Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
J Nucl Cardiol. 2024 Oct;40:101908. doi: 10.1016/j.nuclcard.2024.101908. Epub 2024 Jul 10.
The epidemiology of coronary artery disease (CAD) has shifted, with increasing prevalence of cardiometabolic disease and decreasing findings of obstructive CAD on myocardial perfusion imaging (MPI). Coronary microvascular dysfunction (CMD), defined as impaired myocardial flow reserve (MFR) by positron emission tomography (PET), has emerged as a key mediator of risk. We aimed to assess whether PET MFR provides additive value for risk stratification of cardiometabolic disease patients compared with single-photon emission computed tomography (SPECT) MPI.
We retrospectively followed patients referred for PET, exercise SPECT, or pharmacologic SPECT MPI with cardiometabolic disease (obesity, diabetes, or chronic kidney disease) and without known CAD. We compared rates and hazards of composite major adverse cardiovascular events (MACEs) (annualized cardiac mortality or acute myocardial infarction) among propensity-matched PET and SPECT patients using Poisson and Cox regression. Normal SPECT was defined as a total perfusion deficit (TPD) of <5%, reflecting the absence of obstructive CAD. Normal PET was defined as a TPD of <5% plus an MFR of ≥2.0.
Among 21,544 patients referred from 2006 to 2020, cardiometabolic disease was highly prevalent (PET: 2308 [67%], SPECT: 9984 [55%]) and higher among patients referred to PET (P < 0.001). Obstructive CAD findings (TPD > 5%) were uncommon (PET: 21% and SPECT: 11%). Conversely, impaired MFR on PET (<2.0) was common (62%). In a propensity-matched analysis over a median 6.4-year follow-up, normal PET identified low-risk (0.9%/year MACE) patients, and abnormal PET identified high-risk (4.2%/year MACE) patients with cardiometabolic disease; conversely, those with normal pharmacologic SPECT remained moderate-risk (1.6%/year, P < 0.001 compared to normal PET).
Cardiometabolic disease is common among patients referred for MPI and is associated with a heterogenous level of risk. Compared with pharmacologic SPECT, PET with MFR can detect nonobstructive CAD including CMD and can more accurately discriminate low-risk from higher-risk individuals.
冠状动脉疾病 (CAD) 的流行病学已经发生变化，代谢性心血管疾病的患病率增加，而心肌灌注成像 (MPI) 上阻塞性 CAD 的检出率降低。冠状动脉微血管功能障碍 (CMD) 定义为正电子发射断层扫描 (PET) 显示心肌血流储备 (MFR) 受损，已成为风险的关键介导因素。我们旨在评估 PET MFR 与单光子发射计算机断层扫描 (SPECT) MPI 相比，是否为代谢性心血管疾病患者的风险分层提供附加价值。
我们回顾性随访了因代谢性心血管疾病（肥胖、糖尿病或慢性肾脏病）且无已知 CAD 而接受 PET、运动 SPECT 或药物 SPECT MPI 检查的患者。我们使用泊松和 Cox 回归比较了倾向评分匹配的 PET 和 SPECT 患者之间复合主要不良心血管事件 (MACE)（年化心脏死亡率或急性心肌梗死）的发生率和风险比。正常 SPECT 定义为总灌注缺损 (TPD) <5%，反映无阻塞性 CAD。正常 PET 定义为 TPD <5% 加上 MFR ≥2.0。
在 2006 年至 2020 年期间，21544 名患者中有 2308 名（67%）患有代谢性心血管疾病，PET 组中患有代谢性心血管疾病的患者比例较高（P < 0.001）。阻塞性 CAD 发现（TPD > 5%）很少见（PET：21%和 SPECT：11%）。相反，PET 上的 MFR 受损（<2.0）很常见（62%）。在中位随访 6.4 年的倾向评分匹配分析中，正常 PET 可识别低风险（0.9%/年 MACE）患者，异常 PET 可识别高风险（4.2%/年 MACE）患者；相反，正常药物 SPECT 患者仍为中度风险（1.6%/年，与正常 PET 相比，P < 0.001）。
代谢性心血管疾病在接受 MPI 检查的患者中很常见，且与不同程度的风险相关。与药物 SPECT 相比，结合 MFR 的 PET 不仅可以检测到非阻塞性 CAD，包括 CMD，还可以更准确地区分低风险和高风险个体。
