Long-Term Prognostic Value of 13N-Ammonia Myocardial Perfusion Positron Emission Tomography Added Value of Coronary Flow Reserve

Objectives The goal of this study was to assess the predictive value of myocardial perfusion imaging with N-13-ammonia positron emission tomography (PET) and coronary flow reserve (CFR) on long-term prognosis in patients with suspected myocardial ischemia. Background No prognostic data exist on the predictive value of CFR and N-13-ammonia PET. Methods Perfusion and CFR were assessed in 256 patients using N-13-ammonia PET, and follow-up was obtained in 245 (96%) patients. Sixteen early revascularized patients were excluded and 229 were assigned to normal versus abnormal perfusion or normal versus abnormal CFR (<2.0). Major adverse cardiac events (MACE) (cardiac death, nonfatal myocardial infarction, late revascularization, or hospitalization for cardiac reasons) were assessed using the Kaplan-Meier method. Cox proportional hazard regression was used to identify independent predictors for cardiac events. Results During follow-up (5.4 +/- 2.2 years), 78 patients had at least 1 cardiac event, including 29 cardiac deaths. Abnormal perfusion (n = 126) was associated with a higher incidence of MACE (p < 0.001) and cardiac death (p < 0.05). In patients with normal perfusion, abnormal CFR was independently associated with a higher annual event rate over 3 years compared with normal CFR for MACE (1.4% vs. 6.3%; p < 0.05) and cardiac death (0.5% vs. 3.1%; p < 0.05). In abnormal perfusion, CFR remained predictive throughout the 10-year follow-up (p < 0.001). Conclusions Perfusion findings in N-13-ammonia PET and CFR are strong outcome predictors. CFR allows further risk stratification, suggesting a "warranty" period of 3 years if normal CFR is associated with normal perfusion. Conversely, in patients with abnormal perfusion, an impaired CFR has added value for predicting adverse outcomes. (J Am Coll Cardiol 2009; 54:150-6) (C) 2009 by the American College of Cardiology Foundation