Imaging
Prognostic Value of Stress Myocardial Single-photon-emission Computed Tomography in the Elderly
Santo Dellegrottaglie, 1,2 Pierluigi Costanzo, 1 Alberto Cuocolo, 3 Stefania Paolillo, 1 Massimo Chiariello1 Caterina Marciano, 1 Paola Gargiulo, 1 and Pasquale Perrone-Filardi1 1. Department of Clinical Medicine, Cardiovascular and Immunology Sciences, Federico II University, Naples;
2. Zena and Michael A Wiener Cardiovascular Institute, and Marie-Josée and Henry R Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York; 3. Department of Biomorphological and Functional Sciences, Federico II University, Naples
Abstract
Elderly subjects are expected to account for 30% of the European population by 2050. Currently, more than two-thirds of all cardiovascular deaths are registered in subjects >65 years of age. In the elderly, exercise electrocardiogram (ECG) testing (EET) may be more difficult both to perform and to interpret compared with the situation in younger subjects, but it is still recommended as the initial non-invasive method for evaluating coronary artery disease (CAD). Single-photon-emission computed tomography (SPECT) myocardial perfusion scintigraphy (MPS) has demonstrated the ability to successfully stratify risk of adverse cardiac events in elderly (>65 years of age) as well as in 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 the possibility of accurately identifying myocardial ischaemia in the large subgroup of elderly subjects with ECG abnormalities and of using pharmacological stress in subjects unable to exercise.
Keywords Cardiac imaging, prognosis, elderly, nuclear cardiology, coronary artery disease
Disclosure: The authors have no conflicts of interest to declare. Received: 4 April 2010 Accepted: 18 May 2010 Citation: European Cardiology, 2010;6(2):49–52 Correspondence: Pasquale Perrone-Filardi, Department of Clinical Medicine, Cardiovascular and Immunological Sciences, Federico II University, Via S Pansini 5, Naples 80131, Italy. E:
fpperron@unina.it
In Europe, subjects >65 years of age currently constitute 17% of the entire population, with some variations between countries (see Figure 1).1
been tested in a variety of different subpopulations.6 studies have focused on the use of MPS in elderly patients,7
More importantly, as a consequence of the ageing
population, elderly subjects are expected to account for 30% of the European population by 2050. Currently, cardiovascular disease is the major cause of death in Europe (~20% of all causes) and more than two-thirds of cardiovascular deaths are registered in the elderly.2
Despite the need for effective strategies to assess prognosis in elderly patients with known or suspected coronary artery disease (CAD), few data have been collected so far in this specific population with the commonly used diagnostic modalities.3 American College of Cardiology/American Heart
Regardless of age, Association
The guidelines acknowledge that the elderly represent a special population in whom EET may be more difficult both to perform and to interpret, but there are insufficient data to recommend stress imaging over standard EET in this group of subjects. In fact, despite the need for individualised prognostic information in the elderly, these patients have not been adequately represented in studies of CAD.5
Single-photon-emission computed tomography (SPECT) myocardial perfusion scintigraphy (MPS) represents a well-established method of collecting both diagnostic and prognostic information in patients with known or suspected CAD, and its feasibility and accuracy have
© T O UCH BRIEFINGS 2010
practical guidelines recommend exercise electrocardiogram (ECG) testing (EET) as the initial non-invasive method for evaluating CAD in patients with a normal or near-normal resting ECG who can exercise adequately.4
To date, few and only
recent evidence supports the strong value of MPS for prognostic stratification and selection of optimal therapy in elderly patients evaluated for CAD.8
SPECT MPS versus EET for the Assessment of Myocardial Ischaemia in the Elderly Owing to its wide availability, simplicity and low cost, EET still represents a convenient first-line test for the evaluation of elderly patients with known or suspected CAD. However, the performance of EET with either treadmill or bicycle may pose some practical difficulties in the elderly. Muscle weakness, deconditioning, neurological/orthopaedic disorders and peripheral vascular disease are frequently responsible for a limited exercise capacity in these subjects. In many cases, the use of less challenging protocols for the stress test is required in individuals >65 years of age, and the ischaemic threshold may not always be reached. Even the interpretation of EET results in the elderly may differ from that in the young. The elevated prevalence of CAD in this population leads to a high incidence of false-negative results, leading to reduced negative predictive value for CAD detection.4
In addition, ECG
abnormalities are significantly more common in the elderly, which complicates test interpretation.
In general terms, SPECT MPS may represent a valuable alternative to EET for accurate assessment of myocardial ischaemia in elderly
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