10-year experience of utilizing a stress-first SPECT myocardial perfusion imaging

Donghee Han, Mark C. Hyun, Robert J.H. Miller, Heidi Gransar, Piotr J. Slomka, Damini Dey, Sean W. Hayes, John D. Friedman, Louise E.J. Thomson, Daniel S. Berman, Alan Rozanski

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Background: Despite its potential benefits, the utilization of stress-only protocol in clinical practice has been limited. We report utilizing stress-first single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). Methods: We assessed 12,472 patients who were referred for SPECT-MPI between 2013 and 2020. The temporal changes in frequency of stress-only imaging were assessed according to risk factors, mode of stress, prior coronary artery disease (CAD) history, left ventricular function, and symptom status. The clinical endpoint was all-cause mortality. Results: In our lab, stress/rest SPECT-MPI in place of rest/stress SPECT-MPI was first introduced in November 2011 and was performed more commonly than rest/stress imaging after 2013. Stress-only SPECT-MPI scanning has been performed in 30–34% of our SPECT-MPI studies since 2013 (i.e. 31.7% in 2013 and 33.6% in 2020). During the study period, we routinely used two-position imaging (additional prone or upright imaging) to reduce attenuation and motion artifact and introduced SPECT/CT scanner in 2018. The rate of stress-only study remained consistent before and after implementing the SPECT/CT scanner. The frequency of stress-only imaging was 43% among patients without a history of prior CAD and 19% among those with a prior CAD history. Among patients undergoing treadmill exercise, the frequency of stress-only imaging was 48%, while 32% among patients undergoing pharmacologic stress test. In multivariate Cox analysis, there was no significant difference in mortality risk between stress-only and stress/rest protocols in patients with normal SPECT-MPI results (p = 0.271). Conclusion: Implementation of a stress-first imaging protocol has consistently resulted in safe cancellation of 30% of rest SPECT-MPI studies.

Original languageEnglish
Article number131863
JournalInternational Journal of Cardiology
StatePublished - 15 Apr 2024


  • Cardiac stress testing
  • Coronary artery disease
  • Single-photon emission computed tomography
  • Stress-only myocardial perfusion imaging


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