Diagnostic performance of stress myocardial perfusion imaging for coronary artery disease: a systematic review and meta-analysis

Abstract

Objectives: To determine and compare the diagnostic performance of stress myocardial perfusion imaging (MPI) for the diagnosis of obstructive coronary artery disease (CAD), using conventional coronary angiography (CCA) as the reference standard.

Methods: We searched Medline and Embase for literature that evaluated stress MPI for the diagnosis of obstructive CAD using magnetic resonance imaging (MRI), contrast-enhanced echocardiography (ECHO), single-photon emission computed tomography (SPECT) and positron emission tomography (PET).

Results: All pooled analyses were based on random effects models. Articles on MRI yielded a total of 2,970 patients from 28 studies, articles on ECHO yielded a sample size of 795 from 10 studies, articles on SPECT yielded 1,323 from 13 studies. For CAD defined as either at least 50 %, at least 70 % or at least 75 % lumen diameter reduction on CCA, the natural logarithms of the diagnostic odds ratio (lnDOR) for MRI (3.63; 95 % CI 3.26-4.00) was significantly higher compared to that of SPECT (2.76; 95 % CI 2.28-3.25; P = 0.006) and that of ECHO (2.83; 95 % CI 2.29-3.37; P = 0.02). There was no significant difference between the lnDOR of SPECT and ECHO (P = 0.52).

Conclusion: Our results suggest that MRI is superior for the diagnosis of obstructive CAD compared with ECHO and SPECT. ECHO and SPECT demonstrated similar diagnostic performance.

Fig. 1

Flow chart of systematic literature search

Fig. 2

Funnel plots. The diagnostic odds ratio (DOR) on the x-axis is plotted against the standard error (SE) of the log(DOR) on the y-axis. A symmetrical distribution of studies indicates the absence of publication bias. An asymmetrical distribution with, for example, relatively more smaller studies with a positive result (in the lower right part of the plot) would suggest the presence of publication bias. In the ECHO funnel plot Peltier et al. [56], in the SPECT funnel plot Astarita et al. [58] and in the MRI funnel plot Donati et al. [25] are not included, because their respective DORs could not be calculated (0 false negatives or false positives). a MRI, b ECHO, c SPECT

Fig. 3

Forest plots. The data are sorted by suspected and known CAD versus suspected CAD and CAD definition of ≥50 % versus ≥70 % stenosis from lowest to highest sensitivity and data are reported at the patient level. a MRI, b ECHO, c SPECT. *When data were available for both CAD definitions (≥50 % and ≥70 %) the summary estimates only include data from CAD ≥70 % stenosis

Fig. 4

ROC space with summary estimates for each technique with 95 % confidence areas. This figure shows the diagnostic performance of studies relative to each other with specificity (plotted in reverse) on the x-axis and sensitivity on the y-axis. Perfect diagnostic accuracy is in the upper left corner, where sensitivity and specificity are both 1. a MRI, b ECHO, c SPECT, d All three techniques. The grey rectangles in a refer to the studies using delayed contrast enhancement and in c they refer to the studies using gated SPECT with radiotracer ^99mTc. The size of the rectangles corresponds with the inverse standard error of sensitivity and specificity, which correlates with the size of the study

Fig. 5

Revised probability of CAD. This figure shows the revised (post-test) probability of CAD (y-axis) as a function of prior (pre-test) probability (x-axis) of CAD for positive and negative MPI results, based on the likelihood ratios presented in Table 3 (overall analysis). MRI+, ECHO+ and SPECT+ represent the lines for a positive test result and MRI−, ECHO− and SPECT− represent the lines for a negative test result