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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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          <div class="section"> <a class="named-anchor" id="ab-hoi170038-1"> <!-- named anchor --> </a> <h5 class="section-title" id="d4403033e576">Importance</h5> <p id="d4403033e578">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. </p> </div><div class="section"> <a class="named-anchor" id="ab-hoi170038-2"> <!-- named anchor --> </a> <h5 class="section-title" id="d4403033e581">Objectives</h5> <p id="d4403033e583">To establish the diagnostic accuracy of CCTA, SPECT, and PET and explore the incremental value of hybrid imaging compared with fractional flow reserve. </p> </div><div class="section"> <a class="named-anchor" id="ab-hoi170038-3"> <!-- named anchor --> </a> <h5 class="section-title" id="d4403033e586">Design, Setting, and Participants</h5> <p id="d4403033e588">A prospective clinical study involving 208 patients with suspected CAD who underwent CCTA, technetium 99m/tetrofosmin–labeled SPECT, and [ <sup>15</sup>O]H <sub>2</sub>O 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. </p> </div><div class="section"> <a class="named-anchor" id="ab-hoi170038-4"> <!-- named anchor --> </a> <h5 class="section-title" id="d4403033e597">Main Outcomes and Measures</h5> <p id="d4403033e599">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. </p> </div><div class="section"> <a class="named-anchor" id="ab-hoi170038-5"> <!-- named anchor --> </a> <h5 class="section-title" id="d4403033e602">Results</h5> <p id="d4403033e604">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 ( <i>P</i> &lt; .001) but not in terms of sensitivity ( <i>P</i> &gt; .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%; <i>P</i> = .003) and SPECT (77%; 95% CI, 71%-83%; <i>P</i> = .02). Diagnostic accuracy was not enhanced by either hybrid SPECT and CCTA (76%; 95% CI, 70%-82%; <i>P</i> = .75) or by PET and CCTA (84%; 95% CI, 79%-89%; <i>P</i> = .82), but resulted in an increase in specificity ( <i>P</i> = .004) at the cost of a decrease in sensitivity ( <i>P</i> = .001). </p> </div><div class="section"> <a class="named-anchor" id="ab-hoi170038-6"> <!-- named anchor --> </a> <h5 class="section-title" id="d4403033e632">Conclusions and Relevance</h5> <p id="d4403033e634">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. </p> </div><p class="first" id="d4403033e637">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. </p><div class="section"> <a class="named-anchor" id="ab-hoi170038-7"> <!-- named anchor --> </a> <h5 class="section-title" id="d4403033e643">Question</h5> <p id="d4403033e645">What are the diagnostic performances of coronary computed tomography angiography, single-photon emission tomography, [ <sup>15</sup>O]H <sub>2</sub>O positron emission tomography, and hybrid imaging for the diagnosis of myocardial ischemia using fractional flow reserve as a reference standard? </p> </div><div class="section"> <a class="named-anchor" id="ab-hoi170038-8"> <!-- named anchor --> </a> <h5 class="section-title" id="d4403033e654">Findings</h5> <p id="d4403033e656">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. </p> </div><div class="section"> <a class="named-anchor" id="ab-hoi170038-9"> <!-- named anchor --> </a> <h5 class="section-title" id="d4403033e659">Meaning</h5> <p id="d4403033e661">Coronary computed tomography angiography and [ <sup>15</sup>O]H <sub>2</sub>O 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. </p> </div>

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          JAMA Cardiology
          JAMA Cardiol
          American Medical Association (AMA)
          October 01 2017
          October 01 2017
          : 2
          : 10
          : 1100
          © 2017


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