Comparison of Coronary CT Angiography, SPECT, PET, and Hybrid Imaging for Diagnosis of Ischemic Heart Disease Determined by Fractional Flow Reserve

Ibrahim Danad, Pieter G. Raijmakers, Roel S Driessen, Jonathon Leipsic, Rekha Raju, Chris Naoum, Juhani Knuuti, Maija Mäki, Richard S Underwood, James K. Min, Kimberly Elmore, Wynand J. Stuijfzand, Niels van Royen, Igor I Tulevski, Aernout G Somsen, Marc C Huisman, Arthur A van Lingen, Martijn W Heymans, Peter M van de Ven, Cornelis van Kuijk & 3 others Adriaan A Lammertsma, Albert C van Rossum, Paul Knaapen

Research output: Contribution to journalArticleAcademicpeer-review

Abstract

Importance: 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.

Objectives: To establish the diagnostic accuracy of CCTA, SPECT, and PET and explore the incremental value of hybrid imaging compared with fractional flow reserve.

Design, Setting, and Participants: A prospective clinical study involving 208 patients with suspected CAD who underwent CCTA, technetium 99m/tetrofosmin-labeled SPECT, and [15O]H2O 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.

Main Outcomes and Measures: 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.

Results: 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 (P < .001) but not in terms of sensitivity (P > .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%; P = .003) and SPECT (77%; 95% CI, 71%-83%; P = .02). Diagnostic accuracy was not enhanced by either hybrid SPECT and CCTA (76%; 95% CI, 70%-82%; P = .75) or by PET and CCTA (84%; 95% CI, 79%-89%; P = .82), but resulted in an increase in specificity (P = .004) at the cost of a decrease in sensitivity (P = .001).

Conclusions and Relevance: 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.

Original languageEnglish
Pages (from-to)1100-1107
Number of pages8
JournalJAMA cardiology
Volume2
Issue number10
DOIs
Publication statusPublished - 1 Oct 2017

Cite this

@article{4c4f6b9b4afd406c916a7cc25f5eaf21,
title = "Comparison of Coronary CT Angiography, SPECT, PET, and Hybrid Imaging for Diagnosis of Ischemic Heart Disease Determined by Fractional Flow Reserve",
abstract = "Importance: 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.Objectives: To establish the diagnostic accuracy of CCTA, SPECT, and PET and explore the incremental value of hybrid imaging compared with fractional flow reserve.Design, Setting, and Participants: A prospective clinical study involving 208 patients with suspected CAD who underwent CCTA, technetium 99m/tetrofosmin-labeled SPECT, and [15O]H2O 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.Main Outcomes and Measures: 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.Results: 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 (P < .001) but not in terms of sensitivity (P > .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{\%}; P = .003) and SPECT (77{\%}; 95{\%} CI, 71{\%}-83{\%}; P = .02). Diagnostic accuracy was not enhanced by either hybrid SPECT and CCTA (76{\%}; 95{\%} CI, 70{\%}-82{\%}; P = .75) or by PET and CCTA (84{\%}; 95{\%} CI, 79{\%}-89{\%}; P = .82), but resulted in an increase in specificity (P = .004) at the cost of a decrease in sensitivity (P = .001).Conclusions and Relevance: 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.",
keywords = "Journal Article",
author = "Ibrahim Danad and Raijmakers, {Pieter G.} and Driessen, {Roel S} and Jonathon Leipsic and Rekha Raju and Chris Naoum and Juhani Knuuti and Maija M{\"a}ki and Underwood, {Richard S} and Min, {James K.} and Kimberly Elmore and Stuijfzand, {Wynand J.} and {van Royen}, Niels and Tulevski, {Igor I} and Somsen, {Aernout G} and Huisman, {Marc C} and {van Lingen}, {Arthur A} and Heymans, {Martijn W} and {van de Ven}, {Peter M} and {van Kuijk}, Cornelis and Lammertsma, {Adriaan A} and {van Rossum}, {Albert C} and Paul Knaapen",
year = "2017",
month = "10",
day = "1",
doi = "10.1001/jamacardio.2017.2471",
language = "English",
volume = "2",
pages = "1100--1107",
journal = "JAMA cardiology",
issn = "2380-6583",
publisher = "American Medical Association",
number = "10",

}

Comparison of Coronary CT Angiography, SPECT, PET, and Hybrid Imaging for Diagnosis of Ischemic Heart Disease Determined by Fractional Flow Reserve. / Danad, Ibrahim; Raijmakers, Pieter G.; Driessen, Roel S; Leipsic, Jonathon; Raju, Rekha; Naoum, Chris; Knuuti, Juhani; Mäki, Maija; Underwood, Richard S; Min, James K.; Elmore, Kimberly; Stuijfzand, Wynand J.; van Royen, Niels; Tulevski, Igor I; Somsen, Aernout G; Huisman, Marc C; van Lingen, Arthur A; Heymans, Martijn W; van de Ven, Peter M; van Kuijk, Cornelis; Lammertsma, Adriaan A; van Rossum, Albert C; Knaapen, Paul.

In: JAMA cardiology, Vol. 2, No. 10, 01.10.2017, p. 1100-1107.

Research output: Contribution to journalArticleAcademicpeer-review

TY - JOUR

T1 - Comparison of Coronary CT Angiography, SPECT, PET, and Hybrid Imaging for Diagnosis of Ischemic Heart Disease Determined by Fractional Flow Reserve

AU - Danad, Ibrahim

AU - Raijmakers, Pieter G.

AU - Driessen, Roel S

AU - Leipsic, Jonathon

AU - Raju, Rekha

AU - Naoum, Chris

AU - Knuuti, Juhani

AU - Mäki, Maija

AU - Underwood, Richard S

AU - Min, James K.

AU - Elmore, Kimberly

AU - Stuijfzand, Wynand J.

AU - van Royen, Niels

AU - Tulevski, Igor I

AU - Somsen, Aernout G

AU - Huisman, Marc C

AU - van Lingen, Arthur A

AU - Heymans, Martijn W

AU - van de Ven, Peter M

AU - van Kuijk, Cornelis

AU - Lammertsma, Adriaan A

AU - van Rossum, Albert C

AU - Knaapen, Paul

PY - 2017/10/1

Y1 - 2017/10/1

N2 - Importance: 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.Objectives: To establish the diagnostic accuracy of CCTA, SPECT, and PET and explore the incremental value of hybrid imaging compared with fractional flow reserve.Design, Setting, and Participants: A prospective clinical study involving 208 patients with suspected CAD who underwent CCTA, technetium 99m/tetrofosmin-labeled SPECT, and [15O]H2O 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.Main Outcomes and Measures: 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.Results: 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 (P < .001) but not in terms of sensitivity (P > .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%; P = .003) and SPECT (77%; 95% CI, 71%-83%; P = .02). Diagnostic accuracy was not enhanced by either hybrid SPECT and CCTA (76%; 95% CI, 70%-82%; P = .75) or by PET and CCTA (84%; 95% CI, 79%-89%; P = .82), but resulted in an increase in specificity (P = .004) at the cost of a decrease in sensitivity (P = .001).Conclusions and Relevance: 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.

AB - Importance: 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.Objectives: To establish the diagnostic accuracy of CCTA, SPECT, and PET and explore the incremental value of hybrid imaging compared with fractional flow reserve.Design, Setting, and Participants: A prospective clinical study involving 208 patients with suspected CAD who underwent CCTA, technetium 99m/tetrofosmin-labeled SPECT, and [15O]H2O 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.Main Outcomes and Measures: 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.Results: 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 (P < .001) but not in terms of sensitivity (P > .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%; P = .003) and SPECT (77%; 95% CI, 71%-83%; P = .02). Diagnostic accuracy was not enhanced by either hybrid SPECT and CCTA (76%; 95% CI, 70%-82%; P = .75) or by PET and CCTA (84%; 95% CI, 79%-89%; P = .82), but resulted in an increase in specificity (P = .004) at the cost of a decrease in sensitivity (P = .001).Conclusions and Relevance: 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.

KW - Journal Article

U2 - 10.1001/jamacardio.2017.2471

DO - 10.1001/jamacardio.2017.2471

M3 - Article

VL - 2

SP - 1100

EP - 1107

JO - JAMA cardiology

JF - JAMA cardiology

SN - 2380-6583

IS - 10

ER -