EditorialShould PET replace SPECT for evaluating CAD? The end of the beginning
Section snippets
Clinical limitations
Nonetheless, the study has a number of clinical limitations that should be pointed out. An apparent limitation of the study design was the lack of attenuation correction on the SPECT images. Indeed, previous studies have demonstrated an overall improvement in specificity and, in some studies, also in sensitivity2, 3, 4 with the adjunct use of attenuation correction. However, performance of attenuation correction with SPECT appears to be best accomplished in patients undergoing exercise
Detection of multivessel CAD
In this study by Bateman et al,1 PET was better than SPECT for diagnosing multivessel CAD. Although it is unclear what the precise mix of patients with “multivessel” CAD was (eg, 2 vs 3 vessels vs left main disease) and whether the 2 groups were equally balanced (ie, extent and severity of stenoses), this potential advantage of PET is of great clinical interest. It is a generally accepted fact that although the relative assessments of myocardial perfusion (with SPECT or PET) remain a sensitive
Internal and external validity of current results
The use of an observational study design, single-site data, relatively small cohorts, and nonrandomized study populations methodologically challenges investigators examining noninvasive imaging modalities. In this setting both confounding and bias pose serious challenges to the validity and generalizability of planned studies.16, 17 To overcome these potential limitations, investigators control confounding by a number of means. For example, a study can overcome confounding by evenly
Outcomes-based validation of nuclear cardiology technology
The challenges brought to light by this study call attention to the challenges of how to best validate technology, especially with respect to an outcomes-based approach to technology validation. This area includes comparison of isotopes, stress agents, cameras, software, modality (as in the current study), and many other aspects of imaging. The question of how to best compare PET and SPECT is not dissimilar to the question of how to compare 201Tl with 99mTc sestamibi, 99mTc sestamibi with 99mTc
Future role of hybrid PET-CT
The benefits of PET imaging are likely to be expanded in the near future, as most of the newer scanners are going to be hybrid PET/multidetector CT units. Thus, in addition to the functional assessments obtained with PET (ie, myocardial perfusion and metabolism), the new hybrid PET/CT technology allows detection and quantification of the extent and severity of underlying coronary atherosclerosis and obstructive coronary stenoses. PET and CT combined allow measurement of atherosclerotic burden
Need for outcomes data
Although the study by Bateman et al1 provides an important and necessary first step, there is a need for clinical outcomes data to help establish the role of PET in the diagnosis and management of CAD. This is true to determine not only the performance of PET, per se, but also the added value of PET-CT, its relative accuracy compared with other modalities, and how these tests optimally fit together in testing strategies in various patient groups. This is especially important now that the
Acknowledgment
The authors have indicated they have no financial conflicts of interest.
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