The Association Between Plaque Characterization by CT Angiography and Post-Procedural Myocardial Infarction in Patients With Elective Stent Implantation

OBJECTIVES: This study sought to evaluate the association between volumetric characterization of target lesions by multidetector computed tomography (MDCT) angiography and the risk of post-procedural myocardial injury after elective stent implantation. Previous reports have shown that plaque characterization of the target lesion may provide useful information for stratifying the risk of coronary stenting.

METHODS: A total of 189 consecutive patients were enrolled; they underwent elective stent implantation after volumetric plaque analysis with 64-slice MDCT. Each plaque component and lumen (filled with dye) was defined as follows: 1) low-attenuation plaque (LAP) (<50 HU); 2) moderate-attenuation plaque (MAP) (50 to 150 HU); 3) lumen (151 to 500 HU); and 4) high-attenuation plaque (HAP) (>500 HU). The volume of each plaque component in the target lesion was calculated using Color Code Plaque. Post-procedural creatine kinase-MB isoform and troponin-T (TnT) at 18 h after percutaneous coronary intervention were also evaluated.

RESULTS: The volumes of LAP (87.9 ± 94.8 mm3 vs. 47.4 ± 43.7 mm3, p < 0.01) and MAP (111.6 ± 77.5 mm3 vs. 89.8 ± 67.1 mm3, p < 0.05) were larger in patients with post-procedural myocardial injury (defined as positive TnT) than in those with negative TnT. The volumes of LAP and MAP and fraction of LAP in total plaque (LAP volume/total plaque volume) correlated with biomarkers; the MAP fraction was inversely correlated with biomarkers. The volume of LAP was an independent predictor of positive TnT after adjusting for patient background, conventional IVUS parameters, and procedural factors.

CONCLUSIONS: Post-procedural myocardial injury was associated with the volume and fraction of LAP as detected by MDCT. The volume of LAP was an independent predictor of positive TnT. Plaque analysis by MDCT would be a useful method for predicting post-procedural myocardial injury after percutaneous coronary intervention.

PMID: 20129526

Acute Kidney Injury Following Transcatheter Aortic Valve Implantation: Predictive Factors, Prognostic Value, and Comparison with Surgical Aortic Valve Replacement

OBJECTIVES: Very few data exist on the occurrence of acute kidney injury (AKI) associated with transcatheter aortic valve implantation (TAVI). The objectives of the present study were (i) to determine the incidence, predictive factors, and prognostic value of AKI following TAVI, and (ii) to compare the occurrence of AKI in TAVI vs. surgical aortic valve replacement (SAVR) in patients with pre-procedural chronic kidney disease (CKD).

METHODS: A total of 213 patients (mean age 82 +/- 8 years) undergoing TAVI for the treatment of severe aortic stenosis were included in the study. Acute kidney injury was defined as a reduction of >25% in estimated glomerular filtration rate (eGFR) within 48 h following the procedure or the need for haemodialysis during index hospitalization.

RESULTS: Those patients with pre-procedural CKD (eGFR <60 mL/min/1.73 m(2), n = 119) were compared with 104 contemporary patients with CKD who underwent isolated SAVR. The incidence of AKI following TAVI was 11.7%, with 1.4% of the patients requiring haemodialysis. Predictive factors of AKI were hypertension (OR: 4.66; 95% CI: 1.04-20.87), chronic obstructive pulmonary disease (OR: 2.64, 95% CI: 1.10-6.36), and peri-operative blood transfusion (OR: 3.47, 95% CI: 1.30-9.29). Twenty-one patients (9.8%) died during index hospitalization, and the logistic EuroSCORE (OR: 1.03 for each increase of 1%; 95% CI: 1.01-1.06) and occurrence of AKI (OR: 4.14, 95% CI: 1.42-12.13) were identified as independent predictors of postoperative mortality. Patients with CKD who underwent TAVI were older, had a higher logistic EuroSCORE and lower pre-procedural eGFR values compared with those who underwent SAVR (P < 0.0001 for all). The incidence of AKI was lower (P = 0.001; P = 0.014 after propensity score adjustment) in CKD patients who underwent TAVI (9.2%, need for haemodialysis: 2.5%) compared with those who underwent SAVR (25.9%, need for haemodialysis: 8.7%).

CONCLUSION: Acute kidney injury occurred in 11.7% of the patients following TAVI and was associated with a greater than four-fold increase in the risk of postoperative mortality. Hypertension, chronic obstructive pulmonary disease, and blood transfusion were predictive factors of AKI. In those patients with pre-procedural CKD, TAVI was associated with a significant reduction of AKI compared with SAVR.

PMID: 20037180

Natural History of Very Severe Aortic Stenosis

OBJECTIVES: We sought to assess the outcome of asymptomatic patients with very severe aortic stenosis.

METHODS: We prospectively followed 116 consecutive asymptomatic patients (57 women; age, 67 + or – 16 years) with very severe isolated aortic stenosis defined by a peak aortic jet velocity (AV-Vel) > 5.0 m/s (average AV-Vel, 5.37 + or – 0.35 m/s; valve area, 0.63 + or – 0.12 cm(2)).

RESULTS: During a median follow-up of 41 months (interquartile range, 26 to 63 months), 96 events occurred (indication for aortic valve replacement, 90; cardiac deaths, 6). Event-free survival was 64%, 36%, 25%, 12%, and 3% at 1, 2, 3, 4, and 6 years, respectively. AV-Vel but not aortic valve area was shown to independently affect event-free survival. Patients with an AV-Vel > 5.5 m/s had an event-free survival of 44%, 25%, 11%, and 4% at 1, 2, 3, and 4 years, respectively, compared with 76%, 43%, 33%, and 17% for patients with an AV-Vel between 5.0 and 5.5 m/s (P<0.0001). Six cardiac deaths occurred in previously asymptomatic patients (sudden death, 1; congestive heart failure, 4; myocardial infarction, 1). Patients with an initial AV-Vel > 5.5 m/s had a higher likelihood (52%) of severe symptom onset (New York Heart Association or Canadian Cardiovascular Society class >II) than those with an AV-Vel between 5.0 and 5.5 m/s (27%; P=0.03).

CONCLUSIONS: Despite being asymptomatic, patients with very severe aortic stenosis have a poor prognosis with a high event rate and a risk of rapid functional deterioration. Early elective valve replacement surgery should therefore be considered in these patients.

PMID: 20026771

How Reliable are 40 MHz IVUS and 64-Slice MDCT in Characterizing Coronary Plaque Composition? An Ex Vivo Study with Histopathological Comparison

OBJECTIVES: The present study investigated whether IVUS could serve as a reliable reference in validating MDCT characterization of coronary plaque against a histological gold standard.

METHODS: Twenty-one specimens were postmortem human coronary arteries. Coronary cross-sections were imaged by 40 MHz IVUS and by 64-slice MDCT and characterized histologically as presenting calcified, fibrous or lipid-rich plaques. Plaque composition was analyzed visually and intra-plaque MDCT attenuation was measured in Hounsfield Units (HU).

RESULTS: 83 atherosclerotic plaques were identified. IVUS failed to characterize calcified plaque accurately, with a positive predictive value (ppv) of 75% versus 100% for MDCT. Lipid-rich plaque was even less accurately characterized, with ppv of 60 and 68% for IVUS and MDCT respectively. Mean MDCT attenuation was 966 ± 473 HU for calcified plaque, 83 ± 35 HU for fibrous plaque and 70.92 HU ± 41 HU for lipid-rich plaque. No significant difference in mean MDCT attenuation was found between fibrous and lipid-rich plaques (P = 0.276).

CONCLUSIONS: In vivo validation of MDCT against an IVUS reference thus appears to be an unsuitable and unreliable approach: 40 MHz IVUS suffers from acoustic ambiguities in plaque characterization, and 64-slice MDCT fails to analyze plaque morphology and components accurately.

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Multimodal Assessment of the Aortic Annulus Diameter: Implications for Transcatheter Aortic Valve Implantation

OBJECTIVES: We sought to compare 3 methods of measurements of the aortic annulus, transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and multislice computed tomography (MSCT), and to evaluate their potential clinical impact on transcatheter aortic valve implantation (TAVI) strategy. Exact measurement of the aortic annulus is critical for a patient’s selection and successful implantation.

METHODS: Annulus diameter was measured using TTE, TEE, and MSCT in 45 consecutive patients with severe aortic stenosis referred for TAVI. The TAVI strategy (decision to implant and choice of the prosthesis’ size) was based on manufacturer’s recommendations (Edwards-Sapien prosthesis, Edwards Lifesciences, Inc., Irvine, California).

RESULTS: Correlations between methods were good but the difference between MSCT and TTE (1.22 ± 1.3 mm) or TEE (1.52 ± 1.1 mm) was larger than the difference between TTE and TEE (0.6 ± 0.8 mm; p = 0.03 and p < 0.0001, respectively). Regarding TAVI strategy, agreement between TTE and TEE overall was good (kappa = 0.68), but TAVI strategy would have been different in 8 patients (17%). Agreement between MSCT and TTE or TEE was only modest (kappa = 0.28 and 0.27), and a decision based on MSCT measurements would have modified the TAVI strategy in a large number of patients (40% to 42%). Implantation, performed in 34 patients (76%) based on TEE measurements, was successful in all but 1 patient with grade 3/4 regurgitation.

CONCLUSIONS: In patients referred for TAVI, measurements of the aortic annulus using TTE, TEE, and MSCT were close but not identical, and the method used has important potential clinical implications on TAVI strategy. In the absence of a gold standard, a strategy based on TEE measurements provided good clinical results.

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Normal Stress-Only Versus Standard Stress/Rest Myocardial Perfusion Imaging Similar Patient Mortality With Reduced Radiation Exposure

OBJECTIVES: The aim of this study was to determine whether a normal stress-only single-photon emission computed tomographic myocardial perfusion tomography (SPECT) study confers the same prognosis as a normal SPECT on the basis of evaluation of stress and rest images. Current guidelines recommend stress and rest imaging to confirm that a SPECT study is normal.

METHODS: We determined all-cause mortality in 16,854 consecutive patients who had a normal gated stress SPECT. Median follow-up was 4.5 years. A stress-only protocol was used in 8,034 patients (47.6%), whereas 8,820 (52.4%) had both stress and rest imaging.

RESULTS: The overall unadjusted annual mortality rate in patients who had a normal SPECT with a stress-only protocol was lower than in those who required additional rest imaging (2.57% vs. 2.92%, p = 0.02). After adjustment for baseline clinical characteristics no significant differences in patient mortality were seen between the 2 imaging protocols, but the stress-only group received a 61% lower radiopharmaceutical dosage. Independent predictors of worse survival included increasing age, male sex, diabetes, history of coronary artery disease, and inability to exercise (all p < 0.001) but not the type of SPECT protocol used to image patients.

CONCLUSIONS: Patients determined to have a normal SPECT on the basis of stress imaging alone have a similar mortality rate as those who have a normal SPECT on the basis of evaluation of both stress and rest images. Our results support that additional rest imaging is not required in patients who have a normally appearing initial stress study. A significant reduction in radiation exposure can be achieved with such an approach.

PMID: 19913381

Multimodality Comparison of Quantitative Volumetric Analysis of the Right Ventricle

OBJECTIVES: We undertook volumetric analysis of the right ventricle (RV) by real-time 3-dimensional echocardiography (RT3DE), cardiac magnetic resonance (CMR), and cardiac computed tomography (CCT) on images obtained in RV-shaped phantoms and in patients with a wide range of RV geometry. Assessment of the RV by 2-dimensional (2D) echocardiography remains challenging due to its unique geometry and limitations of the current analysis techniques. RT3DE, CMR, and CCT, which can quantify RV volumes, promise to overcome the limitations of 2D echocardiography.

METHODS: Images were analyzed using RV Analysis software. Volumes measured in vitro were compared with the true volumes. The human protocol included 28 patients who underwent RT3DE, CMR, and CT on the same day. Volumetric analysis of CMR images was used as a reference, against which RT3DE and CCT measurements were compared using linear regression and Bland-Altman analyses. To determine the reproducibility of the volumetric analysis, repeated measurements were performed for all 3 imaging modalities in 11 patients.

RESULTS: The in vitro measurements showed that: 1) volumetric analysis of CMR images yielded the most accurate measurements; 2) CCT measurements showed slight (4%) but consistent overestimation; and 3) RT3DE measurements showed small underestimation, but considerably wider margins of error. In humans, both RT3DE and CCT measurements correlated highly with the CMR reference (r = 0.79 to 0.89) and showed the same trends of underestimation and overestimation noted in vitro. All interobserver and intraobserver variability values were <14%, with those of CMR being the highest.

CONCLUSIONS: Volumetric quantification of RV volume was performed on CMR, CCT, and RT3DE images. Eliminating analysis-related intermodality differences allowed fair comparisons and highlighted the unique limitations of each modality. Understanding these differences promises to aid in the functional assessment of the RV.

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Myocardial Deformation in Aortic Valve Stenosis: Relation to Left Ventricular Geometry

OBJECTIVES: To assess left ventricular (LV) strain and displacement and their relations to LV geometry in patients with aortic stenosis (AS). Association of regional and average LV myocardial strain and displacement with LV geometric pattern and degree of AS.

METHODS: 70 patients with AS (mean age 73±10 years, 54% women) in the Department of Heart Disease, Haukeland University Hospital, Bergen, Norway. Cross-sectional echocardiographic study in patients with AS. Peak circumferential, radial and longitudinal strain, and radial, longitudinal and transverse displacement were measured by 2D speckle tracking. Severity of AS was assessed from energy loss index (ELI). LV hypertrophy was present if LV mass/height^2.7 ≥46.7/49.2 g/m^2.7 in women/men and concentric LV geometry if relative wall thickness ≥0.43. LV geometry was assessed from LV mass/height^2.7 and relative wall thickness in combination.

RESULTS:  Average longitudinal strain was lower in the hypertrophy groups and correlated with higher LV mass index and relative wall thickness, lower stress-corrected mid-wall shortening and smaller ELI (all p<0.05). Average strain and displacement in other directions did not differ between geometric groups. In multivariate regression analysis, lower average longitudinal strain was associated with higher relative wall thickness (β=0.15), lower ejection fraction (β=−0.16), systolic blood pressure (β=−0.16) and energy loss index (β=−0.20) (all p<0.05) (R²=0.72). When relative wall thickness was replaced with LV mass, lower longitudinal strain was also associated with higher LV mass (β=0.21, p<0.05) (R²=0.73).

CONCLUSIONS: In patients with AS, lower average longitudinal strain is related to higher LV mass, concentric geometry and more severe AS.

PMID: 19710026

Primary Percutaneous coronary Intervention by Magnetic Navigation Compared with Conventional Wire Technique

OBJECTIVES: Comparison of magnetic guidewire navigation in percutaneous coronary intervention (MPCI) vs. conventional percutaneous coronary intervention (CPCI) for the treatment of acute myocardial infarction.

METHODS: We compared 65 sequential patients (mean age 61 ± 15 years) undergoing primary MPCI with those of 405 patients undergoing CPCI (mean age 61 ± 13 years). The major endpoint was contrast media use. Technical success and procedural outcomes were evaluated. Clinical demographics and angiographic characteristics of the two groups were similar, except for fewer patients with previous coronary artery bypass grafting (CABG) and hypertension in the CPCI group and fewer patients with diabetes in the MPCI group.

RESULTS: The technical success rate was high in both the MPCI and CPCI groups (95.4 vs. 98%). There was significantly less contrast media usage in the MPCI compared with the CPCI group, median reduction of contrast media of 30 mL with an OR = 0.41 (0.21–0.81). Fluoroscopy times were significantly reduced for MPCI compared with CPCI, median reduction of 7.2 min with an OR = 0.42 (0.20–0.79).

CONCLUSIONS: This comparison indicates the feasibility and non-inferiority of magnetic navigation in performing primary PCI and suggests the possibility of reductions in contrast media use and fluoroscopy time compared with CPCI.

PMID: 20051425

Assessment of Left Atrial Volumes and Function in Orthotopic Heart Transplant Recipients by Dual-Source CT: Comparison With MRI

OBJECTIVES: To compare left atrial performance with dual-source CT (DSCT) with respect to magnetic resonance imaging (MRI) in orthotopic heart transplant recipients.

METHODS: Twenty-nine consecutive heart transplant recipients (27 male; mean age 64.1 +/- 13 years; mean time from transplantation 122.8 +/- 69.7 months) referred for exclusion of cardiac allograft vasculopathy underwent cardiac DSCT and MRI. Standard biatrial technique was employed in 13 subjects whereas 16 were transplanted after the bicaval technique. Axial 5-mm slice-thickness DSCT datasets reconstructed in 5% steps of the cardiac cycle and axial 5-mm SSFP-MRI images were analyzed. Two blinded readers manually traced left atrial contours in random order to estimate end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF). Parameters were compared with a paired sample Student t-test. Concordance correlation coefficient (CCC) was calculated to determine measurement agreement between techniques and observers.

RESULTS: Left atrial volumes were significantly higher with cardiac DSCT (EDV: 170.9 +/- 78.1 mL; ESV: 139.5 +/- 76.6 mL) than with MRI (EDV: 158.2 +/- 72.5 mL; ESV: 124.2 +/- 68.2 mL), whereas left atrial EF was lower with DSCT (EF: 20.8% +/- 7.5% vs. 23.6% +/- 7.7%) (P < 0.05). Measurement agreement between DSCT and MRI was excellent for all parameters (CCC >0.82). Individuals operated with the biatrial anastomosis technique presented significantly higher left atrial volumes and lower EF compared with subjects with bicaval anastomosis. Interobserver agreement was excellent for all parameters (CCC >0.80).

CONCLUSION: Even if DSCT slightly overestimates left atrial volumes with respect to MRI, results remain clinically valid. Bicaval surgical technique offers improved left atrial performance compared with standard biatrial anastomosis. DSCT may be used as a reliable tool to estimate left atrial parameters in orthotopic heart transplant recipients.

PMID: 20027119

Non-Invasive Assessment and Clinical Strategy of Stable Coronary Artery Disease by Magnetic Resonance Imaging, Multislice Computed Tomography and Myocardial Perfusion SPECT

Coronary multislice computed tomography (MSCT) angiography and magnetic resonance angiography (MRA) have emerged as new diagnostic techniques that allow direct visualization of the coronary artery. These new modalities have both advantages and disadvantages concerning radiation exposure, the use of contrast medium, ability of visualizing heavily calcified artery lumens, and spatial and temporal resolution. However, these modalities only provide anatomical information of the coronary artery. Functional assessment of the severity of coronary artery disease (CAD) is essential for the management of patients with known or suspected CAD in practical clinical settings. Myocardial perfusion single-photon emission computed tomography is thought to be the most suitable diagnostic procedure for the determination of therapeutic strategy when coronary MSCT and MRA show significant and also insignificant coronary artery lesions.

PMID: 19966503

Transcatheter Aortic Valve Implantation for Stenosed and Regurgitant Aortic Valve Bioprostheses. CoreValve for Failed Bioprosthetic Aortic Valve Replacements

Transcatheter aortic valve implantation is increasingly being used to treat severe aortic stenosis in patients with high operative risk. In an aging population the incidence of aortic stenosis is rising, and increasing numbers of elderly patients are undergoing aortic valve replacement with bioprosthetic valves. Therefore, there is a corresponding increase in prosthetic degeneration. This presents cardiologists with a cohort of patients for whom the risk of re-do aortic valve surgery is prohibitive. We present the first series of such patients with degenerative bioprosthetic stenosis or regurgitation successfully treated with CoreValve (Medtronic, Luxembourg) implantation.

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Echocardiographic Epicardial Fat: A Review of Research and Clinical Applications

Epicardial fat plays a role in cardiovascular diseases. Because of its anatomic and functional proximity to the myocardium and its intense metabolic activity, some interactions between the heart and its visceral fat depot have been suggested. Epicardial fat can be visualized and measured using standard two-dimensional echocardiography. Standard parasternal long-axis and short-axis views permit the most accurate measurement of epicardial fat thickness overlying the right ventricle. Epicardial fat thickness is generally identified as the echo-free space between the outer wall of the myocardium and the visceral layer of pericardium and is measured perpendicularly on the free wall of the right ventricle at end-systole. Echocardiographic epicardial fat thickness ranges from a minimum of 1 mm to a maximum of almost 23 mm. Echocardiographic epicardial fat thickness clearly reflects visceral adiposity rather than general obesity. It correlates with metabolic syndrome, insulin resistance, coronary artery disease, and subclinical atherosclerosis, and therefore it might serve as a simple tool for cardiometabolic risk prediction. Substantial changes in echocardiographic epicardial fat thickness during weight-loss strategies may also suggest its use as a marker of therapeutic effect. Echocardiographic epicardial fat measurement in both clinical and research scenarios has several advantages, including its low cost, easy accessibility, rapid applicability, and good reproducibility. However, more evidence is necessary to evaluate whether echocardiographic epicardial fat thickness may become a routine way of assessing cardiovascular risk in a clinical setting.

PMID: 19944955

Arterial Remodeling in the Subclinical Carotid Artery Disease

OBJECTIVES: We sought to identify clinical and/or plaque characteristics that affect atherosclerotic disease progression and arterial remodeling in the carotid artery with subclinical stenosis. Increasing severity of stenosis has been associated with a higher risk of stroke. Factors that drive subclinical lesions to become stenotic plaques remain ambiguous. Carotid magnetic resonance imaging (MRI) has been validated with histology to accurately quantify in vivo arterial morphology and plaque composition.

METHODS: A total of 67 asymptomatic participants with 16% to 49% carotid stenosis as demonstrated by duplex ultrasonography were imaged at 1.5-T with a carotid MRI protocol at baseline and at 18-month follow-up. Clinical and/or intra-arterial metrics with a significant association with change in plaque burden during multivariate analysis were evaluated for effects on lumen, wall, and total vessel volume.

RESULTS: From multiple regression analysis, intraplaque hemorrhage (IPH) (p < 0.001) and statin therapy (p = 0.015) were identified as key determinants of change in plaque burden. The group with IPH compared with the group without IPH demonstrated luminal narrowing, with a mean ± SD decrease in lumen volume (–24.9 ± 21.1 mm³/year vs. –0.5 ± 26.9 mm³/year; p = 0.005), a larger increase in wall volume (44.1 ± 36.1 mm³/year vs. 0.8 ± 34.5 mm³/year; p < 0.001), and no difference in total vessel volume (19.3 ± 27.4 mm³/year vs. 0.4 ± 42.4 mm³/year; p = 0.15). The nonstatin group compared with the statin group demonstrated outward remodeling, with an increase in wall volume (22.4 ± 35.6 mm³/year³/year vs. 0.9 ± 38.0 mm³/year; p = 0.026) and total vessel volume (19.2 ± 36.9 mm³/year vs. –4.9 ± 40.4 mm³/year; p = 0.019) and no difference in lumen volume (–5.8 ± 26.6 mm³/year vs. –3.2 ± 29.5 mm³/year; p = 0.72).

CONCLUSIONS: IPH may represent an indication of accelerated plaque growth and impending luminal compromise in the subclinical carotid artery. Statin therapy may stabilize lesions by slowing or halting lesion progression. This phase of plaque stenosis (16% to 49%) may be a critical stage for intrinsic and extrinsic factors to affect the atherosclerotic disease process.

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Prediction of New-Onset Refractory Congestive Heart Failure Using Gated Myocardial Perfusion SPECT Imaging in Patients With Known or Suspected Coronary Artery Disease: Subanalysis of the J-ACCESS Database

OBJECTIVES: The purpose of this study was to evaluate the predictive value of perfusion/function parameters measured by gated myocardial perfusion single-photon emission computed tomography (SPECT) in combination with clinical variables in patients with known or suspected coronary artery disease to predict refractory heart failure (HF).  The increasing number of HF patients requires the establishment of a prophylactic strategy that can identify patients at high risk of HF due to coronary artery disease.

METHODS: We analyzed clinical and stress/rest-gated SPECT data from the multicenter, prospective, and observational J-ACCESS (Japanese Assessment of Cardiac Events and Survival Study by Quantitative Gated SPECT) database of 3,835 known or suspected coronary artery disease patients in which new-onset congestive HF symptoms requiring aggressive medical treatment were observed in 71 patients for 3 years.

RESULTS: The multivariable Cox hazard model revealed that chronic renal dysfunction (hazard ratio (HR): 6.227 [95% confidence interval (CI): 2.920 to 13.279]), the end-systolic volume index (ESVI) (HR: 1.019 [95% CI: 1.011 to 1.029]), and moderate to high stress summed score (SSS) (HR: 3.012 [95% CI: 1.757 to 5.181]) independently (p < 0.0001) predicted HF. In addition to the close (p < 0.0001) correlation of ESVI and SSS with HF incidence, the combined tertiles of SSS and ESVI revealed high-risk patients with a maximally 17.3 times greater risk (5.2%/3 years) compared with the minimal risk (0.3%/3 years) at a normal to low SSS and lower ESVI. Chronic renal dysfunction combined with ESVI and SSS categories had the greatest (p < 0.005 to 0.001) incremental prognostic value with a global chi-square value (125.0) over single or other combined risks.

CONCLUSIONS: Chronic renal dysfunction, greater stress-induced perfusion abnormality, and higher ESVI provide independent and additive information for predicting the risk of refractory HF in known or suspected coronary patients, indicating the efficacy of perfusion/function parameters measured by stress-gated perfusion SPECT for identifying patients at greater risk of future refractory HF.

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