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      Comparison of Coronary CT Angiography, SPECT, PET, and Hybrid Imaging for Diagnosis of Ischemic Heart Disease Determined by Fractional Flow Reserve

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          Abstract

          Importance

          At present, the choice of noninvasive testing for a diagnosis of significant coronary artery disease (CAD) is ambiguous, but nuclear myocardial perfusion imaging with single-photon emission tomography (SPECT) or positron emission tomography (PET) and coronary computed tomography angiography (CCTA) is predominantly used for this purpose. However, to date, prospective head-to-head studies are lacking regarding the diagnostic accuracy of these imaging modalities. Furthermore, the combination of anatomical and functional assessments configuring a hybrid approach may yield improved accuracy.

          Objectives

          To establish the diagnostic accuracy of CCTA, SPECT, and PET and explore the incremental value of hybrid imaging compared with fractional flow reserve.

          Design, Setting, and Participants

          A prospective clinical study involving 208 patients with suspected CAD who underwent CCTA, technetium 99m/tetrofosmin–labeled SPECT, and [ 15O]H 2O PET with examination of all coronary arteries by fractional flow reserve was performed from January 23, 2012, to October 25, 2014. Scans were interpreted by core laboratories on an intention-to-diagnose basis. Hybrid images were generated in case of abnormal noninvasive anatomical or functional test results.

          Main Outcomes and Measures

          Hemodynamically significant stenosis in at least 1 coronary artery as indicated by a fractional flow reserve of 0.80 or less and relative diagnostic accuracy of SPECT, PET, and CCTA in detecting hemodynamically significant CAD.

          Results

          Of the 208 patients in the study (76 women and 132 men; mean [SD] age, 58 [9] years), 92 (44.2%) had significant CAD (fractional flow reserve ≤0.80). Sensitivity was 90% (95% CI, 82%-95%) for CCTA, 57% (95% CI, 46%-67%) for SPECT, and 87% (95% CI, 78%-93%) for PET, whereas specificity was 60% (95% CI, 51%-69%) for CCTA, 94% (95% CI, 88%-98%) for SPECT, and 84% (95% CI, 75%-89%) for PET. Single-photon emission tomography was found to be noninferior to PET in terms of specificity ( P < .001) but not in terms of sensitivity ( P > .99) using the predefined absolute margin of 10%. Diagnostic accuracy was highest for PET (85%; 95% CI, 80%-90%) compared with that of CCTA (74%; 95% CI, 67%-79%; P = .003) and SPECT (77%; 95% CI, 71%-83%; P = .02). Diagnostic accuracy was not enhanced by either hybrid SPECT and CCTA (76%; 95% CI, 70%-82%; P = .75) or by PET and CCTA (84%; 95% CI, 79%-89%; P = .82), but resulted in an increase in specificity ( P = .004) at the cost of a decrease in sensitivity ( P = .001).

          Conclusions and Relevance

          This controlled clinical head-to-head comparative study revealed PET to exhibit the highest accuracy for diagnosis of myocardial ischemia. Furthermore, a combined anatomical and functional assessment does not add incremental diagnostic value but guides clinical decision-making in an unsalutary fashion.

          Abstract

          This head-to-head comparative study evaluates the diagnostic accuracy of coronary computed tomography angiography, single-photon emission tomography, and positron emission tomography and explores the incremental value of hybrid imaging compared with fractional flow reserve.

          Key Points

          Question

          What are the diagnostic performances of coronary computed tomography angiography, single-photon emission tomography, [ 15O]H 2O positron emission tomography, and hybrid imaging for the diagnosis of myocardial ischemia using fractional flow reserve as a reference standard?

          Findings

          In this head-to-head comparative study of 208 adults, sensitivity was 90% for coronary computed tomography angiography, 57% for single-photon emission tomography, and 87% for positron emission tomography, whereas specificity was 60% for coronary computed tomography angiography, 94% for single-photon emission tomography, and 84% for positron emission tomography. Positron emission tomography exhibited the highest diagnostic accuracy compared with single-photon emission tomography and coronary computed tomography angiography.

          Meaning

          Coronary computed tomography angiography and [ 15O]H 2O positron emission tomography are both useful in the diagnosis of myocardial ischemia, while single-photon emission tomography and hybrid imaging guide clinical decision making in an unsalutary fashion.

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          Author and article information

          Journal
          JAMA Cardiol
          JAMA Cardiol
          JAMA Cardiol
          JAMA Cardiology
          American Medical Association
          2380-6583
          2380-6591
          16 August 2017
          18 October 2017
          October 2017
          18 October 2018
          : 2
          : 10
          : 1100-1107
          Affiliations
          [1 ]Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
          [2 ]Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, the Netherlands
          [3 ]Department of Radiology, St Paul’s Hospital, Vancouver, British Columbia, Canada
          [4 ]Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
          [5 ]Department of Nuclear Medicine, Royal Brompton Hospital, London, England
          [6 ]Department of Radiology, Weill Cornell Medical College, New York, New York
          [7 ]Dalio Institute of Cardiovascular Imaging, New York–Presbyterian Hospital, New York
          [8 ]Cardiology Centers of the Netherlands, Amsterdam, the Netherlands
          [9 ]Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, the Netherlands
          Author notes
          Article Information
          Corresponding Author: Paul Knaapen, MD, PhD, Department of Cardiology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands ( p.knaapen@ 123456vumc.nl ).
          Accepted for Publication:
          Published Online:10.1001/jamacardio.2017.2471
          Author Contributions:
          Study concept and design:
          Acquisition, analysis, or interpretation of data:
          Drafting of the manuscript:
          Critical revision of the manuscript for important intellectual content:
          Statistical analysis:
          Obtained funding:
          Administrative, technical, or material support:
          Study supervision:
          Conflict of Interest Disclosures:
          Article
          PMC5710451 PMC5710451 5710451 hoi170038
          10.1001/jamacardio.2017.2471
          5710451
          28813561
          Copyright 2017 American Medical Association. All Rights Reserved.
          Categories
          Research
          Research
          Original Investigation
          Featured
          Online First

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