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Appropriate use criteria (AUC) for single-photon emission computed tomography myocardial perfusion images (SPECT-MPIs) were developed to address the growth of cardiac imaging studies. Long-term prognostic value of AUC in SPECT-MPI has not been tested in existing cohorts. We sought to determine the long-term prognostic value of MPI classified as appropriate. AUC was evaluated in a prospectively designed cohort of patients who underwent clinically indicated MPI. MPI studies were classified based on 2009 AUC for SPECT-MPI. Data regarding downstream coronary angiography (cath), revascularization and all-cause mortality, cardiac death, and nonfatal myocardial infarction (MI) were collected from national registries. Among n = 1,129 MPI scans that received an appropriate grading, 148 all-cause deaths, 109 MIs, 58 cardiac deaths, 152 caths, 113 revascularization procedures occurred over a mean follow-up period of 5.4 ± 1.2 years (0.9% cardiac death rate per year, 1.8% MI rate per year). Most of the scans were low-risk normal MPI scans (summed stress score ≤3; 74.1%). An abnormal scan was associated with higher rates of MI (19.5% vs 6.2%, hazard ratio 1.72, p = 0.017) and cardiac death (13.4% vs 2.3%, hazard ratio 2.12, p = 0.016). In conclusion, MPI scans classified as appropriate have long-term prognostic value, despite a high proportion of low-risk scans. This provides support for clinicians to consider the use of appropriate grading in addition to MPI scan results in patient management.

BackgroundUnderstanding pandemic-related reductions and subsequent recovery of cardiovascular testing in Asia is important for guiding regional public health efforts.ObjectivesThis study sought to evaluate the recovery of cardiovascular testing in Asia 1 year into the COVID-19 pandemic.MethodsIn this subanalysis of a worldwide survey on the impact of COVID-19 on cardiovascular diagnostic care in April 2020 and April 2021, recovery of testing volume in Asia was compared among subregions, World Bank income groups and imaging modalities.ResultsOf 669 sites worldwide, 164 sites were in 33 Asian countries. Cardiovascular testing volumes in Asia decreased by 53% from March 2019 to April 2020, then recovered 96% of this decrease by April 2021, compared with 98% recovery in the rest of the world. Eastern Asia and Western and Central Asia reported recovery rates of 123% and 110%, compared with 50% and 80% recovery in Southern and South-eastern Asia. Testing volumes among high-income and upper-middle-income Asian countries recovered to 117% and 121% but remained depressed at 49% and 14% recovery in lower-middle and low-income countries, respectively. Stress ECG, stress echo and stress positron emission tomography studies experienced median reductions of 48%, 35% and 57% in testing volume between March 2019 and April 2021, while volumes of coronary artery calcium, coronary CT angiography and cardiac MR remained stable during this period.ConclusionsThe recovery of cardiovascular testing in Asia 1 year into the COVID-19 pandemic lagged in the Southern and South-eastern subregions, as well as in lower-income countries. Recovery favoured advanced cardiac imaging modalities over standard stress testing modalities.

Background Exercise treadmill testing is used to evaluate patients for coronary disease and predict risk of future cardiac events. While it is known that the Duke Treadmill Score (DTS) obtained from this test is a useful composite prognostic index used to determine event-free survival, we are less clear about the impact and interactions of pre-existing coronary risk factors on exercise outcome and ejection fraction. ObjectiveTo evaluate the impact of pre-existing coronary risk factors on exercise outcome during cardiac stress testing and cardiac function. Methods We analysed a prospective registry of patients referred for exercise stress myocardial perfusion imaging between 1 January 2006 and 31 December 2008 who had no known coronary disease (CAD). Clinical characteristics including symptoms, medical history and pre-existing coronary risk factors were prospectively collected and validated at time of exercise testing. The DTS was computed immediately after exercise testing by trained cardiologists using standard formula. Cardiac ejection fraction post-stress was obtained by nuclear myocardial perfusion imaging. T-test and ANOVA were used to compare mean DTS between groups. A linear regression model was fitted to determine independent predictors of DTS. Results We looked at 6298 patients (mean age 55 ± 11, 38% females) with diabetes (20%), hypertension (51%), hyperlipidemia (14%), smoking (63%) and family history of CAD (17%). There was a statistically significant correlation between the presence of each risk factor and mean DTS (p < 0.05). Patients who had diabetes had lower mean DTS compared to those who did not have diabetes (DTS = 7.73 vs 9.31, p < 0.001). There were significant differences in DTS between EF categories (EF ≤ 30, median DTS = 6.00; EF = 31–50, median DTS = 8.00; EF > 50, median DTS = 8.50; p = 0.006). The association between DTS and EF with risk factors was cumulative; patients who had 3 risk factors were more likely to have lower DTS (OR 1.419, 95% CI 1.296–1.555, p with EF≤30 vs 18% with EF > 50, p < 0.001); compared to patients with no risk factors. Linear regression analysis showed that female gender (beta = –2.152, p < 0.001) and diabetes (beta = –0.968, p < 0.001) were strong independent predictors of DTS. Conclusions We found significant associations between pre-existing coronary risk factors and exercise outcome. The impact of risk factors was cumulative; in particular gender and diabetes independently predicted DTS.

BackgroundExercise treadmill testing is used to evaluate patients for coronary disease and predict risk of future cardiac events. While it is known that the Duke Treadmill Score (DTS) obtained from this test is a useful composite prognostic index used to determine event-free survival, we are less clear about the impact and interactions of pre-existing coronary risk factors on exercise outcome and ejection fraction.ObjectiveTo evaluate the impact of pre-existing coronary risk factors on exercise outcome during cardiac stress testing and cardiac function.MethodsWe analysed a prospective registry of patients referred for exercise stress myocardial perfusion imaging between 1 January 2006 and 31 December 2008 who had no known coronary disease (CAD). Clinical characteristics including symptoms, medical history and pre-existing coronary risk factors were prospectively collected and validated at time of exercise testing. The DTS was computed immediately after exercise testing by trained cardiologists using standard formula. Cardiac ejection fraction post-stress was obtained by nuclear myocardial perfusion imaging. T-test and ANOVA were used to compare mean DTS between groups. A linear regression model was fitted to determine independent predictors of DTS.ResultsWe looked at 6298 patients (mean age 55 plus or minus 11, 38% females) with diabetes (20%), hypertension (51%), hyperlipidemia (14%), smoking (63%) and family history of CAD (17%). There was a statistically significant correlation between the presence of each risk factor and mean DTS (p < 0.05). Patients who had diabetes had lower mean DTS compared to those who did not have diabetes (DTS = 7.73 vs 9.31, p < 0.001). There were significant differences in DTS between EF categories (EF less than or equal to 30, median DTS = 6.00; EF = 31-50, median DTS = 8.00; EF > 50, median DTS = 8.50; p = 0.006). The association between DTS and EF with risk factors was cumulative; patients who had 3 risk factors were more likely to have lower DTS (OR 1.419, 95% CI 1.296-1.555, p with EF less than or equal to 30 vs 18% with EF > 50, p < 0.001); compared to patients with no risk factors. Linear regression analysis showed that female gender (beta = -2.152, p < 0.001) and diabetes (beta = -0.968, p < 0.001) were strong independent predictors of DTS.ConclusionsWe found significant associations between pre-existing coronary risk factors and exercise outcome. The impact of risk factors was cumulative; in particular gender and diabetes independently predicted DTS.