Prognostic value of positron emission tomography myocardial perfusion imaging beyond traditional cardiovascular risk factors: Systematic review and meta-analysis

Background: Despite substantive growth in utilization of positron emission tomography (PET) myocardial perfusion imaging (MPI), evidence on its prognostic value is limited. We aimed to comprehensively evaluate the prognostic literature of PET perfusion measures according to the most recent American Heart Association recommendations for assessment of novel cardiovascular biomarkers. Methods: We searched the literature for studies reporting associations of PET MPI measures and outcomes in patients with known or suspected coronary artery disease. We documented hazard ratios (HR) and 95% confidence intervals (CI) of association effects and quantitatively synthesized them with random-effects meta-analyses. Discrimination, calibration and risk reclassification after addition of PET MPI measures to standard prognostic models were documented. Results: We identified 20 eligible studies with median n. = 551 patients. In meta-analyses, the extents of ischemic and scarred myocardium were significantly associated with cardiac death. Meta-analyses of multivariate estimates for abnormal summed stress score ≥. 4 and myocardial perfusion reserve <. 2 revealed significant associations with major adverse cardiovascular events [HR (95% CI) 2.30 (1.53-3.44) and 2.11 (1.33-3.36), respectively]. Changes in model discrimination, calibration or risk reclassification were reported in 5 studies (8 prognostic evaluations). There were marginal improvements in discrimination based on C index and no improvements in model calibration. Net reclassification index ranged from 9.8% to 14.2% and risk classification was significantly improved in 4/5 prognostic evaluations. Conclusions: PET MPI measures were strongly associated with adverse patient outcomes. Risk classification was more consistently improved than discrimination and calibration after addition of PET MPI measures, but reporting of such metrics was overall limited.