Estimation of myocardial flow reserve utilizing an ultrafast cardiac SPECT: Comparison with coronary angiography, fractional flow reserve, and the SYNTAX score.

Background: Quantitative assessment of myocardial flow reserve (MFR) by single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is challenging but may facilitate evaluation of multi-vessel coronary artery disease (CAD).

Methods: We enrolled 153 patients with suspected or known CAD, referred for pharmacological stress MPI. They underwent a Tc-perfusion stress/rest SPECT with an ultrafast cadmium-zinc-telluride (CZT) camera. Dynamic data were acquired and time-activity curves fitted to a 1-tissue compartment analysis with input function. K1 was assigned for stress and rest data. The MFR index (MFRi) was calculated as K1 stress/K1 at-rest. The findings were validated by invasive coronary angiography in 69 consecutive patients.

Results: The global MFRi was 1.46 (1.16-1.76), 1.33 (1.12-1.54), and 1.18 (1.01-1.35), for 1-vessel disease (VD), 2-VD, and 3-VD, respectively. In the 3-VD, global MFRi was lower than that in 0-VD (1.63 [1.22-2.04], P<0.0001) and 1-VD (P=0.003). Multivariate logistic regression analysis for 3-VD showed significant associations with smoking history (odds ratio [OR]: 4.4 [0.4-8.4]), left ventricular ejection fraction (OR: 61.6 [57.5-66.0]), and global MFRi (OR: 119.6 [111.5-127.7], P=0.002). A cut-off value of 1.3 yielded 93.3% sensitivity and 75.9% specificity for diagnosing 3-VD. Fractional flow reserve positively correlated with regional MFRi (r=0.62, P=0.008), and the SYNTAX score correlated negatively with global MFRi (r=0.567, P=0.0003).

Conclusion: We developed and validated a clinically available method for MFR quantification by dynamic Tc-perfusion SPECT utilizing a CZT camera, which improves the detectability of multi-vessel CAD.