Does 99mTC-sestamibi single-photon emission computed tomography stress testing detect coronary artery disease in patients being evaluated for chest pain?
      99mTc-sestamibi single-photon emission computed tomography (SPECT) stress testing has high sensitivity, specificity, and accuracy (>90%) for detecting coronary artery disease (CAD) in controlled study populations. However, its ability to detect CAD in a population being evaluated for chest pain is less clearly established. We studied 283 consecutive patients (60% women, 40% men) from 5 counties in North Carolina referred for cardiac catheterization. Patients had chest pain but no history of CAD. 99mTc-sestamibi SPECT stress testing was performed before catheterization. Stress-induced 99mTc-sestamibi SPECT abnormalities were identified in 62% of patients. Catheterization identified CAD (lesions ≥75% in a major vessel or large branch) in 32% of patients with stress-induced SPECT abnormalities and 23% of patients without stress-induced abnormalities. Calculated sensitivity, specificity, and predictive accuracy for CAD detection were 69%, 42%, and 50%, respectively. To account for referral bias, we evaluated the local normalcy rate of 99mTc-sestamibi SPECT stress testing and estimated the number of patients with negative studies not going on to catheterization. Assuming no false negatives in this group, sensitivity, specificity, and accuracy are, respectively, 69%, 80%, and 79%. Assuming 23% false negatives (percent observed at catheterization), sensitivity, specificity, and accuracy are 33%, 77%, and 60%. Thus, true sensitivity appears to fall between 33% and 69%. These data indicate that uncertainty exists regarding the ability of 99mTc-sestamibi SPECT stress testing to accurately detect CAD in a population being evaluated for chest pain.
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