LETTER TO THE EDITOR The yield, safety and prognostic value of myocardial perfusion imaging with positron emission tomography for risk stratification of high risk chest pain patients To the Editor, Chest pain is one of the most common causes of presentation to the emergency room (ER). The workup of this common problem is not standardized. Myocardial perfusion imaging is a useful adjunct to the non-invasive assessment of patients with stable angina, baseline ECG abnormalities, post-revascularisation assessment, and heart failure, and in those unable to exercise. Functional imaging is clearly superior to standard exercise testing when used to diagnose coronary artery disease. The degree of severity shown on the scan reveals the likelihood of further cardiac event rates. Sherif Iskander, MD and Ami E. Iskandrian, MD, FACC in their review looked at Risk Assessment using Single-Photon Emission Computed Tomographic Technetium-99m Sestamibi Imaging when they analysed published data in English comprising more than 12,000 patients in 14 studies.1 In Another Publication George A. Beller, MD and Barry L. Zaret, MD wrote about Contributions of nuclear cardiology to diagnosis and prognosis of patients with coronary artery disease when they looked at pooled published data of around 4,000 patients using technetium and thallium based radiotracers.2 This is a retrospective study of all high-risk patients presenting to the ER of a tertiary care center with a chief complaint of chest pain and had no evidence of myocardial ischemia by electrocardiogram or cardiac biomarker. A total of 28 consecutive high risk patients who presented to Emergency room in King Abdulaziz
J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2014 American Society of Nuclear Cardiology.
Cardiac Center with chest pain (mean age 66 years, 50% females) were included. There was a high prevalence of cardiac risk factors in these patients (61% diabetes, 100% hypertension, and 100% dyslipidemia) as well as obesity (mean body mass index was 30 kgm-2). Most patients had known prior coronary artery disease (71% prior revascularization, 41% prior myocardial infarction). The baseline ECG showed old left bundle branch block in 10% of the study cohort. During stress test, the vasodilator (dipyridamol 0.56 mgkg) ECG showed ischemic changes in 14% of the study population without hemodynamic compromise. PET MPI (rubidium-82 supplied by BRACCO revealed reversible defects in 57% of patients; they were later admitted for coronary angiography. Patients with no evidence of ischemia were discharged home. At 30-day follow-up, none of these patients had any major adverse cardiac events. In this high-risk cohort with chest pain, vasodilator PET MPI is safe and well-tolerated despite high yield. Highrisk patients with normal PET MPI can be safely discharged home and had no events at 30 days. Rubidium82 MPI is a useful method of risk stratification of high risk patients presenting with Chest pain to ER. EXAMPLES Case 1 A 69-year-old male with prior MI and RCA stenting came with CP to ER and initial workup was Negative.
Suliman et al The Yield, Safety and Prognostic Value of Myocardial Perfusion Imaging
Result: There was large area of severe partial ischemia of the inferolateral area. Case 2 A 85-year-old female with long history of IHD and old MI, came to ER with chest pain, initial workup was negative.
Journal of Nuclear CardiologyÒ
I. Suliman, MBBS(Khartoum), ECFMG(USA), MRCP(UK) A. AlJizeeri, MBBS, MD M. Naseem, MBBS, MRCP M. Naveed, MBBS, MRCP M. AlZaibag, MBBS, FRCP, FACC M. Al-Mallah, MD, MSc, FACC, FAHA, FESC King Abdulaziz Cardiac Center, Riyadh, Saudi Arabia [email protected]
References 1. Iskander S, Iskandrian AE. Risk assessment using single-photon emission computed tomographic technetium-99m sestamibi imaging. J Am Coll Cardiol 1998;32:57-62. 2. Beller GA, Zaret BL. Contributions of nuclear cardiology to diagnosis and prognosis of patients with coronary artery disease. Circulation 2000;101:1465-78. doi:10.1007/s12350-014-0038-7
Result: showed largely fixed apical and inferior apical defect, no significant reversible ischemia.
J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2014 American Society of Nuclear Cardiology.
Cardiac Center with chest pain (mean age 66 years, 50% females) were included. There was a high prevalence of cardiac risk factors in these patients (61% diabetes, 100% hypertension, and 100% dyslipidemia) as well as obesity (mean body mass index was 30 kgm-2). Most patients had known prior coronary artery disease (71% prior revascularization, 41% prior myocardial infarction). The baseline ECG showed old left bundle branch block in 10% of the study cohort. During stress test, the vasodilator (dipyridamol 0.56 mgkg) ECG showed ischemic changes in 14% of the study population without hemodynamic compromise. PET MPI (rubidium-82 supplied by BRACCO revealed reversible defects in 57% of patients; they were later admitted for coronary angiography. Patients with no evidence of ischemia were discharged home. At 30-day follow-up, none of these patients had any major adverse cardiac events. In this high-risk cohort with chest pain, vasodilator PET MPI is safe and well-tolerated despite high yield. Highrisk patients with normal PET MPI can be safely discharged home and had no events at 30 days. Rubidium82 MPI is a useful method of risk stratification of high risk patients presenting with Chest pain to ER. EXAMPLES Case 1 A 69-year-old male with prior MI and RCA stenting came with CP to ER and initial workup was Negative.
Suliman et al The Yield, Safety and Prognostic Value of Myocardial Perfusion Imaging
Result: There was large area of severe partial ischemia of the inferolateral area. Case 2 A 85-year-old female with long history of IHD and old MI, came to ER with chest pain, initial workup was negative.
Journal of Nuclear CardiologyÒ
I. Suliman, MBBS(Khartoum), ECFMG(USA), MRCP(UK) A. AlJizeeri, MBBS, MD M. Naseem, MBBS, MRCP M. Naveed, MBBS, MRCP M. AlZaibag, MBBS, FRCP, FACC M. Al-Mallah, MD, MSc, FACC, FAHA, FESC King Abdulaziz Cardiac Center, Riyadh, Saudi Arabia [email protected]
References 1. Iskander S, Iskandrian AE. Risk assessment using single-photon emission computed tomographic technetium-99m sestamibi imaging. J Am Coll Cardiol 1998;32:57-62. 2. Beller GA, Zaret BL. Contributions of nuclear cardiology to diagnosis and prognosis of patients with coronary artery disease. Circulation 2000;101:1465-78. doi:10.1007/s12350-014-0038-7
Result: showed largely fixed apical and inferior apical defect, no significant reversible ischemia.
