Temporal trends in the frequency of inducible myocardial ischemia during cardiac stress testing: 1991 to 2009

J Am Coll Cardiol. 2013 Mar 12;61(10):1054-65. doi: 10.1016/j.jacc.2012.11.056.


Objectives: This study sought to assess whether the frequency of inducible myocardial ischemia during stress-rest single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has changed over time.

Background: The prevalence of cardiac death and other clinical cardiac events have declined in recent decades, but heretofore no study has examined if there has been a temporal change in the frequency of inducible myocardial ischemia during cardiac stress testing.

Methods: We assessed 39,515 diagnostic patients undergoing stress-rest MPI between 1991 and 2009. Patients were assessed for change in demographics, clinical symptoms, risk factors, and frequency of abnormal and ischemic SPECT-MPI.

Results: There was a marked progressive decline in the prevalence of abnormal SPECT studies, from 40.9% in 1991 to 8.7% in 2009 (p < 0.001). Similarly, the prevalence of ischemic SPECT-MPI declined, from 29.6% to 5.0% (p < 0.001), as did the prevalence of severe ischemia. The decline of SPECT-MPI abnormality occurred among all age and symptom subgroups, falling to only 2.9% among recent exercising patients without typical angina. We also noted a progressive trend toward performing more pharmacological rather than exercise stress in all age and weight groups, and pharmacological stress was more likely than exercise to be associated with SPECT-MPI abnormality (odds ratio: 1.43, 95% confidence interval: 1.3 to 1.5; p < 0.001).

Conclusions: Over the past 2 decades, the frequency and severity of abnormal stress SPECT-MPI studies has progressively decreased. Notably, the frequency of abnormal SPECT-MPI is now very low among exercising patients without typical angina. These findings suggest the need for developing more cost-effective strategies for the initial work-up of patients who are presently at low risk for manifesting inducible myocardial ischemia during cardiac imaging procedures.

MeSH terms

  • Adenosine*
  • Age Factors
  • Aged
  • Angina, Stable / epidemiology
  • Body Mass Index
  • Cardiotonic Agents / therapeutic use
  • Coronary Artery Disease / diagnosis
  • Diabetes Mellitus / epidemiology
  • Dyspnea / epidemiology
  • Electrocardiography
  • Exercise Test / trends*
  • Female
  • Follow-Up Studies
  • Hospitalization
  • Humans
  • Hypertension / epidemiology
  • Logistic Models
  • Male
  • Middle Aged
  • Myocardial Ischemia / diagnostic imaging*
  • Myocardial Perfusion Imaging*
  • Prospective Studies
  • Sex Factors
  • Smoking / epidemiology
  • Tomography, Emission-Computed, Single-Photon*
  • Vasodilator Agents*


  • Cardiotonic Agents
  • Vasodilator Agents
  • Adenosine