Original Article
Negative predictive value of stress myocardial perfusion imaging and coronary computed tomography angiography: A meta-analysis

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Abstract

Background

Comparing the prognostic value of a negative finding by stress single-photon emission computed tomography myocardial perfusion imaging (MPI) and coronary computed tomography angiography (CCTA) may be useful to evaluate how better identify low-risk patients. We performed a meta-analysis to compare the long-term negative predictive value (NPV) of normal stress MPI and normal CCTA in subjects with suspected coronary artery disease (CAD).

Methods and Results

Studies published between January 2000 and November 2016 were identified by database search. We included MPI and CCTA studies that followed-up ≥100 subjects for ≥5 years and providing data on clinical outcome for patients with negative tests. Summary risk estimates for normal perfusion at MPI or <50% coronary stenosis at CCTA were derived in random effect regression analysis, and causes of heterogeneity were determined in meta-regression analysis. We identified 12 eligible articles (6 MPI and 6 CCTA) including 33,129 patients (26,757 in MPI and 6372 in CCTA studies) with suspected CAD. The pooled annualized event rate (AER) for occurrence of hard events (death and nonfatal myocardial infarction) was 1.06 (95% confidence interval, CI 0.49-1.64) in MPI and 0.61 (95% CI 0.35-0.86) in CCTA studies. The pooled NPV was 91% (95% CI 86-96) in MPI and 96 (95% CI 95-98) in CCTA studies. The summary rates between MPI and CCTA were not statistically different. At meta-regression analysis, no significant association between AER and clinical and demographical variables considered was found for overall studies.

Conclusions

Stress MPI and CCTA have a similar ability to identify low-risk patients with suspected CAD.

Introduction

Coronary artery disease (CAD) is a leading cause of death and disability in developed countries.1 In patients with known or suspected CAD, stress single-photon emission computed tomography myocardial perfusion imaging (MPI) accounts for the vast majority of tests currently performed for ischemia detection. The diagnostic role of this imaging modality is well established, and a negative stress test with MPI is able to identify subjects at low risk of future cardiovascular events.2 Coronary computed tomography angiography (CCTA) also provides valuable information for risk stratification and clinical decision-making in subjects with known or suspected CAD.3,4 Both these two imaging modalities are considered as a appropriate for the prognostic evaluation of several subgroups of patients and are often used interchangeably in clinical practice.5,6 The prognostic value of an abnormal stress MPI and CCTA for the occurrence of hard cardiac events is similar, while CCTA is more predictive when also coronary revascularization is considered as event.7 Although it is commonly assumed that a negative stress MPI reliably identifies patients at low cardiac risk, it appears that long-term mortality risk varies substantially according to the presence of selected CAD risk factors.8 Also CCTA has an excellent negative predictive value for risk stratification and is being increasingly used as an alternative to MPI for prognostic evaluation.9 Comparing the prognostic value of a negative finding by MPI and CCTA may be useful to evaluate how better identify low-risk patients, decreasing the need for additional testing and interventions. Thus, we performed a meta-analysis of published studies, including patients with suspected CAD, to compare the long-term predictive value for adverse cardiac ischemic events of normal stress MPI and normal CCTA.

Section snippets

Materials and Methods

The present meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement (see the supplementary material for PRISMA Checklist).10

Search Results

The complete literature search is presented in Figure 1. The initial search identified 3966 potentially eligible citations. After removing 462 duplicate records, 3504 records were screened by the reviewers. After the titles and abstracts evaluation, 3419 citations were discharged because they were judged to be non-relevant or non-pertinent. Thus, 85 full-text articles (51MPI and 34 CCTA studies) were blinded assessed by each investigator for eligibility. After revision, 73 articles were

Discussion

From this, meta-analysis is appeared that both stress MPI and CCTA have a high long-term warranty for adverse cardiac events. Evidence to determine the comparative effectiveness and safety of different noninvasive testing strategies for CAD is limited. While there is a robust body of literature on the diagnostic performance of these tests based on traditional measures of test accuracy (e.g., sensitivity and specificity), only a small number of studies were identified which evaluated the impact

New Knowledge Gained

MPI and CCTA are alternatively used in clinical practice, but the choice of the most appropriate prognostic approach in patients with suspected CAD is debated. From this, meta-analysis is appeared that both stress MPI and CCTA have a high long-term warranty for adverse cardiac events.

Conclusion

Stress MPI and CCTA have a similar ability to identify low-risk patients with suspected CAD and may be alternatively used to decrease the need for additional testing and interventions.

Disclosure

The authors have indicated that they have no financial conflict of interest.

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    Roberta Green and Valeria Cantoni are co-first authors and they contributed equally to this study.

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