Combined analysis of resting regional wall thickening and stress perfusion with electrocardiographic-gated technetium 99m-labeled sestamibi single-photon emission computed tomography: prediction of stress defect reversibility.
BACKGROUND: The high photon flux and stable distribution of the myocardial perfusion agent 99mTc-labeled sestamibi allow the perfusion data to be acquired in an electrocardiographic (ECG)-gated mode, such that information on resting regional wall thickening may be obtained simultaneously with stress perfusion data. The objective of this study was to assess whether visual analysis of resting regional wall thickening provided by ECG-gated acquisition of 99mTc-labeled sestamibi stress perfusion images correlates with and predicts the reversibility of stress-induced perfusion defects, potentially obviating the need for rest imaging. METHODS AND RESULTS: Fifty-nine patients referred for myocardial perfusion imaging were studied with rest and stress single-photon emission computed tomographic (SPECT) sestamibi imaging, and the stress perfusion data were acquired in an ECG-gated mode. Visual analysis of the presence and reversibility of stress perfusion defects on standard imaging was correlated with the wall thickening data from the poststress gated SPECT images. Quantitative circumferential profile analysis of the short-axis images was performed to assess the influence of relative stress perfusion defect severity on the correlation between wall thickening and defect reversibility. Among the 72 segments with stress-induced perfusion defects and visually apparent wall thickening on ECG-gated SPECT images, 69 were reversible on rest imaging (positive predictive value of 96% for wall thickening to predict stress defect reversibility). Of the 35 segments with stress-induced defects and no apparent wall thickening on ECG-gated SPECT images, however, 14 (40%) demonstrated significant stress defect reversibility on rest imaging. This result represents a negative predictive value of only 60% for the lack of apparent wall thickening to predict correctly an irreversible stress defect. Among the segments with reversible stress perfusion defects and visually apparent wall thickening, relative stress sestamibi activity was higher (51% +/- 10% [percentage of peak]) than in segments with reversible stress defects and no visually apparent wall thickening (39% +/- 4% of peak activity [p < 0.0001]). CONCLUSIONS: Visual evidence of wall thickening by poststress ECG-gated SPECT sestamibi imaging in the territory of a stress-induced perfusion defect correlates highly with stress defect reversibility on rest imaging and may obviate the need to perform rest imaging, thereby potentially reducing the time and cost involved in myocardial perfusion imaging. The absence of visually apparent wall thickening, however, underestimates the prevalence of stress defect reversibility on rest imaging; in such instances, rest imaging must be performed to differentiate ischemia from infarction in the territory of a stress perfusion defect.