Original Article
Prevalence, location, and extent of significant coronary artery disease in patients with normal myocardial perfusion imaging

https://doi.org/10.1007/s12350-013-9837-5Get rights and content

Abstract

Background

False-negative myocardial perfusion imaging (MPI) can by due to left main (LM) or three-vessel disease causing “balanced ischemia”. However, so far prevalence of LM or three-vessel-disease in patients with normal MPI is unclear. We assessed prevalence, location, and extent of significant coronary artery disease (CAD) in patients with normal MPI.

Methods

Between 2006 and 2010, 256 patients with normal MPI who had invasive angiography because of persisting or worsening of the same initial symptoms were studied. Significant CAD was defined as stenosis > 70% or LM > 50%.

Results

A total of 93 patients (36%) had significant CAD. Significant CAD was observed more frequently in males, higher age and those with typical angina complaints. Significant LM disease was present in 7%, three-vessel disease in 10%, two-vessel disease in 22%, and single vessel disease (not left main) in 61%. In those with single vessel disease, the location was the LAD in 40%, the RCA in 30%, and the LCX in 30%.

Conclusions

In selected patients with normal MPI, one-third had significant CAD. The majority of these patients had single vessel disease (not left main). LM or three vessel disease, causing “balanced ischemia”, is a less common cause of false-negative MPI.

Introduction

Myocardial perfusion imaging (MPI) using single-photon emission computed tomography (SPECT) provides valuable diagnostic and prognostic information in patients referred for non-invasive detection of myocardial ischemia.1, 2, 3, 4 However, its pure functional character renders it unable to detect atherosclerosis without hemodynamic consequences.

Moreover, left main disease and three vessel disease may cause false-negative MPI.5, 6, 7, 8 So far, the location and extent of significant artery stenosis in patients with normal MPI are not clear.7

Therefore, the aim of our study was to assess the prevalence, location, and the extent of significant coronary artery stenoses in patients with normal MPI who underwent invasive coronary angiography because of persisting or worsening of the same initial symptoms.

Section snippets

Study population

We performed a retrospective analysis of all 11,402 patients who underwent MPI-using 99mTc-Tetrofosmin (Technetium-99m) SPECT in the Isala hospital, in Zwolle, the Netherlands between January 2006 and December 31st 2009. Of these patients, a total of 1,602 patients (14%) underwent invasive coronary angiography within 6 months after MPI because of persisting or worsening symptoms as expressed during their outpatient follow-up. Of the 1,602 patients, in 256 patients MPI was assessed as normal.

Baseline Characteristics

Mean age of the 256 patients was 63 ± 11 years, 47% were female and the mean body mass index (BMI) was 28 ± 4 kg/m2. Hypertension and hypercholesterolemia were found in more than half of the patients. A total of 13% of patients had a history of previous percutaneous coronary intervention (PCI) and 11% had undergone a CABG before the SPECT. Aspirin, beta-blocker and statin were prescribed to the majority of the patients when they were referred to invasive coronary angiography. Fifty-four percent

Discussion

In this study, the prevalence, location, and extent of significant coronary artery disease was assessed in 256 patients with normal MPI who underwent invasive angiography within six months because of persistent anginal complaints. We found that in this selected population, one-third (93 patients) had angiographically significant coronary disease. Surprisingly, unprotected left main disease and/or three-vessel disease were present in only 11% of the patients with significant CAD. The majority of

New Knowledge Gained

So-called balanced ischemia is only in a minority the cause of false-negative MPI.

Conclusion

In selected patients with normal SPECT MPI who were referred for invasive coronary angiography because of persisting or worsening of the same initial complaints, one-third had significant coronary artery disease. The majority of these patients (61%) had single vessel disease (not left main included). Probably, left main or three vessel disease, causing “balanced ischemia”, is less important as cause of false-negative MPI.

Conflict of interest

The authors have indicated that they have no financial conflict of interest.

Disclosures

None.

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