Non-invasive Techniques for Detection of Coronary Artery Disease

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US Cardiology 2006;2005:2(1):1-7

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A significant amount of data has accumulated over the past 20 years, demonstrating the value of exercise or pharmacologic stress non-invasive cardiovascular imaging techniques for the diagnostic and prognostic assessment of patients with suspected or known cardiovascular disease.1-8 Stress can be induced by either multistage exercise testing that is symptom-limited or by pharmacologic means with either a vasodilator (e.g. dipyridamole or adenosine) or an inotropic agent (e.g. dobutamine). The combination of low-level exercise with vasodilator stress radionuclide myocardial perfusion imaging enhances both the quality of images (diminished visceral tracer uptake) and reduces vasodilator-induced side effects.

Detection of Coronary Artery Disease
Radionuclide Single-photon Emission Computed Tomography Stress Perfusion Imaging

The sensitivity of radionuclide exercise myocardial perfusion imaging for detection of coronary artery disease (CAD) averaged 87% in 33 studies pooled from the literature.8 Specificity averaged 73% with a normalcy rate significantly higher at 91%. The normalcy rate is a variable that reduces the effect of referral bias inherent in specificity determinations that require cardiac catheterization in normal coronary angiograms for the gold standard for true negative test results. This is because the preponderance of referrals to the catheterization laboratory among patients undergoing stress perfusion imaging are those who have abnormal scans. Thus, a bias is inherent in the fact that more false positive patients are referred for coronary angiography than true negative patients. The normalcy rate is defined as the percentage of patients who have <5% pretest likelihood of CAD and who have normal myocardial perfusion studies. The sensitivity and specificity of exercise myocardial perfusion imaging are higher than the sensitivity and specificity of electrocardiographic treadmill testing alone.9 When patients with resting ST-segment depression are excluded, the sensitivity and specificity of the exercise echocardiogram (ECG) stress test were only 67% and 84%, respectively.10

With respect to myocardial perfusion imaging employing the single-photon emission computed tomography (SPECT) technique, the major problem is with specificity. This is predominantly due to attenuation artifacts (breast attenuation in women and posterobasal attenuation) that may be misconstrued as defects attributed to underlying coronary artery stenoses. The use of technetium-99m (99mTc)-labeled perfusion agents (e.g. sestamibi and tetrofosmin) combined with ECG-gating substantially improves the specificity of SPECT perfusion imaging compared with ungated thallium-201(201Tl) scintigraphy.11

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