High negative predictive value of workload ≥7 METS on exercise testing in patients with normal gated myocardial perfusion imaging: Was imaging really required?

Document Type: Original Article

Authors

1 Department of Nuclear Cardiology, Karachi Institute of Heart Diseases (KIHD), Karachi, Pakistan

2 Department of Radiology, The Aga Khan University Hospital (AKUH), Karachi, Pakistan AND Department of Nuclear Medicine, Dr. Ziauddin Medical University, Karachi, Pakistan

3 Dow University of Health Sciences (DUHS), Karachi, Pakistan

Abstract

Introduction: Good functional capacity has a high negative predictive value (NPV) in patients with known or suspected coronary artery disease (CAD) similar to a normal gated myocardial perfusion imaging (GMPI). Aim of this study was to evaluate NPV of functional capacity during treadmill exercise in patients with normal GMPI in Pakistani population.
Methods: This was a prospective study which included 1318 individuals with normal exercise GMPI. On the basis of maximal age predicted heart rate (MAPHR) and metabolic equivalents (METS) achieved, these patient were divided into Group A: ≥ 85% MAPHR and ≥7 METS (714 patients), Group B: ≥85% MAPHR and <7METS (145 patients), Group C: <85% MAPHR and ≥7 METS (289 patients) and Group D: <85% MAPHR and <7 METS (170 patients). Patients were followed up on telephone (15 ±3 months) for fatal or non-fatal myocardial infarction (FMI and NFMI).
Results: There was no MI in any group but NFMIs was reported in 2.07% in Group B and 2.35% in Group D. NPV of a normal GMPI in relation with functional capacity was found to be 100% for Group A and C (≥7METS), 97.9% and 97.6% for Group B and D (<7METS) respectively.

Conclusion: We conclude that patients with ≥7 METS with normal GMPI had 100% NPV for FMI or NFMIs and omitting GMPI in these patients would save cost and avoid radiation exposure.

Keywords

Main Subjects


Gaziano JM. Global burden of cardiovascular disease. In: Libby P, Braunwald E. Braunwald’s Heart Disease. 8th ed. Philadelphia, PA: Saunders-Elsevier Publishing Co., Inc.; 2008. p. 1–22.

Thom T, Haase N, Rosamond W, Howard VJ, Rumsfeld J, Manolio T, Zheng ZJ, Flegal K, O'Donnell C, Kittner S, Lloyd-Jones D, Goff DC Jr, Hong Y, Adams R, Friday G, Furie K, Gorelick P, Kissela B, Marler J, Meigs J, Roger V, Sidney S, Sorlie P, Steinberger J, Wasserthiel-Smoller S, Wilson M, Wolf P; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006 Feb 14;113(6):e85-151.

Metz LD, Beattie M, Hom R, Redberg RF, Grady D, Fleischmann KE. The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta-analysis. J Am Coll Cardiol. 2007 Jan 16;49(2):227-37.

Thomas GS. President’s message: Advances in cardiovascular medicine. J Nucl Cardiol 2007;14:136-138.

Shaw LJ, Hendel R, Borges-Neto S, Lauer MS, Alazraki N, Burnette J, Krawczynska E, Cerqueira M, Maddahi J; Myoview Multicenter Registry. Prognostic value of normal exercise and adenosine (99m)Tc-tetrofosmin SPECT imaging: results from the multicenter registry of 4,728 patients. J Nucl Med. 2003 Feb;44(2):134-9. 

Zaman MU, Usmani S, Niyaz K, Kamal S, Hameed A. Validation of prognostic and negative predictive values of normal cardiac perfusion study in local population. PJR 2009;19(3):77-79

Fazel R, Krumholz HM, Wang Y, Ross JS, Chen J, Ting HH, Shah ND, Nasir K, Einstein AJ, Nallamothu BK. Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med. 2009 Aug 27;361(9):849-57.

Gianrossi R, Detrano R, Mulvihill D, Lehmann K, Dubach P, Colombo A, McArthur D, Froelicher V.  Exercise-induced ST depression in the diagnosis of coronary artery disease. A meta-analysis. Circulation. 1989 Jul;80(1):87-98.

Snader CE, Marwick TH, Pashkow FJ, Harvey SA, Thomas JD, Lauer MS. Importance of estimated functional capacity as a predictor of all-cause mortality among patients referred for exercise thallium single-photon emission computed tomography: report of 3,400 patients from a single center. J Am Coll Cardiol. 1997 Sep;30(3):641-8.

Gulati M, Black HR, Shaw LJ, Arnsdorf MF, Merz CN, Lauer MS, Marwick TH, Pandey DK, Wicklund RH, Thisted RA. The prognostic value of a nomogram for exercise capacity in women. N Engl J Med. 2005 Aug 4;353(5):468-75.

Morris CK, Ueshima K, Kawaguchi T, Hideg A, Froelicher VF. The prognostic value of exercise capacity: a review of the literature. Am Heart J. 1991 Nov;122(5):1423-31.

Bourque JM, Charlton GT, Holland BH, Belyea CM, Watson DD, Beller GA. Prognosis in patients achieving ≥10 METS on exercise stress testing: was SPECT imaging useful? J Nucl Cardiol. 2011 Apr;18(2):230-7.

Gibbons RJ, Balady GJ, Beasley JW, Bricker JT, Duvernoy WF, Froelicher VF, Mark DB, Marwick TH, McCallister BD, Thompson PD Jr, Winters WL, Yanowitz FG, Ritchie JL, Gibbons RJ, Cheitlin MD, Eagle KA, Gardner TJ, Garson A Jr, Lewis RP, O'Rourke RA, Ryan TJ. ACC/AHA Guidelines for Exercise Testing. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol. 1997 Jul;30(1):260-311.

Shareiff S, Shah-e-Zaman K. Exercise tolerance test in patients presenting with chest pain and normal eland normal electrocardiogram. J Coll Physicians Surg Pak 2002;12:348–352.

Shera AS, Rafique G, Khwaja IA, Baqai S, Khan IA, King H. Pakistan National Diabetes Survey prevalence of glucose intolerance and associated factors in North West at Frontier Province (NWFP) of Pakistan. J Pak Med Assoc. 1999 Sep;49(9):206-11.

Fang ZY1, Sharman J, Prins JB, Marwick TH. Determinants of exercise capacity in patients with type 2 diabetes. Diabetes Care. 2005 Jul;28(7):1643-8.

Brubaker PH, Kitzman DW.  Chronotropic incompetence: causes, consequences, and management. Circulation. 2011 Mar 8;123(9):1010-20.

Orso F1, Baldasseroni S, Maggioni AP. Heart rate in coronary syndromes and heart failure. Prog Cardiovasc Dis. 2009 Jul-Aug;52(1):38-45.

Uz Zaman M, Fatima N, Samad A, Ishaq M, Rasheed Z, Balcoh DJ, Rehman K, Bano J, Asif Wali M. Overall and gender-based negative predictive value of a normal gated myocardial perfusion SPECT study: a single center experience. Ann Nucl Med. 2011 Apr;25(3):207-11.

Kodama S, Saito K, Tanaka S, Maki M, Yachi Y, Asumi M, Sugawara A, Totsuka K, Shimano H, Ohashi Y, Yamada N, Sone H. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA. 2009 May 20;301(19):2024-35.

Morise AP, Jalisi F. Evaluation of pretest and exercise test scores to assess all-cause mortality in unselected patients presenting for exercise testing with symptoms of suspected coronary artery disease. J Am Coll Cardiol. 2003 Sep 3;42(5):842-50.

Goraya TY, Jacobsen SJ, Pellikka PA, Miller TD, Khan A, Weston SA, Gersh BJ, Roger VL. Prognostic value of treadmill exercise testing in elderly persons. Ann Intern Med. 2000 Jun 6;132(11):862-70.

Peterson PN, Magid DJ, Ross C, Ho PM, Rumsfeld JS, Lauer MS, Lyons EE, Smith SS, Masoudi FA. Association of exercise capacity on treadmill with future cardiac events in patients referred for exercise testing. Arch Intern Med. 2008 Jan 28;168(2):174-9. 

Bhat A, Desai A, Amsterdam EA. Usefulness of high functional capacity in patients with exercise-induced ST-depression to predict a negative result on exercise echocardiography and low prognostic risk. Am J Cardiol. 2008 Jun 1;101(11):1541-3.

Bourque JM, Holland BH, Watson DD, Beller GA.  Achieving an exercise workload of > or = 10 metabolic equivalents predicts a very low risk of inducible ischemia: does myocardial perfusion imaging have a role? J Am Coll Cardiol. 2009 Aug 4;54(6):538-45.

Mercuri M1, Rehani MM, Einstein AJ. Tracking patient radiation exposure: challenges to integrating nuclear medicine with other modalities.J J Nucl Cardiol. 2012 Oct;19(5):895-900.