol was utilized for both stress tests. Clinicians who performed the treadmill stress ECG test during the follow-up visit were blinded as to the results of the patient’s baseline treadmill test.

Scan images were evaluated quantitatively using the Cedars-Sinai AutoSPECT and AutoQuant programs. Semiquantitative analysis was performed using summed scoring with a 17 segment 5-point scale. There were two readers who looked at each patient study. The mean of the semiquantitative summed scores assigned by these two readers were used for statistical analysis.

RESULTS: There were 123 patients included in the study population. The treadmill exercise stress test was positive for evidence of inducible myocardial ischemia in 72%. The myocardial perfusion scan showed inducible hypoperfusion affecting greater than 10% of the myocardium in 20% of patients. The perfusion scan showed inducible hypoperfusion of 1% to 10% of the myocardium in 54% of the patients. The remaining 26% of patients had no reversible defects on perfusion scintigraphy.

Six months later at the follow-up evaluation, improvement was seen in the Seattle Angina Questionnaire and in exercise capacity. Looking at the entire patient population, the Seattle Angina Questionnaire physical limitation score improved from 66 to 75, which was highly statistically significant. Exercise capacity also showed a highly significant improvement, with the average exercise tolerance increasing from 7 to 9 METS. The New York Heart Association functional class, however, was unchanged in 62%, improved in 33%, and worse in 5%.

Univariate and multivariate predictors of improvement were then assessed. The independent predictors of improvement identified were male gender, limiting chest pain on baseline exercise testing, and the degree of inducible hypoperfusion on nuclear myocardial perfusion imaging. These were all statistically significant on both univariate and multivariate analyses.

CONCLUSION: Only 20% of patients undergoing percutaneous coronary intervention had inducible myocardial ischemia of 10% or greater. The combination of limiting chest pain with treadmill stress testing and significant reversible perfusion defects on perfusion scintigraphy help predict a large gain in improvement after revascularization.

ARTICLE: Does myocardial perfusion scintigraphy predict improvement in symptoms and exercise capacity following successful elective percutaneous coronary intervention? Al-Housni MB, Hutchings F, Dalby M, Dubowitz M, Grocott-Mason R, Ilsley CD, Mason M, Mitchell AG, Kelion AD.J Nucl Cardiol. 2009 Jul 9. [Epub ahead of print]. From the Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, United Kingdom. Pubmed.

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