Effect of the stress level achieved during symptom-limited exercise technetium-99m sestamibi myocardial tomography on the detection of coronary artery disease

Background: The stress level achieved during exercise thallium-201 myocardial imaging may influence its sensitivity for detecting coronary artery disease (CAD). The effect of exercise adequacy on the accuracy of technetium-99m sestamibi (MIBI) imaging has not been studied. Hypothesis: The study was undertaken to assess the effect of exercise level achieved on sensitivity for detecting CAD. Methods: A consecutive series of 250 patients (mean age 60 ± 10 years) with CAD by angiography underwent symptom-limited exercise MIBI single-photon emission computed tomography. Single-vessel CAD was found in 66 patients, double-vessel CAD in 84, triple-vessel CAD in 80, and left main disease in 20. Results: No significant differences were found in sensitivities of an abnormal MIBI scan or a reversible defect among 102 patients reaching 85% of age-predicted heart rate and 148 who did not (82 vs. 89% and 66 vs. 70%, respectively, p = NS). Patients (n = 128) able to exercise ≤6 min had a higher incidence of abnormal scans and reversible defects than 122 patients with a greater exercise duration (91 vs. 82% and 75 vs. 61%, respectively, both p<0.02). Sensitivity of an abnormal MIBI scan for multivessel disease was greater than for single-vessel disease in patients who achieved ≤85% of age-predicted heart rate (91 vs. 59%, p<0.01) and in those who exercised >6 min (89 vs. 66%, p<0.01). No significant differences in the sensitivities of an abnormal MIBI study for multivessel versus single- vessel CAD were seen in patients achieving lower peak levels of exercise. Sensitivity of ischemic ST depression was lower than that of MIBI tomography at all levels of exercise. Conclusions: The sensitivity of exercise MIBI tomography for angiographic CAD is relatively independent of the peak heart rate achieved. Exercise duration of >6 min is associated with a significantly higher MIBI abnormality rate than a duration of >6 min, possibly reflecting the effect of myocardial ischemic burden on exercise ventricular function. Regardless of level of stress or its duration, exercise MIBI tomography improves the sensitivity for CAD detection compared with stress-induced ischemic ST depression.