Original ArticleA highly predictive cardiac positron emission tomography (PET) risk score for 90-day and one-year major adverse cardiac events and revascularization
Introduction
Annually approximately 3.8 million patients undergo cardiac stress testing in the USA.1 As high as 15% of these patients will have a false-negative result and 2.4% of these misdiagnosed patients have a subsequent major adverse cardiac event (MACE).2 Cardiac PET/CT (positron emission tomography/computed tomography) may reduce these misdiagnoses by providing higher image quality.3, 4, 5, 6, 7, 8, 9, 10 While PET has been around for decades, clinical use of cardiac PET/CT has been relatively limited. However, new radiopharmaceuticals and changes in reimbursement have contributed to the recent rapid growth of PET/CT.11,12 Like other imaging modalities, the comprehensive interpretation of PET/CT scans has a steep learning curve, especially in more complex or ambiguous cases.13, 14, 15, 16 There is also inherent variability in the interpretation of cardiac images and cardiac risk assessment.17, 18, 19, 20, 21 However, developing a risk assessment score for MACE and revascularization (MACE-Revasc) using the large amount of data gathered (e.g., ischemic burden and myocardial blood flow) by PET/CT could help minimize the learning curve and reduce inter-operator variability in risk assessment.
The purpose of this study was to develop a PET/CT-based risk assessment score for 90-day and one-year MACE-Revasc outcomes. This was done using data from Intermountain Medical Center, which switched to a PET/CT-centric myocardial perfusion imaging center in 2013 and conducts about 4000-5000 cardiac PET/CT scans annually.3,22 Therefore, for the development of a PET-based risk assessment, we were able to have large training, development, and test data sets containing common, standard clinical PET/CT elements. A key focus in the development of the risk assessment score was to ensure that it was useful clinically. Consequently, the developed numeric score was based on assigned weights for categorical values of common clinical and PET/CT results. We compared the developed risk score to ischemic burden and the interpreting cardiologist assessment of risk as documented in the official clinical interpretation of the studies.
Section snippets
Methods
This study was approved by the Intermountain Healthcare Institutional Review Board with a waiver of consent. Investigations were performed in accordance with the Declaration of Helsinki.
Study population characteristics and MACE-Revasc outcomes
The patient and clinical characteristics for the three study populations are shown in Table 1. In general, the PET/CT patients were on average 65 years old, just over half were male, many had risk factors for coronary artery disease, and over a quarter had a prior history of MI or revascularization. While there existed statistically significant differences between the sets, the largest and clinically significant difference was in the decrease in a history of coronary artery disease for the test
Discussion
We have derived a PET/CT 90-day MACE-Revasc risk score and a PET/CT one-year MACE-Revasc risk score that are highly predictive of events. These scores had statistically significant, although moderate, improvement over ischemic burden alone and the cardiologist’s assessment of risk. Both contained less than 10 factors and were based on summing integer values. Thus, these risk scores allow for easy implementation into practice.
Both the PET/CT 90-day and one-year MACE-Revasc risk scores were
Conclusion
A PET/CT 90-day MACE-Revasc risk score and a PET/CT one-year MACE-Revasc risk score were generated that incorporate routinely collected PET/CT results combined with a minimum number of clinical features for simple calculation. These risk scores provide improved prediction over ischemic burden alone and improve the classification, compared to cardiologists, of high-risk patients. The use of these simple PET/CT MACE-Revasc risk scores in an external patient population should be examined as well
New knowledge gained
The derived PET/CT MACE-Revasc risk scores outperformed ischemic burden alone and the predicted risk of cardiologists. This finding indicates that the combined use of PET/CT data in an easy to calculate risk score may improve clinical assessment and care.
Disclosures
Benjamin D. Horne is an inventor of clinical decision tools (risk scores) that are licensed to CareCentra and Alluceo and is the PI of grants involving clinical decision tools that were funded by CareCentra, GlaxoSmithKline, and AstraZeneca. Benjamin D. Horne is a member of the scientific advisory board of Labme Inc. Jeffrey L. Anderson was a paid consultant until June 2020 for Johnson & Johnson and is the PI of grants funded by Novartis and Milestone. Raymond O. McCubrey, Steve M. Mason, Viet
Funding
This study was internally funded.
JNC thanks Weihua Zhou, Ph.D. and Weihua Zhou, Michigan Technological University, MI, USA, and Cheng Wang, Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China for providing the Chinese abstract.
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Raymond O. McCubrey and Steve M. Mason are co-first authors, both contributed equally to this project.