Gated stress-only 99mTc myocardial perfusion SPECT imaging accurately assesses coronary artery disease

In today's cost containment environment it is important to consider changes to standard protocols which would reduce cost, particularly if there is no significant loss of diagnostic accuracy. The aim of the present study was to assess the usefulness of a gated stress-only Tc sestamibi protocol in comparison to conventional gated dual isotope rest-stress myocardial perfusion single photon emission computed tomography (SPECT) in the detection and localization of coronary artery disease (CAD). Sixty-five consecutive patients (65+/-10 years, 22 women) who had undergone conventional gated perfusion SPECT were chosen retrospectively. Fifty-three of these 65 patients had previous coronary arteriography, 45 with at least one stenosis, eight without stenosis, and 12 of these 65 patients had <5% likelihood of CAD. Three readers interpreted the gated stress-only and dual isotope studies in separate sessions blinded to (1). their previous readings, (2). the interpretation by others, and (3). the angiographic results. Readers used a five-point scale to score their visual and quantitative assessment of perfusion, function and compromised vascular territory. Their average score was used for determination of the accuracy by using receiver operating characteristic (ROC) analysis of the techniques. The areas under ROC curves were determined for the detection of CAD and localization of vascular territories. Fifty-four of these patients had 97 significant stress induced perfusion defects as determined by the CEqual quantitative program. The agreement between protocols for the assessment of reversibility in these 97 defects was analysed. There were no statistically significant differences between dual isotope rest/stress and gated stress-only studies for the detection and localization of CAD. The area under the dual isotope rest/stress ROC curve was 0.78+/-0.07 compared to the area under the gated stress-only ROC curve of 0.80+/-0.06, resulting in P=0.30. For the combined vessels comparison of the area under the dual isotope rest/stress ROC curve was 0.73+/-0.04 versus the area under the gated stress-only ROC curve of 0.74+/-0.04, resulting in P=0.27. Similar non-significant differences were obtained when comparing the area under the dual isotope versus gated stress-only ROC curves for the left anterior descending vascular territory (LAD, 0.61+/-0.08 vs 0.660.08, P=0.14), the left circumflex vascular territory (LCX, 0.82+/-0.07 vs 0.81+/-0.06, P =0.47) or the right coronary vascular territory (RCA, 0.80+/-0.06 vs 0.78+/-0.06, P=0.28). The analysis of the reversibility of stress induced perfusion defects yielded a global agreement between protocols of 93% (kappa=0.42). The differences were due to the expert readers, using the gated stress-only protocol, misinterpreting some patients with attenuation artefacts, subendocardial infarction and functional stunning. These results show that the lower cost gated stress-only myocardial Tc myocardial perfusion SPECT studies are comparable to the conventional dual isotope studies when the clinical question is the detection and localization of coronary artery disease. Nevertheless, we also showed that this approach is limited when attempting to interpret the reversibility of stress induced perfusion defects in patients who exhibit attenuation artefacts, subendocardial infarction and functional stunning.     

Prognosis of stress-only SPECT myocardial perfusion imaging with prone imaging

Background

Stress-only single-photon emission computed tomography myocardial perfusion imaging (SO SPECT MPI) is associated with similarly benign prognosis as stress-rest SPECT MPI. However, previous studies have used attenuation correction rather than prone imaging to increase the rate of SO studies.

Objectives

To assess the prognosis of SO SPECT MPI performed with prone imaging.

Methods

We performed a retrospective cohort analysis of all patients who underwent a Tc-99m gated SPECT MPI over a 58-month period.

Results

Two thousand four hundred and sixty five patients were followed up. Of them, 1114 (45.2%) patients had a SO supine test, 388 (15.7%) underwent a SO supine and prone test, and the remaining 963 (39.1%) patients underwent a full stress-rest SPECT MPI. There was a similar annual mortality rate between the SO supine/prone group (1.3%), the SO supine (1.5%), and the stress-rest (1.5%) group (P = 0.47). Patients in the stress-rest group were significantly more likely to suffer from myocardial infarction (MI) as compared to the other two groups with an annual rate of 0.7% as compared to 0.4% (P = 0.049).

Conclusions

Normal supine-prone SO SPECT MPI is associated with a similarly benign prognosis as stress-rest SPECT MPI. The adjunction of prone imaging to the stress supine significantly increases the rate of SO SPECT MPI

     

瑞加诺生负荷心肌灌注显像诊断冠心病的初步临床研究

目的 探讨瑞加诺生注射液作为负荷药物行核素心肌灌注显像（MPI）诊断冠心病的有效性及安全性。 方法 选取2017年9月至2018年10月于山西医科大学第一医院住院的疑似冠心病的42名受试者进行回顾性研究。采用完全随机法将受试者分为2组:瑞加诺生组[男性8名、女性9名,年龄（59.83±7.88）岁]和腺苷组[男性12名、女性13名,年龄（56.32±7.34）岁],分别行瑞加诺生和腺苷注射液的静息MPI后再行负荷MPI,之后2周内所有受试者均行冠状动脉血管造影（CAG）检查。以CAG结果为标准,分析2组MPI诊断冠心病的效能并观察不良反应。计量资料的组间比较采用两独立样本t检验、配对t检验或方差分析、Wilcoxon Z秩和检验;计数资料的组间比较采用McNemar检验或Fisher's确切概率法;瑞加诺生和腺苷的MPI检查方法的一致性比较采用Kappa检验。 结果 2组一般资料、CAG阳性率及狭窄程度的比较,差异均无统计学意义（t=?1.503~1.201,Z=?1.346~?0.228,Fisher's确切概率法,均P>0.05）。瑞加诺生负荷MPI诊断冠心病的灵敏度为70.00%（7/10）、特异度为87.80%（36/41）、阳性预测值为58.33%（7/12）、阴性预测值为92.31%（36/39）、准确率为84.31%（43/51）;腺苷负荷MPI诊断冠心病的灵敏度为71.43%（10/14）、特异度为86.89%（53/61）、阳性预测值为55.56%（10/18）、阴性预测值为92.98%（53/57）、准确率为84.00%（63/75）,2种MPI方法诊断效能的各项指标的比较差异均无统计学意义（Fisher's确切概率法,均P=1.00）,其分别与CAG结果比较,均存在中度一致性（κ=0.537、0.525,均P<0.001）。药物不良反应为轻微和暂时的,2组间在脸红、胸痛和胸闷、呼吸困难、头晕和头痛、恶心、心悸等不良反应的比较,差异均无统计学意义（Fisher's确切概率法,均P>0.05）,只有腹部不适的差异有统计学意义（Fisher's确切概率法,P=0.044）。 结论 瑞加诺生作为心脏负荷试验药物用于MPI诊断冠心病,与腺苷注射液比较具有相似的有效性及安全性。     

Value of attenuation correction in stress-only myocardial perfusion imaging using CZT-SPECT

Background

Attenuation correction (AC) improves the diagnostic outcome of stress-only myocardial perfusion imaging (MPI) using conventional SPECT. Our aim was to determine the value of AC using a cadmium zinc telluride-based (CZT)-SPECT camera.

Methods and results

We retrospectively included 107 consecutive patients who underwent stress-optional rest MPI CZT-SPECT/CT. Next, we created three types of images for each patient; (1) only displaying reconstructed data without the CT-based AC (NC), (2) only displaying AC, and (3) with both NC and AC (NC + AC). Next, two experienced physicians visually interpreted these 321 randomized images as normal, equivocal, or abnormal. Image outcome was compared with all hard events over a mean follow-up time of 47.7 ± 9.8 months. The percentage of images interpreted as normal increased from 45% using the NC images to 72% using AC and to 67% using NC + AC images (P < .001). Hard event hazard ratios for images interpreted as normal were not different between using NC and AC (1.01, P = .99), or NC and NC + AC images (0.97, P = .97).

Conclusions

AC lowers the need for additional rest imaging in stress-first MPI using CZT-SPECT, while long-term patient outcome remained identical. Use of AC reduces the need for additional rest imaging, decreasing the mean effective dose by up to 1.2 mSv.

     

Correct spatial normalization of myocardial perfusion SPECT improves detection of multivessel coronary artery disease

BACKGROUND: This study sought to improve the detection of multivessel coronary artery disease (CAD) with the use of rest and exercise single photon emission computed tomography (SPECT) perfusion scintigraphy by developing a processing scheme, which provides proper regional normalization of the images for interpretation. When SPECT perfusion images are interpreted, one area of myocardium serves as "normal." We hypothesized that if this "normal" region changes location from rest to stress, the stress images must be adjusted for proper interpretation. By taking into account the level of tracer activity in this "normal" area on the resting images, we could more accurately identify patients with multivessel CAD.Methods and results Dual-isotope rest (thallium 201) and exercise dobutamine or adenosine stress (technetium 99m sestamibi) perfusion SPECT studies were examined in 258 patients with 2- or 3-vessel CAD on coronary arteriography performed within 6 months of each other (mean interval, 19 days). If a shift in regional location of the "normal" segment from rest to stress was present, the images were (1) interpreted in the usual fashion for the number of vessels with ischemia (PRE-NORM) and (2) reinterpreted after quantitative normalization (ie, adjusting the display window until the intensity of the "normal" segment was matched at rest and stress [POST-NORM]). Interpretation was performed with blinding to arteriographic results. An angiographic stenosis was defined as luminal diameter stenosis greater than 50%. Three control groups comprising (1) single-vessel CAD (n = 119), (2) no significant angiographic CAD (n = 118), and (3) a normalcy group of low pre- and post-test probability of CAD (n = 44) were also studied to determine the incidence of false-positive results induced by the renormalization technique. A shift in the "normal" segment occurred in 81 studies of 258 patients (31%), 80 of which were read as abnormal PRE-NORM (sensitivity, 99%); however, for their 216 stenosed vessels, only 143 were detected PRE-NORM (vessel sensitivity, 66%; accuracy, 65%). The mean POST-NORM change in the display was 11%. POST-NORM, all 82 patients' studies were interpreted as abnormal (sensitivity, 100%), and 196 of 216 vascular territories were abnormal (vessel sensitivity, 91%; accuracy, 83%; both P <.0001 vs PRE-NORM). In the single-vessel disease, no significant disease, and normalcy groups, 19 of 119, 15 of 118, and 11 of 44 patients, respectively, demonstrated a shift in the peak pixel location. However, there were no significant changes in single-vessel sensitivity, angiographic specificity, or normalcy in these patients. CONCLUSIONS: With multivessel CAD, the "normal" region on SPECT often changes in location from rest to stress, potentially masking the extent and severity of multivessel ischemia. Renormalization of the images to match their resting level before image interpretation allows diagnosis of contralateral ischemia and strikingly improves the detection of multivessel CAD, without a substantive loss in specificity.     

Prognostic value of stress-gated 99m-technetium SPECT myocardial perfusion imaging: Risk stratification of patients with multivessel coronary artery disease and prior coronary revascularization

Background

This study assessed the prognostic value of stress-gated 99mTc-sestamibi myocardial perfusion SPECT (MPS) in patients with multivessel coronary artery disease (CAD) and prior revascularization according to the presence and severity of ischemia.

Methods and Results

We studied the outcome of 472 patients with multivessel CAD and prior revascularization (coronary angioplasty, 290 patients; bypass surgery, 182 patients), who underwent exercise or dipyridamole 99mTc-sestamibi MPS for evaluation of ischemia. Visual scoring of perfusion images used 20 segments and a 5-point scale. Gated post-stress EF was automatically calculated. Endpoints included hard events: cardiac death (CD) and nonfatal myocardial infarction (MI). During a mean follow-up of 3.0 ± 1.0 years, 37 hard events occurred, including CD in 15 (3%) and MI in 22 (5%) patients. In a risk-adjusted multivariable Cox model, a history of prior MI, diabetes, abnormal MPS, moderate-to-severe ischemia, and post-stress EF <35% were important predictors of cardiac events. Four-year risk-adjusted survival was 97.9% for normal MPS, 87.3% for abnormal MPS with ischemia, and 82.1% for moderate-to-severe ischemia.

Conclusions

Among patients with previous coronary revascularization, stress-gated 99mTc-sestamibi MPS provides prognostic information for the prediction of cardiac events. A normal perfusion scan confers an excellent prognosis and an exceedingly low hard event rate (<1%/year). The presence of moderate-to-severe ischemia or a post-stress EF <35% identifies patients at highest risk of subsequent cardiac events.     

Dobutamine stress myocardial perfusion imaging in coronary artery disease.

The accurate noninvasive diagnosis and functional evaluation of coronary artery disease is an important step in selecting the appropriate management strategy. Dobutamine stress myocardial perfusion imaging is an alternative to exercise in patients with limited exercise capacity. In many centers, the test is performed on patients who have a contraindication for vasodilator stress testing. Recent studies have shown hyperemia induced by the standard dobutamine-atropine stress test is not less than hyperemia induced by dipyridamole. The feasibility of the test is 90% and is often higher in patients without beta-blocker therapy. The safety of the test has been well studied and was also demonstrated in specific patients groups, such as patients with left ventricular dysfunction, the elderly, and heart transplant recipients. The diagnostic accuracy has been demonstrated in patients with and without myocardial infarction and in specific groups such as those with hypertension, left ventricular hypertrophy, and heart transplant recipients and after revascularization. The technique has a high sensitivity for prediction of functional recovery in patients with myocardial dysfunction referred for revascularization. The presence and severity of myocardial perfusion abnormalities assessed by this method are powerful predictors of cardiac events, incremental to clinical data. This article describes the methodology, safety, feasibility, diagnostic accuracy, and prognostic value of dobutamine stress myocardial perfusion imaging in patients with known or suspected coronary artery disease, with additional considerations for the application of the test in specific patient groups.     

Intracoronary myocardial perfusion imaging: patterns in patients with coronary artery disease

Myocardial imaging following the intracoronary injection of radiolabeled particles is used to identify transmural scars in patients being evaluated for coronary atherosclerosis. Selective imaging of the microcirculation derived from each major coronary vessel is accomplished using a dual radionuclide technique. This report illustrates the various normal and abnormal imaging patterns encountered in patients with coronary artery disease. The regional myocardial nomenclature proposed by the American Heart Association Council on Cardiovascular Surgery is used. Correlation of the nuclear study with the contrast arteriogram and ventriculogram is essential for identifying both transmural scars and regions of collateral circulation. The procedure is safe and can be performed during routine coronary angiography.     

慢性稳定型冠心病的核素心肌灌注显像临床应用进展

多项临床试验证明,核素心肌灌注显像在冠心病诊断、危险度分层、预后判断、病人处理方案等方面具有突出的作用和优越的价值。在ACC/AHA(美国心脏病学院/美国心脏学会)有关冠心病和核心脏病学指南中,心肌灌注显像的上述作用得到了充分肯定。合理应用该项技术可以提高对冠心病诊断、处理的整体水平,并使有限的医疗资源得到更合理利用,这在我国目前显得十分迫切和需要。     

核素心肌灌注显像定量分析技术诊断本地人群冠心病的价值

Objective To evaluate the accuracy of automated quantification of myocardial perfusion imaging (MPI) using a method based on a Western normal database for the detection of coronary artery disease (CAD) in a group of Chinese patients. Methods Seventy-two Chinese patients who underwent coronary angiography (CAG) and MPI within 3 months were recruited into this study. Eighty selected from 140 Chinese patients with low probability of CAD ( ＜ 5% ) were enrolled into local normal database of 99Tcm-methoxyisobutylisonitrile (MIBI) MPI using Cedars quantitative perfusion SPECT (QPS) database. Two Western MPI normal databases (CSMC MibiMbiAuto and Mibimibi) were used for processing the Chinese CAD patients recruited in this study, and the results were compared with those using local normal database and visual interpretation. T-test and z-test were used for statistical analysis. Results The extent (EXT)measurement obtained from Mibimibi and local database was ( 10.73 ± 14.54)% and ( 14.22 ± 16.51 )%,respectively ( t = 7.87, P ＜ 0.001 ); the severity (SEV) was 1.07 ± 0.93 and 1.34 ± 1.20, respectively ( t =7.45, P＜0.001). The area under curve(AUC) by using EXT measurement for local database (0.85 ±0.05) was larger than that for CSMC MibiMbiAuto ( AUC = 0.72 ± 0.06, z = 2.50, P ＜ 0.01 ) and Mibimibi ( AUC = 0.77 ± 0.06, z = 2.47, P = 0.014). The AUC of local database showed no significant difference from that of visual interpretation (AUC=0.83 ±0.05, z=0.05, P＞0.05). Conclusion Quantification of MPI of our Chinese patients using Western normal database would decrease the accuracy for the detection of CAD.     

核素心肌灌注显像定量分析技术诊断本地人群冠心病的价值

目的 研究基于西方人群的核素心肌灌注显像（MPI）定量分析技术应用于本地人群时对冠心病的诊断准确性.方法 （1）选择72例3个月内同期行冠状动脉造影（CAG）和MPI的患者为试验组 （2）在Cedars quantitative perfusion SPECT（QPS）软件平台上,建立QPS简单法数据库,从140例冠心病可能性＜5%、已行两日法99Tcm-甲氧基异丁基异腈（MIBI）MPI的患者中选择80例建立本地人正常MPI数据库 （3）采用2种西方人正常MPI数据库（分别为数据库1和数据库2）和本地人正常MPI数据库,对试验组患者的MPI图像进行定量分析,并与目测法结果进行比较.均数间比较采用t检验,受试者工作特征（ROC）曲线下面积（AUC）比较采用z检验.结果 数据库2和本地人正常MPI数据库对试验组患者的MPI进行定量分析显示,缺血总范围（EXT）分别为（10.73±14.54）%和（14.22±16.51）%（t=7.87,P＜0.001）,缺血总严重程度（SEV）分别为1.07±0.93和1.34±1.20（t=7.45,P＜0.001）.以EXT为定量诊断参数时,本地人正常MPI数据库所得AUG为0.85±0.05,与数据库1（0.72±0.06,z=2.50,P＜0.01）和数据库2（0.77±0.06,z=2.47,P＜0.01）的AUC比较,差异均有统计学意义,但与目测半定量法负荷总积分（V-SSS）作为诊断参数的AUC（0.83±0.05）相比差异无统计学意义（z=0.05,P＞0.05）.结论 以西方人正常MPI数据库为基础的定量分析技术应用于本地人群时会低估患者的心肌缺血面积和严重程度,会降低对冠心病诊断的准确性.     

Incremental value of left ventricular ejection fraction for detection of multivessel coronary artery disease in exercise (201)Tl gated myocardial perfusion imaging.

Assessment of reversible defects in exercise (201)Tl perfusion SPECT has low sensitivity and high specificity for detection of multivessel coronary artery disease (CAD). The goal of this study was to evaluate whether the left ventricular ejection fraction (LVEF) in exercise (201)Tl gated SPECT had incremental diagnostic value over perfusion data for detection of multivessel CAD. METHODS: One hundred eighty-two patients underwent exercise (201)Tl gated SPECT. Automated LV function analysis software was used for calculation of the postexercise and the rest LVEF. The best threshold between 0- to 1-vessel CAD and 2- to 3-vessel CAD was determined as the cutoff that on receiver-operating-characteristic analysis resulted in the best sensitivity for detection of multivessel CAD with an associated specificity of >90%. RESULTS: Only 18 (26.9%) of 67 patients with multivessel CAD had reversible defects in multiple territories. Sensitivities of the postexercise and the rest LVEF and the worsening of the LVEF by exercise did not differ from those of perfusion data alone. Sensitivities of the combination of perfusion data and the postexercise and rest LVEF did not differ from those of perfusion data alone, whereas the sensitivity of the combination of perfusion data and worsening of the LVEF (i.e., reversible defects in multiple territories or worsening of the LVEF >5.6% [or both]) was significantly greater than that of perfusion data alone (43.3% vs. 26.9%; P < 0.05), with an acceptable level of specificity (90.4%). CONCLUSION: The worsening of the LVEF by exercise has the potential to detect patients with multivessel CAD among those without multivessel patterns of reversible defects.     

负荷CT心肌灌注在冠心病中应用的初步研究进展

冠心病是因冠状动脉血流和心肌氧需求之间不平衡而导致的缺血性心肌损害,仅凭冠状动脉狭窄来诊断冠心病不能准确反映心肌缺血状况,也不能对缺血性心脏事件的发生做出较准确的预警.负荷CT心肌灌注成像则可定性及定量地评价心肌血流状态,检测心肌微循环及心肌活性,对心脏事件的发生进行预测并对早期干预提供客观依据等.对负荷CT心肌灌注的检测原理、方法及在冠心病中临床应用的初步研究进展进行综述.     

运动试验心肌显像异常及其类型对冠心病患者预后判断的价值

目的评价运动试验心肌显像异常及其类型对判断冠心病患者预后的价值。方法对６９例冠心病患者进行运动负荷心肌显像及运动ＥＣＧ试验，心肌显像均有异常。４５例经冠状动脉造影证实为冠心病，随访时间６～１１０个月，未发生心脏事件者随访皆≥１２个月。结果随访中１５例发生心脏事件，发生率为８７％／年。经多因素Ｃｏｘ回归分析表明，心肌显像可逆缺损节段数与发生心脏事件有密切关系。１３例显像不可逆缺损范围不大者，与以往报道的正常组结果比较，未发生心脏事件率差异无显著性（χ２＝００９，Ｐ＞００５）。表明心肌显像正常或呈不可逆缺损范围不大者预后良好。结论可逆缺损节段数是预测冠心病患者日后发生心脏事件的较好指标。     

定量门控201Tl心肌显像对冠心病患者的预后价值

目的 研究定量门控201Tl心肌显像对冠心病患者预后评估及冠心病治疗方案选择的价值.方法 对84例患者进行静息和运动负荷201Tl门控心肌灌注SPECT显像,并随访(32.92±16.77)个月.对心肌灌注图像进行评分(1～4分),计算总负荷评分(SSS)、总静息评分(SRS)和总差值分(SDS=SRS-SSS)、负荷左室射血分数(EF)值和静息EF值.结果 随访中9例发生心脏事件,年发生率为3.90%.SSS、SDS、SRS以及EF值均是心脏事件的独立预测因素(P＜0.005).Cox比例风险回归分析示SSS是心脏事件的最强预测因素.根据患者的负荷后EF值、SDS等可将患者分为低危、中危和高危组.结论 应用定量门控201Tl心肌显像可以对冠心病患者进行正确的预后评估,并可指导选择治疗方案.SSS是心脏事件的最强预测因素.     

Increased prognostic value of combined myocardial perfusion imaging and exercise electrocardiography in patients with coronary artery disease

BACKGROUND: Myocardial perfusion imaging (MPI) with technetium-99m-labeled sestamibi and exercise electrocardiography (EECG) are widely used for risk stratification of patients with known or suspected coronary artery disease (CAD). However, no large-scale studies have addressed the prognostic power of the combined information from these diagnostic tools. METHODS AND RESULTS: We studied 697 consecutive patients who underwent a 2-day Tc-99m sestamibi cardiac perfusion imaging protocol. The EECG was performed on a bicycle ergometer by symptom-limited exercise. Causes of death were obtained from death certificates. Univariate survival analyses were performed with a Kaplan-Meier estimate and a corresponding log-rank test. A multivariate Cox proportional hazards model was applied to test for potential predictor covariates obtained from hospital records. The predominant risk factors of cardiac death were fixed perfusion defects (relative risk, 2.55; range, 1.43 to 4.55) and an impaired circulatory exercise response (relative risk, 3.26; range, 1.74 to 6.08). The major prognostic information of MPI was the ability to detect patients with a definitively low risk. Patients with impaired circulatory response to exercise test and fixed perfusion defects were at a very high risk. CONCLUSION: The combined results of MPI and EECG provide substantial information on the long-term risk of cardiac death in patients with suspected CAD.     

Incremental value of assessment of regional wall motion for detection of multivessel coronary artery disease in exercise (201)Tl gated myocardial perfusion imaging.

Assessment of reversible perfusion defects in exercise (201)Tl perfusion SPECT has low sensitivity and high specificity for detection of multivessel coronary artery disease (CAD). The goal of this study was to evaluate whether worsening of left ventricular regional wall motion assessed by an automated algorithm in exercise (201)Tl electrocardiography-gated SPECT had incremental diagnostic value over perfusion data for detection of multivessel CAD. METHODS: Two hundred one patients underwent exercise (201)Tl gated SPECT. Software that automatically analyzes left ventricular function was used to assess exercise and rest regional wall motion. Regional wall motion on initial images was compared with that on rest images, that is, delayed images for patients without reinjection images and reinjection images for patients with reinjection images. The left ventricle was divided into 9 segments, with individual segments assigned to 3 coronary territories. Worsening of wall motion was defined as worsening in any segment on initial images compared with rest images. RESULTS: Of 73 patients with multivessel CAD, 20 (27.4%) had reversible perfusion defects in multiple coronary territories, 26 (35.6%) exhibited worsening of regional wall motion in multiple territories, and 37 (50.7%) had reversible perfusion defects or worsening of regional wall motion in multiple territories. The sensitivity of the combination of reversible perfusion defect and worsening of regional wall motion was significantly higher than that of reversible perfusion defect alone for detection of multivessel CAD (50.7% vs. 27.4%, P < 0.05). The specificity of the combination of reversible perfusion defect and worsening of regional wall motion for detecting multivessel CAD did not differ from that of reversible perfusion defect alone and that of worsening of regional wall motion alone (94.5% vs. 99.2% and 97.7%, respectively, P = not statistically significant). CONCLUSION: Combined assessment of worsening of left ventricular regional wall motion by exercise and perfusion data in exercise (201)Tl gated myocardial SPECT was more sensitive, with acceptable specificity, than was assessment with perfusion data alone for detection of multivessel CAD.