Malhotra Saurabh, Doukky Rami
Division of Cardiology, Cook County Health, Chicago, IL.
Division of Cardiology, Rush University, Chicago, IL.
Cardiovasc Innov Appl. 2019 Apr;4(1):63-69. doi: 10.15212/CVIA.2019.0005.
The diagnostic and prognostic value of appropriate use criteria (AUC) for coronary artery disease (CAD) is well established. Whether the diagnostic yield of AUC for predicting CAD is preserved among the elderly is not known.
We analyzed a multi-site prospective cohort of 1511 consecutive patients (mean age 59 ±13 years, 57% males) who underwent outpatient, community-based SPECT myocardial perfusion imaging (MPI). Appropriateness of the studies was determined based on the 2013 multimodality AUC for detection and risk assessment of stable ischemic heart disease. An abnormal SPECT MPI was defined by either a summed stress score ≥ 4 or a summed difference score ≥ 2.
Abnormal SPECT MPI was present in 190 patients (12.5%), while ischemia on MPI alone was present in 122 (8%). In multivariate logistic regression analysis, age ≥ 60 years, male gender, hypertension, diabetes mellitus, and known CAD were independent predictors of an abnormal SPET MPI, while appropriate indication of testing was not. Age ≥ 60 years was also an independent predictor of inducible myocardial ischemia, while appropriate indication for testing was not. Among elderly (≥ 60 year), regardless of appropriateness of testing, there was no difference in the prevalence of an abnormal SPECT (19% vs. 14%, p=0.14) or prevalence of SPECT ischemia (11% vs. 11%, p=1.00). Among younger patients however, appropriate testing predicted a greater prevalence of an abnormal SPECT (12% vs. 7%, p=0.013).
In this multi-site cohort, testing based on AUC did not discriminate the risk of an abnormal SPECT MPI among the elderly. Caution is advised when relying on AUC for referring elderly patients for SPECT MPI.
冠状动脉疾病（CAD）适当使用标准（AUC）的诊断和预后价值已得到充分证实。对于老年人，AUC预测CAD的诊断效能是否依然存在尚不清楚。
我们分析了一个多中心前瞻性队列，该队列包括1511例连续接受门诊社区单光子发射计算机断层扫描心肌灌注成像（MPI）的患者（平均年龄59±13岁，57%为男性）。根据2013年用于稳定型缺血性心脏病检测和风险评估的多模态AUC确定检查的适当性。异常SPECT MPI定义为负荷总分≥4或差值总分≥2。
190例患者（12.5%）存在异常SPECT MPI，其中仅MPI显示缺血的有122例（8%）。在多因素逻辑回归分析中，年龄≥60岁、男性、高血压、糖尿病和已知CAD是SPET MPI异常的独立预测因素，而检查的适当指征不是。年龄≥60岁也是诱导性心肌缺血的独立预测因素，而检查的适当指征不是。在老年人（≥60岁）中，无论检查是否适当，异常SPECT的患病率（19%对14%，p=0.14）或SPECT缺血的患病率（11%对11%，p=1.00）均无差异。然而，在年轻患者中，适当的检查预测异常SPECT的患病率更高（12%对7%，p=0.013）。
在这个多中心队列中，基于AUC的检查并不能区分老年人中SPECT MPI异常的风险。在依靠AUC推荐老年患者进行SPECT MPI检查时应谨慎。
