Imaging
indicated that even in very old (>80 years of age) patients, a non- ischaemic MPS was associated with a relatively low risk of cardiac events (3.2% per year). In agreement with this report, Hachamovitch et al. recently confirmed that even in very old patients (>85 years of age), MPS is able to stratify groups with significantly different levels of risk of cardiac death (see Figure 2).8
Gated SPECT provides additional information on ventricular systolic function and may be conveniently applied for prognostic evaluation in combination with data on myocardial perfusion.21
In a group of
patients ≥75 years of age with known or suspected CAD evaluated by gated SPECT, De Winter et al. identified the summed rest score and the resting left ventricular end-systolic volume as independent predictors of cardiac death.22
Hachamovitch et al. showed that
combining left ventricular ejection fraction and perfusion data enhanced risk stratification, with the lowest level of risk observed
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9. Gentile R, Vitarelli A, Schillaci O, et al., Diagnostic
when both normal ejection fraction and preserved perfusion were present (see Figure 4).8
Conclusions In conclusion, SPECT MPS has the ability to successfully stratify risk of adverse cardiac events in elderly (>65 years of age) as well as very elderly (>80 years of age) patients. The finding of a normal MPS study in an elderly patient has been repeatedly associated with a low level of risk (~1% annual event rate). Practical advantages over EET are represented by the possibility of accurately identifying myocardial ischaemia in the large subgroup of elderly subjects with ECG abnormalities and the opportunity of using a pharmacological stress test in subjects unable to exercise. An MPS-guided approach for the referral of elderly patients for revascularisation procedures seems to be feasible, but its clinical efficacy needs to be prospectively verified. n
accuracy and prognostic implications of stress testing for coronary artery disease in the elderly, Ital Heart J, 2001;2:539–45.
10. Lam JY, Chaitman BR, Glaenzer M, et al., Safety and diagnostic accuracy of dipyridamole-thallium imaging in the elderly, J Am Coll Cardiol, 1988;11:585–9.
11. Wang FP, Amanullah AM, Kiat H, et al., Diagnostic efficacy of stress technetium 99m-labeled sestamibi myocardial perfusion single-photon emission computed tomography in detection of coronary artery disease among patients over age 80, J Nucl Cardiol, 1995;2:380–88.
12. Klocke FJ, Baird MG, Lorell BH, et al., ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging, Circulation, 2003;108(11):1404–18.
13. Goraya TY, Jacobsen SJ, Pellikka PA, et al., Prognostic value of treadmill exercise testing in elderly persons, Ann Intern Med, 2000;132:862–70.
14. Kwok JM, Miller TD, Hodge DO, Gibbons RJ, Prognostic value of the Duke treadmill score in the elderly, J Am Coll Cardiol, 2002;39:1475–81.
15. Valeti US, Miller TD, Hodge DO, Gibbons RJ, Exercise single-photon emission computed tomography provides effective risk stratification of elderly men and elderly women, Circulation, 2005;111:1771–6.
16. Hashimoto A, Palmer EL, Scott JA, et al., Complications of exercise and pharmacologic stress tests: differences in younger and elderly patients, J Nucl Cardiol, 1999;6:612–19.
17. Elhendy A, van Domburg RT, Bax JJ, et al., Safety, hemodynamic profile, and feasibility of dobutamine stress technetium myocardial perfusion single-photon emission CT imaging for evaluation of coronary artery disease in the elderly, Chest, 2000;117:649–56.
18. Kawamura M, Ohta Y, Katoh K, Nishimura S, Medium- to long-term prognostic impact of dipyridamole thallum-201 myocardial single-photon emission computed
tomography in elderly patients, Circ J, 2003;67:913–17
19. Calnon DA, McGrath PD, Doss AL, et al., Prognostic value of dobutamine stress technetium-99m-sestamibi single- photon emission computed tomography myocardial perfusion imaging: stratification of a high-risk population, J Am Coll Cardiol, 2001;38:1511–17.
20. Zafrir N, Mats I, Solodky A, et al., Prognostic value of stress myocardial perfusion imaging in octogenarian population, J Nucl Cardiol, 2005;12:671–5.
21. Sharir T, Germano G, Kavanagh PB, et al., Incremental prognostic value of post-stress left ventricular ejection fraction and volume by gated myocardial perfusion single photon emission computed tomography, Circulation, 1999;100:1035–42.
22. De Winter O, Velghe A, Van de Veire N, et al., Incremental prognostic value of combined perfusion and function assessment during myocardial gated SPECT in patients aged 75 years or older, J Nucl Cardiol, 2005;12:662–70.
23. Steingart RM, Hodnett P, Musso J, et al., Exercise myocardial perfusion imaging in elderly patients, J Nucl Cardiol, 2002;9:573–80.
24. Lima RS, De Lorenzo A, Pantoja MR, Siqueira A, Incremental prognostic value of myocardial perfusion 99m-technetium-sestamibi SPECT in the elderly, Int J Cardiol, 2004;93:137–43.
25. Schinkel AF, Elhendy A, Biagini E, et al., Prognostic stratification using dobutamine stress 99mTc-tetrofosmin myocardial perfusion SPECT in elderly patients unable to perform exercise testing, J Nucl Med, 2005;46:12–18.
26. Nagao T, Chikamori T, Hida S, et al.; Q-PROVE Study Group, Quantitative gated single-photon emission computed tomography with (99m)Tc sestamibi predicts major cardiac events in elderly patients with known or suspected coronary artery disease: the QGS-Prognostic Value in the Elderly (Q-PROVE) Study, Circ J, 2007;71:1029–34.
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