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. 2020 Feb 1;41(6):759-768.
doi: 10.1093/eurheartj/ehz389.

Myocardial blood flow reserve assessed by positron emission tomography myocardial perfusion imaging identifies patients with a survival benefit from early revascularization

Krishna K Patel  1   2 , John A Spertus  1   2 , Paul S Chan  1   2 , Brett W Sperry  1   2 , Firas Al Badarin  1   2 , Kevin F Kennedy  2 , Randall C Thompson  1   2 , James A Case  3 , A Iain McGhie  1   2 , Timothy M Bateman  1   2
Affiliations

Myocardial blood flow reserve assessed by positron emission tomography myocardial perfusion imaging identifies patients with a survival benefit from early revascularization

Krishna K Patel et al. Eur Heart J. .

Abstract

Aims: Positron emission tomography (PET) myocardial perfusion imaging (MPI) can non-invasively measure myocardial blood flow reserve (MBFR). We aimed to examine whether MBFR identifies patients with a survival benefit after revascularization, helping to guide post-test management.

Methods and results: We examined all-cause mortality in 12 594 consecutive patients undergoing Rb82 rest/stress PET MPI from January 2010 to December 2016, after excluding those with cardiomyopathy, prior coronary artery bypass surgery (CABG), and missing MBFR. Myocardial blood flow reserve was calculated as the ratio of stress to rest absolute myocardial blood flow. A Cox model adjusted for patient and test characteristics, early revascularization (percutaneous coronary intervention or CABG ≤90 days of MPI), and the interaction between MBFR and early revascularization was developed to identify predictors of all-cause mortality. After a median follow-up of 3.2 years, 897 patients (7.1%) underwent early revascularization and 1699 patients (13.5%) died. Ischaemia was present in 4051 (32.3%) patients, with 1413 (11.2%) having ≥10% ischaemia. Mean MBFR was 2.0 ± 1.3, with MBFR <1.8 in 4836 (38.5%). After multivariable adjustment, every 0.1 unit decrease in MBFR was associated with 9% greater hazard of all-cause death (hazard ratio 1.09, 95% confidence interval 1.08-1.10; P < 0.001). There was a significant interaction between MBFR and early revascularization (P < 0.001); such that patients with MBFR ≤1.8 had a survival benefit with early revascularization, regardless of type of revascularization or level of ischaemia.

Conclusion: Myocardial blood flow reserve on PET MPI is associated with all-cause mortality and can identify patients who receive a survival benefit with early revascularization compared to medical therapy. This may be used to guide revascularization, and prospective validation is needed.

Keywords: Myocardial blood flow reserve; Myocardial perfusion imaging; Positron emission tomography; Survival.

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Figures

Figure 1
Figure 1
Kaplan–Meier unadjusted survival estimates as a function of myocardial blood flow reserve at baseline.
Figure 2
Figure 2
Kaplan–Meier unadjusted survival estimates as a function of percent ischaemic myocardium at baseline (A), and substratified by myocardial blood flow reserve within 0% (B), 1–10% (C) and >10% (D) ischaemia.
Figure 3
Figure 3
Hazards for death with early revascularization compared to medical therapy based on global myocardial blood flow reserve by positron emission tomography myocardial perfusion imaging.
Figure 4
Figure 4
Analysis of interaction of myocardial blood flow reserve with early revascularization vs. medical therapy on long-term death, within levels of ischaemia. Estimates derived from the fully adjusted Cox proportional hazards analysis (three-way interaction of ischaemia * myocardial blood flow reserve * early revascularization P = 0.90).
Figure 5
Figure 5
Hazards for cardiac death with early revascularization compared to medical therapy based on global myocardial blood flow reserve by positron emission tomography myocardial perfusion imaging.
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