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PET MPI LVEF Reserve, Revascularization, and Mortality
Quick Takes
- Patients who have no augmentation or a drop in LVEF with stress (LVEF-R ≤0) had a survival benefit if they underwent 90-day revascularization.
- Of note, among patients with prior MI or prior revascularization with PCI or CABG, neither reduced LVEF-R nor receipt of early revascularization provided independent prognostic value.
- Additional prospective studies are indicated to assess whether integrating perfusion, LVEF response, and quantitative flow information improves patient selection for revascularization compared to assessment of perfusion alone.
Study Questions:
What is the prognostic utility of positron emission tomography (PET) myocardial perfusion imaging (MPI) left ventricular ejection fraction reserve (LVEF-R) regarding survival for patients post-revascularization?
Methods:
The investigators followed 14,649 unique consecutive patients undergoing 82Rb rest/stress PET MPI from January 2010 to January 2016 (excluding known cardiomyopathy). Adjusted Cox models were built to predict all-cause death, and the three-way interaction of known coronary artery disease (CAD) (prior myocardial infarction [MI]/revascularization), LVEF-R, and 90-day revascularization was tested.
Results:
Known CAD was present in 4,982 (34.0%). Ischemia was detected in 5,396 (36.8%; ≥10% in 1,909 [13%]). Mean LVEF-R was 4.2% ± 5.7%, and was ≤0, 1-5, and >5 in 3,349 (22.9%), 5,266 (35.9%), and 6,034 (41.2%). Over median follow-up of 3.4 (interquartile range, 1.9-5.2) years, 1,324 (8.1%) had 90-day revascularization and there were 2,192 (15.0%) deaths. In multivariable modeling, there was a significant three-way interaction between known CAD, LVEF-R, and 90-day revascularization (p = 0.025), such that LVEF-R ≤0 identified patients with survival benefit with 90-day revascularization in those without prior CAD (interaction for p = 0.005), independently beyond % ischemia and myocardial flow reserve. Among patients with known CAD, LVEF-R was not prognostic of death (hazard ratio, 0.99; 95% confidence interval, 0.98-1.02; p = 0.98).
Conclusions:
The authors report that a lack of augmentation or drop in LVEF with vasodilator stress on PET MPI independently identifies patients who have better survival with revascularization within 90 days post-MPI compared to medical therapy.
Perspective:
In this large cohort of patients undergoing PET MPI, the authors examined the role of change in LVEF with stress and reported that patients who have no augmentation or a drop in LVEF with stress (LVEF-R ≤0) had a survival benefit if they underwent 90-day revascularization. Of note, among patients with prior MI or prior revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), neither reduced LVEF-R nor receipt of early revascularization provided independent prognostic value. Additional prospective studies are indicated to assess whether integrating perfusion, LVEF response, and quantitative flow information improves patient selection for revascularization compared to assessment of perfusion alone.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Computed Tomography, Nuclear Imaging
Keywords: Myocardial Perfusion Imaging, Myocardial Revascularization, Positron-Emission Tomography
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