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      Prognostic Value of Myocardial Perfusion Imaging in Symptomatic and Asymptomatic Patients after Percutaneous Coronary Intervention

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          Abstract

          The aim of this study was to evaluate the value of myocardial perfusion imaging (MPI) in predicting major adverse cardiovascular events (MACE) in symptomatic and asymptomatic patients after percutaneous coronary intervention (PCI). We revised retrospectively patients after PCI that underwent MPI and were followed for a year for the presence of MACE. We found no differences in the incidence of MACE between symptomatic and asymptomatic patients. On multivariate analysis, the presence of ischemia by MPI was the most important independent predictor of MACE (OR 5.09, CI 95% 2.15–12.05, p < 0.001). The presence of myocardial ischemia by MPI performed after PCI, and no symptom status, predicts a worse outcome during 1 year of follow-up.

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          Most cited references 12

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          Clinical and angiographic factors associated with asymptomatic restenosis after percutaneous coronary intervention.

          Angiographic restenosis after percutaneous coronary interventional procedures is more common than recurrent angina. Clinical and angiographic factors associated with asymptomatic versus symptomatic restenosis after percutaneous coronary intervention were compared. All patients with angiographic restenosis from the BENESTENT I, BENESTENT II pilot, BENESTENT II, MUSIC, WEST 1, DUET, FINESS 2, FLARE, SOPHOS, and ROSE studies were analyzed. Multivariate analysis evaluated 46 clinical and angiographic variables, comparing those with and without angina. The 10 studies recruited 2690 patients who underwent percutaneous revascularization and 6-month follow-up angiography (86% of those eligible). Restenosis (>/=50% diameter stenosis) occurred in 607 patients and was clinically silent in 335 (55%). Male sex (P=0.008), absence of antianginal therapy with nitrates (P=0.0002) and calcium channel blockers (P=0.02) at 6 months, greater reference diameter after the procedure (P=0.04), greater reference diameter at follow-up (P=0.004), and lesser lesion severity (percent stenosis) at 6 months (P=0.0004) were univariate predictors of asymptomatic restenosis. By multivariate analysis, only male sex (P=0.04), greater reference diameter at follow-up (P=0.002), and lesser lesion severity at 6 months (P=0.0001) were associated with restenosis without angina. Approximately half of patients with angiographic restenosis have no symptoms. The only multivariate predictors of silent restenosis at 6 months were male sex, greater reference diameter at follow-up, and lesser lesion severity on follow-up angiography.
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            Myocardial perfusion imaging following percutaneous coronary intervention: the importance of restenosis, disease progression, and directed reintervention.

            Percutaneous coronary intervention (PCI) has become a mainstay in the treatment of patients with coronary artery disease. Currently, more than one million coronary angioplasty and stent implantation procedures are performed annually. Although increasingly complex lesions and higher risk patients are being successfully treated percutaneously, restenosis and disease progression continue to cause significant morbidity. Restenosis occurs in approximately one-third of patients, one-half of who remain asymptomatic, while disease progression occurs at rates approaching 7% per year. Despite technological advances, unadjusted mortality rates have actually increased since the mid-1980s, and the current annual risk of a major adverse cardiac event following PCI is 5% to 7%. Although randomized clinical trials are needed to more definitively show a benefit, when performed six or more months following PCI, myocardial perfusion imaging reliably identifies patients most at risk of a poor long-term outcome. Directed reintervention can have a salutary impact on the prognosis of these patients. In view of recent data showing a positive impact of imaging and reintervention in patients after PCI, current guidelines should be reassessed.
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              Long-term outcome of patients with silent versus symptomatic ischemia six months after percutaneous coronary intervention and stenting.

              We sought to evaluate the incidence of silent ischemia versus symptomatic ischemia six months after percutaneous coronary intervention (PCI) and its impact on prognosis and to test the utility of myocardial perfusion single-photon emission computed tomography (SPECT), or MPS, for risk stratification in these patients. Silent ischemia is frequent after PCI. However, little is known about silent ischemia and long-term outcome after PCI and stenting. In 356 consecutive patients with successful PCI and stenting and follow-up MPS after six months, long-term follow-up (4.1 +/- 0.3 years) was performed. The MPS images were interpreted by defining summed stress, rest, and difference scores (summed difference score [SDS] = extent of ischemia) and related to symptoms and outcome. Critical events included cardiac death, myocardial infarction, and target vessel revascularization. Eighty-one patients (23%) had evidence of target vessel ischemia, which was silent in 62%. The only independent predictor of silent ischemia was SDS (odds ratio 0.64, p = 0.001). During follow-up, 67 critical events occurred. For patients with an SDS of 0, 1-4, and >4, the critical event rates were 17%, 29%, and 69%, respectively. Similarly, patients without ischemia, silent ischemia, and symptomatic ischemia had 17%, 32%, and 52% of critical events, respectively. Diabetes (relative risk 1.98, p = 0.03) and SDS (relative risk 1.2, p < 0.001) were independent predictors of critical events. The MPS image added incremental information for the prediction of critical events. Six months after PCI and stenting, 23% of patients had target vessel ischemia, which was silent in 62%. Silent ischemia predicted a worse outcome than did no ischemia and tended to have a better outcome than symptomatic ischemia. This was closely related to the extent of ischemia. The SDS added incremental value to pre-scan findings with respect to diagnosis and prognosis, indicating the utility of MPS for risk stratification after PCI and stenting.
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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2007
                December 2006
                31 May 2006
                : 107
                : 1
                : 38-43
                Affiliations
                Department of Cardiology, Rabin Medical Center, Beilinson Campus, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
                Article
                93611 Cardiology 2007;107:38–43
                10.1159/000093611
                16741356
                © 2007 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 2, Tables: 4, References: 15, Pages: 6
                Categories
                Original Research

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