Functional compared to anatomical imaging in the initial evaluation of patients with suspected coronary artery disease: An international, multi-center, randomized controlled trial (IAEA-SPECT/CTA study)

Ganesan Karthikeyan, Barbara Guzic Salobir, Borut Jug, Niveditha Devasenapathy, Erick Alexanderson, Joao Vitola, Otakar Kraft, Elgin Ozkan, Saket Sharma, Gaurav Purohit, Maja Dolenc Novak, Aloha Meave, Sergio Trevethan, Rodrigo Cerci, Sandra Zier, Lucia Gotthardtová, Tomáš Jonszta, Timucin Altin, Cigdem Soydal, Chetan Patel, Gurpreet Gulati, Diana Paez, Maurizio Dondi, Ravi Kashyap, Ganesan Karthikeyan, Barbara Guzic Salobir, Borut Jug, Niveditha Devasenapathy, Erick Alexanderson, Joao Vitola, Otakar Kraft, Elgin Ozkan, Saket Sharma, Gaurav Purohit, Maja Dolenc Novak, Aloha Meave, Sergio Trevethan, Rodrigo Cerci, Sandra Zier, Lucia Gotthardtová, Tomáš Jonszta, Timucin Altin, Cigdem Soydal, Chetan Patel, Gurpreet Gulati, Diana Paez, Maurizio Dondi, Ravi Kashyap

Abstract

Objective: To test the hypothesis that, in the initial evaluation of patients with suspected coronary artery disease (CAD), stress myocardial perfusion imaging (MPI) would result in less downstream testing than coronary computed tomographic angiography (CCTA).

Methods: In this international, randomized trial, mildly symptomatic patients with an intermediate likelihood of having CAD, and asymptomatic patients at intermediate risk of cardiac events, underwent either initial stress-rest MPI or CCTA. The primary outcome was downstream noninvasive or invasive testing at 6 months. Secondary outcomes included cumulative effective radiation dose (ERD) and costs at 12 months.

Results: We recruited 303 patients (151 MPI and 152 CTA) from 6 centers in 6 countries. The initial MPI was abnormal in 29% (41/143) and CCTA in 56% (79/141) of patients. Fewer patients undergoing initial stress-rest MPI had further downstream testing at 6 months (adjusted OR 0.51, 95% CI 0.28-0.91, P = 0.023). There was a small increase in the median cumulative ERD with MPI (9.6 vs. 8.8 mSv, P = 0.04), but no difference in costs between the two strategies at 12 months.

Conclusion: In the management of patients with suspected CAD, a strategy of initial stress MPI is substantially less likely to require further downstream testing than initial testing with CCTA.

Trial registration: clinicaltrials.gov identification number NCT01368770.

Keywords: Myocardial perfusion imaging—SPECT; computed tomography; coronary artery disease.

Figures

Figure 1
Figure 1
Enrolment, randomization, and follow-up of trial participants. MPI Myocardial perfusion imaging, CCTA coronary CT angiography
Figure 2
Figure 2
A 73-year-old male with exertional dyspnea and a positive family history of coronary artery disease was randomized to undergo exercise MPI. Stress (top) and rest (bottom) Tc-99 m tetrofosmin myocardial perfusion images demonstrate reversible ischemia in the apex, apical segment of the anterior wall, and apical segment of the lateral wall. MPI myocardial perfusion imaging
Figure 3
Figure 3
A 68-year-old diabetic male patient with atypical symptoms underwent CCTA which showed a calcium score of 640 Agatston and a partially calcified proximal LAD plaque, causing moderate stenosis (1A -LAD curved multiplanar reconstruction). Subsequent exercise stress MPI revealed severe ischemia (arrows) in the anterior wall, antero lateral region and apex (1B). MPI myocardial perfusion imaging, CCTA coronary CT angiography, LAD left anterior descending coronary artery

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Source: PubMed

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