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. 2023 Oct 24;82(17):1662-1672.
doi: 10.1016/j.jacc.2023.08.027.

Impact of Positron Emission Tomographic Myocardial Perfusion Imaging on Patient Selection for Revascularization

Krishna K Patel  1 , A Iain McGhie  2 , Kevin F Kennedy  2 , Randall C Thompson  2 , John A Spertus  2 , Brett W Sperry  2 , Leslee J Shaw  3 , Timothy M Bateman  2
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Free article

Impact of Positron Emission Tomographic Myocardial Perfusion Imaging on Patient Selection for Revascularization

Krishna K Patel et al. J Am Coll Cardiol. .
Free article

Abstract

Background: Positron emission tomography (PET) myocardial perfusion imaging (MPI) quantifies left ventricular ejection fraction (LVEF) at peak stress. PET LVEF reserve (LVEF-R = stress LVEF - rest LVEF) offers diagnostic and prognostic value.

Objectives: The purpose of this study was to determine if PET LVEF-R identifies patients with survival benefit postrevascularization.

Methods: We followed 14,649 unique consecutive patients undergoing 82Rb rest/stress PET MPI from January 2010 to January 2016 (excluding known cardiomyopathy). Adjusted Cox models were built to predict all-cause death, and the 3-way interaction of known coronary artery disease (CAD) (prior myocardial infarction/revascularization), LVEF-R, and 90-day revascularization was tested.

Results: Known CAD was present in 4,982 (34.0%). Ischemia was detected in 5,396 (36.8%; ≥10% in 1,909 [13%]). Mean LVEF-R was 4.2% ± 5.7%, and was ≤0, 1 to 5, and >5 in 3,349 (22.9%), 5,266 (35.9%), and 6,034 (41.2%). Over median follow-up of 3.4 years (IQR: 1.9-5.2 years), 1,324 (8.1%) had 90-day revascularization, and there were 2,192 (15.0%) deaths. In multivariable modeling, there was a significant 3-way interaction among known CAD, LVEF-R, and 90-day revascularization (P = 0.025), such that LVEF-R ≤0 identified patients with survival benefit with 90-day revascularization in those without prior CAD (interaction P = 0.005), independently beyond percent ischemia and myocardial flow reserve. Among patients with known CAD, LVEF-R was not prognostic of death (HR: 0.99; 95% CI: 0.98-1.02; P = 0.98).

Conclusions: A lack of augmentation or drop in LVEF with vasodilator stress on PET MPI independently identifies patients who have better survival with revascularization within 90 days post-MPI compared with medical therapy, in absence of prior myocardial infarction or revascularization. Multiparametric assessment of ischemia with PET can optimize post-test management.

Keywords: LVEF reserve; myocardial perfusion imaging; positron emission tomography; stress imaging.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Patel has received a research grant from Jubilant DraxImage, Inc; and has received support from an unrestricted grant from the Blavatnik Family Foundation. Dr Spertus has served as a consultant to United Healthcare, Janssen, Merck, Bristol Myers Squibb, Terumo, Bayer, and Imbria Pharmaceuticals; has received research grants from Abbott Vascular, Janssen, and Bristol Myers Squibb; is the Principal Investigator of an analytic center for the American College of Cardiology; owns copyright for Seattle Angina Questionnaire, Kansas City Cardiomyopathy Questionnaire, and Peripheral Artery Questionnaire; and serves on the Board of Directors for Blue Cross-Blue Shield of Kansas City. Dr Sperry has received professional fees from Pfizer, Alnylam, and Eidos/BridgeBio. Dr Shaw has received support from an unrestricted grant from the Blavatnik Family Foundation. Dr Bateman has received research grants from Bracco, GEHC, and Spectrum Dynamics; has served as a consultant to GEHC and Synetik; has equity interest in CVIT; and has intellectual property rights for Imagen SPECT and PET software products. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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