Seminars in Nuclear Medicine
Volume 37, Issue 1 , Pages 2-16 , January 2007

Comparative Use of Radionuclide Stress Testing, Coronary Artery Calcium Scanning, and Noninvasive Coronary Angiography for Diagnostic and Prognostic Cardiac Assessment

  • Daniel S. Berman, MD

      Affiliations

    • Departments of Imaging and Medicine, Cedars-Sinai Medical Center, CSMC Burns and Allen Research Institute, Los Angeles, CA.
    • Departments of Medicine and Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA.
    • Corresponding Author InformationAddress reprint requests to Daniel S. Berman, MD, Director, Cardiac Imaging, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Room 1258, Los Angeles, CA 90048.
    • ,
  • Leslee J. Shaw, PhD

      Affiliations

    • Emory University School of Medicine, Atlanta, GA.
    • ,
  • Rory Hachamovitch, MD

      Affiliations

    • Departments of Imaging and Medicine, Cedars-Sinai Medical Center, CSMC Burns and Allen Research Institute, Los Angeles, CA.
    • ,
  • John D. Friedman, MD

      Affiliations

    • Departments of Imaging and Medicine, Cedars-Sinai Medical Center, CSMC Burns and Allen Research Institute, Los Angeles, CA.
    • ,
  • Donna M. Polk, MD, MPH

      Affiliations

    • Departments of Medicine and Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA.
    • ,
  • Sean W. Hayes, MD

      Affiliations

    • Departments of Imaging and Medicine, Cedars-Sinai Medical Center, CSMC Burns and Allen Research Institute, Los Angeles, CA.
    • ,
  • Louise E.J. Thomson, MB, ChB

      Affiliations

    • Departments of Imaging and Medicine, Cedars-Sinai Medical Center, CSMC Burns and Allen Research Institute, Los Angeles, CA.
    • ,
  • Guido Germano, PhD

      Affiliations

    • Departments of Imaging and Medicine, Cedars-Sinai Medical Center, CSMC Burns and Allen Research Institute, Los Angeles, CA.
    • Departments of Medicine and Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA.
    • ,
  • Nathan D. Wong, PhD

      Affiliations

    • Departments of Imaging and Medicine, Cedars-Sinai Medical Center, CSMC Burns and Allen Research Institute, Los Angeles, CA.
    • Heart Disease Prevention Program, Department of Medicine, University of California, Irvine, CA.
    • ,
  • Xingping Kang, MD

      Affiliations

    • Departments of Imaging and Medicine, Cedars-Sinai Medical Center, CSMC Burns and Allen Research Institute, Los Angeles, CA.
    • ,
  • Alan Rozanski, MD

      Affiliations

    • Department of Medicine, St. Luke’s Roosevelt Hospital Center, New York, NY.

References 

  1. Berman DS, Hachamovitch R, Shaw LJ, et al. Roles of nuclear cardiology, cardiac computed tomography, and cardiac magnetic resonance: assessment of patients with suspected coronary artery disease. J Nucl Med. 2006;47:74–82
  2. Berman DS, Hachamovitch R, Shaw LJ, et al. Roles of nuclear cardiology, cardiac computed tomography, and cardiac magnetic resonance: noninvasive risk stratification and a conceptual framework for the selection of noninvasive imaging tests in patients with known or suspected coronary artery disease. J Nucl Med. 2006;47:1107–1118
  3. Rozanski A, Berman DS. The efficacy of cardiovascular nuclear medicine exercise studies. Semin Nucl Med. 1987;17:104–120
  4. Hachamovitch R, Hayes SW, Friedman JD, et al. Stress myocardial perfusion SPECT is clinically effective and cost-effective in risk-stratification of patients with a high likelihood of CAD but no known CAD. J Am Coll Cardiol. 2004;43:200–208
  5. Hachamovitch R, Hayes S, Friedman JD, et al. Determinants of risk and its temporal variation in patients with normal stress myocardial perfusion scans: what is the warranty period of a normal scan?. J Am Coll Cardiol. 2003;41:1329–1340
  6. Klocke FJ, Baird MG, Lorell BH, 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;108:1404–1418
  7. Shaw LJ, Iskandrian AE. Prognostic value of gated myocardial perfusion SPECT. J Nucl Cardiol. 2004;11:171–185
  8. Shaw LJ, Hendel RC, Borges-Neto S, et al. Prognsotic value of normal exercise and adenosine (99m)Tc-tetrofosmin SPECT imaging: results from the multicenter registry of 4,728 patients. J Nucl Med. 2003;44:134–139
  9. Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation. 2003;107:149–158
  10. Berman DS: Noninvasive imaging in coronary artery disease: changing roles, changing players. J Nucl Cardiol, in press
  11. Kang X, Berman DS, Lewin HC, et al. Incremental prognostic value of myocardial perfusion single photon emission computed tomography in patients with diabetes mellitus. Am Heart J. 1999;138:1025–1032
  12. Abidov A, Hachamovitch R, Rozanski A, et al. Prognostic implications of atrial fibrillation in patients undergoing myocardial perfusion single-photon emission computed tomography. J Am Coll Cardiol. 2004;44:1062–1070
  13. Abidov A, Rozanski A, Hachamovitch R, et al. Complaints of dyspnea among patients referred for cardiac stress testing. N Engl J Med. 2005;353:1889–1898
  14. Berman DS, Kang X, Hayes SW, et al. Adenosine myocardial perfusion single-photon emission computed tomography in women compared with men (Impact of diabetes mellitus on incremental prognostic value and effect on patient management). J Am Coll Cardiol. 2003;41:1125–1133
  15. Azarbal B, Hayes SW, Lewin HC, et al. The incremental prognostic value of percentage of heart rate reserve achieved over myocardial perfusion single-photon emission computed tomography in the prediction of cardiac death and all-cause mortality: superiority over 85% of maximal age-predicted heart rate. J Am Coll Cardiol. 2004;44:423–430
  16. Abidov A, Bax JJ, Hayes SW, et al. Transient ischemic dilation ratio of the left ventricle is a significant predictor of future cardiac events in patients with otherwise normal myocardial perfusion SPECT. J Am Coll Cardiol. 2003;42:1818–1825
  17. Staniloff HM, Forrester JS, Berman DS, et al. Prediction of death, myocardial infarction, and worsening chest pain using thallium scintigraphy and exercise electrocardiography. J Nucl Med. 1986;27:1842–1848
  18. Mowatt G, Vale L, Brazzelli M, et al. Systematic review of the effectiveness and cost-effectiveness, and economic evaluation, of myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction. Health Technol Assess. 2004;8:1–207iii-iv
  19. Hachamovitch RHS, Friedman JD, Cohen I, et al. Is there a referral bias against revascularization of patients with reduced LV ejection fraction? (influence of ejection fraction and inducible ischemia on post-SPECT management of patients without history of CAD). J Am Coll Cardiol. 2003;42:1286–1294
  20. Hachamovitch R, Hayes SW, Friedman JD, et al. 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;107:2900–2907
  21. Boden WE, O’Rourke RA, Teo KK, et al. Design and rationale of the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) trial Veterans Affairs Cooperative Studies Program no. 424. Am Heart J. 2006;151:1173–1179
  22. Kaminek M, Myslivecek M, Skvarilova M, et al. Increased prognostic value of combined myocardial perfusion SPECT imaging and the quantification of lung Tl-201 uptake. Clin Nucl Med. 2002;27:255–260
  23. Berman DS, Hachamovitch R, Shaw LJ, et al: Nuclear cardiology, in Fuster V, Alexander RW, O’Rourke RA, et al (eds): Hurst’s The Heart (ed 12). New York, NY, McGraw-Hill Companies (in press)
  24. Sharir T, Berman DS, Lewin HC, et al. Incremental prognostic value of rest-redistribution Tl-201 single-photon emission computed tomography. Circulation. 1999;100:1964–1970
  25. Sharir T, Kang X, Germano G, et al: Prognostic value of post-stress left ventricular volume and ejection fraction by gated myocardial perfusion single-photon emission computed tomography in women: gender related differences in normal limits and outcomes. J Nucl Cardiol, in press
  26. Sharir T, Bacher-Stier C, Dhar S, et al. Identification of severe and extensive coronary artery disease by postexercise regional wall motion abnormalities in Tc-99m sestamibi gated single-photon emission computed tomography. Am J Cardiol. 2000;86:1171–1175
  27. Sharir T, Germano G, Kang X, et al. Prediction of myocardial infarction versus cardiac death by gated myocardial perfusion SPECT: Risk stratification by the amount of stress-induced ischemia and the poststress ejection fraction. J Nucl Med. 2001;42:831–837
  28. Klein J, Chao SY, Berman DS, et al. Is ‘silent’ myocardial ischemia really as severe as symptomatic ischemia? (The analytical effect of patient selection biases). Circulation. 1994;89:1958–1966
  29. Mieres JH, Shaw LJ, Hendel RC, et al. American Society of Nuclear Cardiology consensus statement: Task Force on Women and Coronary Artery Disease—the role of myocardial perfusion imaging in the clinical evaluation of coronary artery disease in women. [correction] J Nucl Cardiol. 2003;10:95–101
  30. Udelson JE, Heller GV, Wackers FJ, et al. Randomized, controlled dose-ranging study of the selective adenosine A2A receptor agonist binodenoson for pharmacological stress as an adjunct to myocardial perfusion imaging. Circulation. 2004;109:457–464
  31. Miller DD. Impact of selective adenosine A2A receptor agonists on cardiac imaging feeling the lightning, waiting on the thunder. J Am Coll Cardiol. 2005;46:2076–2078
  32. Johnson LL, Verdesca SA, Aude WY, et al. Postischemic stunning can affect left ventricular ejection fraction and regional wall motion on post-stress gated sestamibi tomograms. J Am Coll Cardiol. 1997;30:1641–1648[see comments]
  33. Abbott BG, Afshar M, Berger AK, et al. Prognostic significance of ischemic electrocardiographic changes during adenosine infusion in patients with normal myocardial perfusion imaging. J Nucl Cardiol. 2003;10:9–16
  34. Hachamovitch R, Rozanski A, Hayes SW, et al: Predicting therapeutic benefit from myocardial revascularization procedures: Are measurements of resting left ventricular ejection fraction and stress-induced myocardial ischemia both necessary? J Nucl Cardiol (in press)
  35. Greenland P, Bonow RO, Brundage BH, et al: Computed tomography: ACC/AHA writing committee to update the 2000 clinical expert consensus document on electron-beam computed tomography for the diagnosis and prognosis for coronary artery disease. J Am Coll Cardiol, in press
  36. Rumberger JA, Simons DB, Fitzpatrick LA, et al. Coronary artery calcium area by electron-beam computed tomography and coronary atherosclerotic plaque area (A histopathologic correlative study). Circulation. 1995;92:2157–2162
  37. Diamond GA, Staniloff HM, Forrester JS, et al. Computer-assisted diagnosis in the noninvasive evaluation of patients with suspected coronary artery disease. J Am Coll Cardiol. 1983;1:444–455
  38. Agatston AS, Janowitz WR, Hildner FJ, et al. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol. 1990;15:827–832
  39. Budoff MJ, Achenbach S, Blumenthal RS, et al: Assessment of coronary artery disease by cardiac computed tomography: a statement for health professionals from the American Heart Association. Circulation, in press
  40. Becker CR, Kleffel T, Crispin A, et al. Coronary artery calcium measurement: agreement of multirow detector and electron beam CT. Am J Roentgenol. 2001;176:1295–1298
  41. Daniell AL, Wong ND, Friedman JD, et al. Concordance of coronary artery calcium estimates between MDCT and electron beam tomography. AJR Am J Roentgenol. 2005;185:1542–1545
  42. Callister TQ, Cooil B, Raya SP, et al. Coronary artery disease: improved reproducibility of calcium scoring with an electron-beam CT volumetric method. Radiology. 1998;208:807–814
  43. Callister TQ, Raggi P, Cooil B, et al. Effect of HMG-CoA reductase inhibitors on coronary artery disease as assessed by electron-beam computed tomography. N Engl J Med. 1998;339:1972–1978
  44. Hoff JA, Chomka EV, Krainik AJ, et al. Age and gender distributions of coronary artery calcium detected by electron beam tomography in 35,246 adults. Am J Cardiol. 2001;87:1335–1339
  45. Carr JJ, Nelson JC, Wong ND, et al. Calcified coronary artery plaque measurement with cardiac CT in population-based studies: standardized protocol of Multi-Ethnic Study of Atherosclerosis (MESA) and Coronary Artery Risk Development in Young Adults (CARDIA) study. Radiology. 2005;234:35–43
  46. Shaw LJ, Raggi P, Schisterman E, et al. Prognostic value of cardiac risk factors and coronary artery calcium screening for all-cause mortality. Radiology. 2003;228:826–833
  47. Raggi P, Callister TQ, Cooil B, et al. Identification of patients at increased risk of first unheralded acute myocardial infarction by electron-beam computed tomography. Circulation. 2000;101:850–855
  48. Cheng YJ, Church TS, Kimball TE, et al. Comparison of coronary artery calcium detected by electron beam tomography in patients with to those without symptomatic coronary heart disease. Am J Cardiol. 2003;92:498–503
  49. McClelland RL, Chung H, Detrano R, et al. Distribution of coronary artery calcium by race, gender, and age: Results from the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2006;113:30–37
  50. O’Rourke RA, Brundage BH, Froelicher VF, et al. American College of Cardiology/American Heart Association Expert Consensus Document on electron-beam computed tomography for the diagnosis and prognosis of coronary artery disease. J Am Coll Cardiol. 2000;36:326–340
  51. Schmermund A, Denktas AE, Rumberger JA, et al. Independent and incremental value of coronary artery calcium for predicting the extent of angiographic coronary artery disease: comparison with cardiac risk factors and radionuclide perfusion imaging. J Am Coll Cardiol. 1999;34:777–786
  52. Taylor AJ, Bindeman J, Feuerstein I, et al. Coronary calcium independently predicts incident premature coronary heart disease over measured cardiovascular risk factors: mean 3-year outcomes in the prospective army coronary calcium project. J Am Coll Cardiol. 2005;46:807–814
  53. Greenland P, LaBree L, Azen SP, et al. Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA. 2004;291:210–215
  54. Kondos GT, Hoff JA, Sevrukov A, et al. Electron-beam tomography coronary artery calcium and cardiac events: a 37-month follow-up of 5635 initially asymptomatic low- to intermediate-risk adults. Circulation. 2003;107:2571–2576
  55. Vliegenthart R, Oudkerk M, Hofman A, et al. Coronary calcification improves cardiovascular risk prediction in the elderly. Circulation. 2005;112:572–577
  56. LaMonte MJ, FitzGerald SJ, Church TS, et al. Coronary artery calcium score and coronary heart disease events in a large cohort of asymptomatic men and women. Am J Epidemiol. 2005;162:421–429
  57. Arad Y, Goodman KJ, Roth M, et al. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic disease events: the St. Francis Heart Study. J Am Coll Cardiol. 2005;46:158–165
  58. Virmani R, Burke AP, Farb A, et al. Pathology of the vulnerable plaque. J Am Coll Cardiol. 2006;47:C13–C18
  59. Stein PD, Beemath A, Kayali F, et al. Multidetector computed tomography for the diagnosis of coronary artery disease: a systematic review. Am J Med. 2006;119:203–216
  60. Schuijf JD, Bax JJ, Shaw LJ, et al. Meta-analysis of comparative diagnostic performance of magnetic resonance imaging and multislice computed tomography for noninvasive coronary angiography. Am Heart J. 2006;151:404–411
  61. Leber A, Knez A, Ziegler FV, et al. Quantification of obstructive and nonobstructive coronary lesions by 64-slice computed tomography: a comparative study with quantitative coronary angiography and intravascular ultrasound. J Am Coll Cardiol. 2005;46:147–154
  62. Ropers D, Anders K, Lell M, et al. Noninvasive coronary artery imaging using 64-slice spiral computed tomography: initial experiences. Circulation. 2004;110:III-522;(abstr)
  63. Ropers D, Anders K, Baum U, et al. Noninvasive coronary angiography by retrospectively ECG-gated 64-slice spiral computed tomography: initial clinical experiences. (abstr) J Am Coll Cardiol. 2005;45:311A
  64. Ransohoff DF, Feinstein AR. Problems of spectrum and bias in evaluating the efficacy of diagnostic tests. N Engl J Med. 1978;299:926–930
  65. Raff GL, Gallagher MJ, O’Neill WW, et al. Diagnostic accuracy of noninvasive coronary angiography using 64-slice spiral computed tomography. J Am Coll Cardiol. 2005;46:552–557
  66. Jakobs TF, Becker CR, Ohnesorge B, et al. Multislice helical CT of the heart with retrospective ECG gating: reduction of radiation exposure by ECG-controlled tube current modulation. Eur Radiol. 2002;12:1081–1086
  67. Abada HT, Larchez C, Daoud B, et al. MDCT of the coronary arteries: feasibility of low-dose CT with ECG-pulsed tube current modulation to reduce radiation dose. AJR Am J Roentgenol. 2006;186:S387–S390
  68. Schoepf UJ, Becker CR, Ohnesorge BM, et al. CT of coronary artery disease. Radiology. 2004;232:18–37
  69. Berman DS, Wong ND, Gransar H, et al. Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography. J Am Coll Cardiol. 2004;44:923–930
  70. Committee to Assess Health Risks from Exposure to Low Levels of Ionizing RadiationNational Research Council. Health Risks from Exposure to Low Levels of Ionizing Radiation. BEIR VII Phase 2. Washington, DC: National Academies Press; 2005;
  71. Berman DS. Fourth Annual Mario S. Verani, MD Memorial Lecture: Noninvasive imaging in coronary artery disease: Changing roles, changing players. J Nucl Cardiol. 2006;13:457–473
  72. He ZX, Hedrick TD, Pratt CM, et al. Severity of coronary artery calcification by electron beam computed tomography predicts silent myocardial ischemia. Circulation. 2000;101:244–251
  73. Moser KW, O’Keefe JH, Bateman TM, et al. Coronary calcium screening in asymptomatic patients as a guide to risk factor modification and stress myocardial perfusion imaging. J Nucl Cardiol. 2003;10:590–598
  74. Wong ND, Rozanski A, Gransar H, et al. Metabolic syndrome and diabetes are associated with an increased likelihood of inducible myocardial ischemia among patients with subclinical atherosclerosis. Diabetes Care. 2005;28:1445–1450
  75. Hecht HS, Superko HR, Smith LK, et al. Relation of coronary artery calcium identified by electron beam tomography to serum lipoprotein levels and implications for treatment. Am J Cardiol. 2001;87:406–412
  76. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285:2486–2497
  77. Hecht HS, Budoff MJ, Berman DS, et al. Coronary artery calcium scanning: Clinical paradigms for cardiac risk assessment and treatment. Am Heart J. 2006;151:1139–1146
  78. Grover SA, Coupal L, Hu XP. Identifying adults at increased risk of coronary disease (How well do the current cholesterol guidelines work?). JAMA. 1995;274:801–806
  79. Nasir K, Michos ED, Blumenthal RS, et al. Detection of high-risk young adults and women by coronary calcium and National Cholesterol Education Program Panel III guidelines. J Am Coll Cardiol. 2005;46:1931–1936
  80. Naghavi M, Falk E, Hecht HS, et al. From vulnerable plaque to vulnerable patient—Part III: Executive summary of the Screening for Heart Attack Prevention and Education (SHAPE) Task Force report. Am J Cardiol. 2006;98:2–15
  81. Berman DS, Hachamovitch R, Shaw LJ, et al. Nuclear cardiology. In:  Fuster VAR,  O’Rourke RA,  Roberts R, et al. editor. Hurst’s The Heart. (ed 11). New York: McGraw-Hill Companies; 2004;p. 563–597
  82. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med. 1979;300:1350–1358
  83. Hoffmann U, Ferencik M, Cury RC, et al. Coronary CT angiography. J Nucl Med. 2006;47:797–806
  84. Berman DS, Abidov A, Kang X, et al. Prognostic validation of a 17-segment score derived from a 20-segment score for myocardial perfusion SPECT interpretation. J Nucl Cardiol. 2004;11:414–423

 Funded in part by a grant from The Eisner Foundation.

PII: S0001-2998(06)00057-2

doi: 10.1053/j.semnuclmed.2006.08.002

Seminars in Nuclear Medicine
Volume 37, Issue 1 , Pages 2-16 , January 2007

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