INCREMENTAL PROGNOSTIC VALUE OF EXERCISE TL-201 MYOCARDIAL SINGLE-PHOTON EMISSION COMPUTED-TOMOGRAPHY LATE AFTER CORONARY-ARTERY BYPASS-SURGERY

Objectives. This study assessed the incremental prognostic value of exercise thallium-201 myocardial perfusion single-photon emission computed tomography (SPECT) performed greater than or equal to 5 years after coronary artery bypass surgery. Background. Thallium-201 scintigraphy has shown significant prognostic value in a variety of populations with suspected and known coronary artery disease. However, its value in patients with previous bypass surgery remains unknown. Methods. We studied 294 patients who were prospectively followed up. Cox proportional hazards models for prediction of ''hard'' events (cardiac death and nonfatal infarctions) sere constructed, with variables considered for inclusion in hierarchic order: clinical and exercise data first, followed by scintigraphic information. Results. Mean (+/-SD) follow up duration after scintigraphy was 31 +/- 11 months. There were 20 cardiac deaths and 21 nonfatal acute myocardial infarctions. Twenty nine patients had late (>60 days after thallium-201 SPECT) revascularization procedures or underwent repeat bypass surgery or percutaneous transluminal angioplasty. Shortness of breath and peak exercise heart rate were the most important clinical predictors of hard events. Two scintigraphic variables added significant prognostic information to the clinical model: the thallium-201 summed reversibility score (summation of segmental differences between stress and redistribution scores) and the presence of increased lung uptake of the radiotracer. The global chi-square statistic for this model was twice as high as that for the clinical/exercise model alone (49.7 vs. 24.2). When a second multivariate Cox model was built adding ''soft'' events (i.e., late revascularization procedures) as outcomes of interest, the summed reversibility score was selected as an independent scintigraphic predictor of events. The global chi-square statistic for this model was 50.7, three times as high as that for the clinical/exercise model alone. Conclusions. After evaluation of treadmill and exercise data, thallium-201 myocardial perfusion SPECT provided incremental prognostic information in patients late after bypass.