Division of Cardiology, Rush University Medical Center, Chicago, IL (R.D., K.H., N.F., M.O.R.); Division of Adult Cardiology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL (R.D., Y.G.); Department of Medicine, Iowa Methodist Medical Center, Des Moines (G.B.); Division of Hospitalist Medicine, Rockford Memorial Hospital, Rockford, IL (V.S.D.); Division of Cardiology, Mount Sinai Hospital, Chicago, IL (E.G.-S.); and Cardiovascular Division, University of Miami, Miller School of Medicine, Miami, FL (R.C.H.).
Circulation. 2013 Oct 8;128(15):1634-43. doi: 10.1161/CIRCULATIONAHA.113.002744. Epub 2013 Sep 10.
Appropriate use criteria (AUC) have been developed to aid in the optimal use of single-photon emission computed tomography (SPECT)-myocardial perfusion imaging (MPI), a technique that is a mainstay of risk assessment for ischemic heart disease. The impact of appropriate use on the prognostic value of SPECT-MPI is unknown.
A prospective cohort study of 1511 consecutive patients undergoing outpatient, community-based SPECT-MPI was conducted. Subjects were stratified on the basis of the 2009 AUC for SPECT-MPI into an appropriate or uncertain appropriateness group and an inappropriate group. Patients were prospectively followed up for 27±10 months for major adverse cardiac events of death, death or myocardial infarction, and cardiac death or myocardial infarction. In the entire cohort, the 167 subjects (11%) with an abnormal scan experienced significantly higher rates of major adverse cardiac events and coronary revascularization than those with normal MPI. Among the 823 subjects (54.5%) whose MPIs were classified as appropriate (779, 51.6%) or uncertain (44, 2.9%), an abnormal scan predicted a multifold increase in the rates of death (9.2% versus 2.6%; hazard ratio, 3.1; P=0.004), death or myocardial infarction (11.8% versus 3.3%; hazard ratio, 3.3; P=0.001), cardiac death or myocardial infarction (6.7% versus 1.7%; hazard ratio, 3.7; P=0.006), and revascularization (24.7% versus 2.7%; hazard ratio, 11.4; P<0.001). Among the 688 subjects (45.5%) with MPI classified as inappropriate, an abnormal MPI failed to predict major adverse cardiac events, although it was associated with a high revascularization rate. Furthermore, appropriate MPI use provided incremental prognostic value beyond myocardial perfusion and ejection fraction data.
When performed for appropriate indications, SPECT-MPI continues to demonstrate high prognostic value. However, inappropriate use lacks effectiveness for risk stratification, further emphasizing the need for optimal patient selection for cardiac testing.
适当使用标准（AUC）已被开发出来，以帮助优化单光子发射计算机断层扫描（SPECT）-心肌灌注成像（MPI）的使用，该技术是缺血性心脏病风险评估的主要手段。适当使用对 SPECT-MPI 预后价值的影响尚不清楚。
对 1511 例连续门诊社区 SPECT-MPI 患者进行前瞻性队列研究。根据 2009 年 SPECT-MPI 的 AUC 将受试者分为适当或不确定适当组和不适当组。前瞻性随访患者 27±10 个月，主要不良心脏事件为死亡、死亡或心肌梗死以及心源性死亡或心肌梗死。在整个队列中，167 例（11%）异常扫描患者的主要不良心脏事件和冠状动脉血运重建率明显高于 MPI 正常患者。在 823 例（54.5%）MPI 被归类为适当（779，51.6%）或不确定（44，2.9%）的患者中，异常扫描预测死亡（9.2%对 2.6%；风险比，3.1；P=0.004）、死亡或心肌梗死（11.8%对 3.3%；风险比，3.3；P=0.001）、心源性死亡或心肌梗死（6.7%对 1.7%；风险比，3.7；P=0.006）和血运重建（24.7%对 2.7%；风险比，11.4；P<0.001）的发生率呈倍数增加。在 MPI 被归类为不适当的 688 例（45.5%）患者中，异常 MPI 未能预测主要不良心脏事件，尽管它与高血运重建率相关。此外，适当的 MPI 使用提供了比心肌灌注和射血分数数据更高的预后价值。
当用于适当的适应证时，SPECT-MPI 继续显示出较高的预后价值。然而，不适当的使用缺乏风险分层的有效性，进一步强调了为心脏检查选择最佳患者的必要性。
