Sensitivity and Predictors of False-Negative SPECT Myocardial Perfusion Imaging in a High-Burden Coronary Artery Disease Population: A Retrospective Analysis Using Revascularization as the Reference Standard

Background Coronary artery disease (CAD) places a disproportionate burden on rural Appalachian communities. Scioto County, Ohio has among the highest rates of CAD-related hospitalizations in the state, approaching double the national average. Single-photon emission computed tomography (SPECT) myocardial perfusion imaging remains a widely used non-invasive screening modality, yet its diagnostic performance in high-burden populations with significant comorbidities has not been well characterized. We aimed to evaluate the diagnostic performance of SPECT for predicting subsequent revascularization and identify predictors of false-negative results in our patient population. Methods A retrospective analysis was conducted using prospectively collected data from the American College of Cardiology CathPCI registry at a single community hospital. All cardiac catheterizations performed between Q3 2013 and Q1 2018 were included. Sensitivity for predicting subsequent revascularization was calculated using catheterization with subsequent intervention (percutaneous coronary intervention or coronary artery bypass grafting) as the reference standard. Logistic regression models were constructed to identify predictors of false-negative SPECT results. This study was reported in accordance with the STROBE guidelines for observational studies. Results Over the study period, 7,312 cardiac catheterizations were performed, with 3,116 (42.6%) requiring intervention. Among 3,189 patients with SPECT data, sensitivity for predicting subsequent revascularization was 82.0%. Among the subset of patients with negative SPECT who nevertheless proceeded to catheterization, 32.8% were found to require intervention, a rate reflecting the high-risk, selected nature of this subgroup rather than the population-level false-negative rate. Sensitivity was highest for left main and ramus lesions (91%) and lowest for mid-distal left anterior descending (LAD) lesions (82%). In multivariable analysis, false-negative results were independently associated with family history of CAD (OR 1.73, 95% CI 1.25–2.40, p < 0.001) and were less likely with critical circumflex (OR 0.60, 95% CI 0.44–0.81, p < 0.001), right coronary artery (OR 0.54, 95% CI 0.40–0.73, p < 0.001), and prior myocardial infarction (OR 0.60, 95% CI 0.41–0.88, p < 0.01). Conclusions SPECT sensitivity for predicting revascularization in this high-burden CAD population was broadly consistent with contemporary meta-analytic benchmarks, though direct comparison is limited by differing reference standards. Family history of CAD was independently associated with false-negative SPECT results, a finding not previously reported in the SPECT literature. In patients with a strong family history of CAD, particularly in settings where SPECT remains the primary cardiac imaging modality, these findings suggest that a lower threshold for further evaluation may be warranted when SPECT results are negative.