Nuclear medicine physicians and cardiologist have disagreement in time of application of cardiac SPECT and coronarography in cases suspected for coronary disease.
Nuclear physicians consider that cardiac SPECT is one non invasive method with very high efficiency for detection of coronary disease.
Cardiologists consider that cardiac SPECT is not sufficient for detection of coronary disease and prefer coronarography as first diagnostic method
Based in our experience and reported data, cardiac SPECT is the method of choice for detection of coronary disease. Cardiac Gated SPECT offers information about viability of myocardium and coronary vessels, whereas coronarography is standard method but with considerably risk of complications.
According to current guidelines, SPECT is the method of choice for stable angina with intermediate risk of coronary artery disease based on risk factors (such as age, family history, smoking, etc). For low-intermediate risk, one can also adopt a CTA-first policy, where CTA is used to exclude coronary artery disease through Calcium scoring and CT-angiography (and maybe CT perfusion, this is still under investigation). For the intermediate-high risk patient, or the patient with unstable angina, coronary angiography, with or without FFR, is still the primary diagnostic test. So, in short, the diagnostic test that you should perform first depends on the a priori chance of coronary artery disease due to some having very high specificity (CT CaCsc ruleout) and others having very high sensitivity (CAG-FFR). Also, keep in mind what you're interested in: SPECT only offers functional data, CAG only anatomical. Sometimes you're going to need both.
I fully agree with Dr. Laurens Swart and as interventional cardiologist I'm very comfortable to say that coronary angiography WITH FFR can join both anatomical and functional data. Second, I do not agree with Dr. Rame Miftari about "considerably risk of complications" in coronary angiography. In good hands and an adequately prepared cath lab the risk of complications is extremely low. Finally, besides the anamnese and clinical examination the coronary angiography is the exam that gives the most combination of information and the only one that can lead to terapeuthic decision when necessary.
As far as I understand, the current trend of cardiovascular imaging is not to detect stenosis only, but the test must be able to stratify the future CV risk and guide invasive intervention. Many trials have shown that critical stenosis >50% detected by CT angiography does not translate to ischaemia. Therefore, stress-imaging such as SPECT/ PET, stress echo and stress MR, plays an important role in risk stratification in the intermediate groups. For low risk group, exercise stress test is enough. CT + FFR are still new and need more data. Please refer to the guidelines:
2013 ESC guidelines on the management of stable coronary artery disease. European Heart Journal (2013) 34, 2949–3003
ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease. J Am Coll Cardiol. 2014 Feb 4;63(4):380-406.
Clinical DecisionMakingWithMyocardial Perfusion Imagingin Patients With Known or Suspected CoronaryArteryDisease. Semin Nucl Med (2014) 44,320-329
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