Miller, Todd D.

Background— Appropriateness criteria for stress imaging have been published to promote the effective use of stress nuclear scintigraphy and stress echocardiography. We sought to evaluate the application of the stress echocardiography appropriateness criteria to patients undergoing stress echocardiography in an academic medical center. Methods and Results— The stress echocardiography criteria were applied to 298 consecutive patients who underwent stress echocardiography. Patients were rated as appropriate, uncertain, inappropriate, or not classifiable. Results were compared with those of a previous analysis in the same patients using the single-photon computed tomography myocardial perfusion imaging (SPECT MPI) criteria. The level of agreement between 2 cardiac nurse abstractors for categorizing appropriateness by the stress echocardiography criteria was good (κ=0.72). Overall, 54% of patients were classified as appropriate, 8% as uncertain, and 19% as inappropriate; 19% were not classifiable. By the SPECT MPI criteria, 64% of patients were classified as appropriate, 9% as uncertain, and 18% as inappropriate; 9% were not classifiable ( P <0.001 compared with stress echocardiography criteria). By the stress echocardiography criteria, 6 clinical situations or indications accounted for more than 90% of the inappropriate tests; most of these involved asymptomatic patients. Conclusions— Applying stress echocardiography appropriateness criteria to a patient population is feasible, although 1 in 5 of our patients was not classifiable. Overall, the stress echocardiography criteria classified patients differently compared with the SPECT MPI criteria. Future refinements of the appropriateness criteria for stress imaging should address gaps in the criteria and disparities between the stress echocardiography and SPECT MPI criteria.

Background— In a recent study, we reported that the Duke treadmill score was unable to effectively stratify elderly patients according to risk. The purpose of this study was to evaluate the prognostic value of exercise single-photon emission computed tomography (SPECT) in this same population and to examine results by gender. Methods and Results— A cohort of 247 elderly (age ≥75 years) patients (108 women, 139 men, age 77±3 years) who underwent exercise thallium-201 SPECT were followed up for a median duration of 6.4 years. SPECT variables were significantly associated with cardiac death: summed stress score (SSS) χ 2 =19.5, P <0.001; summed difference score χ 2 =12.3, P <0.001; increased lung uptake χ 2 =9.6, P =0.002; and left ventricular enlargement χ 2 =8.3, P =0.004. The Duke score was not significantly associated with cardiac death (χ 2 <1, P =NS). The SSS classified most patients as low risk (49%) or high risk (35%); the Duke score classified the majority (68%) as intermediate risk. Annual cardiac mortality rates for patients categorized by SSS as low risk and high risk were 0.8% and 5.8%, respectively. Cardiac survival rates according to SSS risk categories were significantly different for both women ( P =0.012) and men ( P =0.003). Conclusions— SPECT classified most elderly patients into clinically useful low- and high-risk categories and accurately predicted outcomes in both genders. If these results can be validated in future studies, exercise SPECT rather than standard treadmill testing may emerge as the initial noninvasive testing strategy in elderly patients who are able to exercise.