Original article
Incremental value of regional wall motion abnormalities
for detecting obstructive coronary artery disease by
rest-only electrocardiogram-gated single-photon
emission computerized tomography myocardial perfusion
imaging in suspected coronary artery disease patients
Bao Liua,b, Wenji Yua,b, Jianfeng Wanga,b, Xiaoliang Shaoa,b,
Feifei Zhanga,b, Minfu Yangc, Xiaoyu Yangd, Zhifang Wue, Sijin Lie,
Yunmei Shia,b, Bing Wanga,b, Yiduo Xua,b and Yuetao Wanga,b
Objective  The purpose of this study was to determine
whether regional wall motion (WM) abnormalities
by rest-only 99mtechnetium-sestamibi (99mTc-MIBI)
electrocardiogram (ECG)-gated single-photon emission
computerized tomography (SPECT) myocardial perfusion
imaging (MPI) had incremental diagnostic value for
detecting obstructive coronary artery disease (CAD) in
suspected CAD patients.
Methods  This study retrospectively studied 255
consecutive suspected CAD patients who underwent
rest-only ECG-gated SPECT MPI and were performed
coronary angiography within 3 months. Obstructive CAD
was defined as ≥70% narrowing of the inner diameter of
the left anterior descending coronary artery, left circumflex
coronary artery and right coronary artery or their main
branches and ≥50% narrowing of the left main coronary
artery. QPS and QGS were used to assess rest perfusion
and WM. Summed rest score ≥4 and summed motion
score ≥2 exhibited in two consecutive segments in one
territory was considered abnormal.
Results  The sensitivity of the combination of perfusion
and regional WM abnormalities was significantly higher
than perfusion alone for detecting obstructive CAD
(46.8% vs. 30.9%; P < 0.001), with similar specificity
(91.9% vs. 95.0; P = 0.063). The global chi-square value of
Introduction
The prevalence of coronary artery disease (CAD) has
been increasing year by year in China and has brought
a huge disease burden [1]. Coronary stenosis is a result
of underlying CAD and coronary angiography has been
the gold standard for anatomical stenosis. A severe coro-
nary stenosis has been usually defined as ≥70% diameter
narrowing [2]. Notably, in the narrow coronary arteries of
71–90%, 80% were functionally significant with myocar-
dial ischemia [3].
Single-photon emission computerized tomography
(SPECT) myocardial perfusion imaging (MPI) is a
0143-3636 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
combination of perfusion and WM increased from 31.40 to
50.71 (P < 0.001) compared to perfusion. The sensitivity of
combination of perfusion and WM for detecting obstructive
CAD in patients with multivessel disease was higher than
single-vessel disease (56.1% vs. 25.0%; P < 0.001), with
similar specificity.
Conclusion  Regional WM abnormalities at rest, as
shown by rest-only 99mTc-MIBI ECG-gated SPECT MPI,
have additional diagnostic value over perfusion alone for
detecting obstructive CAD in suspected CAD patients.
Nucl Med Commun 42: 276–283 Copyright © 2020 Wolters
Kluwer Health, Inc. All rights reserved.
Nuclear Medicine Communications 2021, 42:276–283
Keywords: coronary artery disease, electrocardiogram-gated,
myocardial perfusion imaging,
single-photon emission computerized tomography, wall motion
a
Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow
University,  bChangzhou Key Laboratory of Molecular Imaging, Changzhou,
Jiangsu Province,  cDepartment of Nuclear Medicine, Affiliated Beijing Chaoyang
Hospital of Capital Medical University, Beijing,  dDepartment of Cardiology, The
Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu Province
and  eDepartment of Nuclear Medicine, The First Hospital of Shanxi Medical
University, Taiyuan, Shanxi Province, China
Correspondence to Yuetao Wang, MD, Department of Nuclear Medicine,
The Third Affiliated Hospital of Soochow University, No.185, Juqian Street,
Changzhou, Jiangsu Province 213003, China
Tel: +86 013852040196; fax: +86 519 86621235; e-mail: yuetao-w@163.com
Received 23 August 2020 Accepted 26 October 2020
widely used noninvasive method for detection of
ischemia and CAD [4,5]. At rest, even if the coronary
arteries are significantly narrowed, the myocardial blood
flow can still be normal. Usually, the diagnosis of myocar-
dial ischemia requires a combination of stress and resting
MPI. Abnormal stress MPI and resting MPI partially or
completely returned to normal is a typical manifestation
of myocardial ischemia. Due to decreased coronary flow
reserve of diseased vessels, the increase of myocardial
blood flow under stress is limited, which is manifested
as sparse or defective perfusion in the corresponding cor-
onary artery supply territory. Electrocardiogram (ECG)-
gated 99mtechnetium-sestamibi (99mTc-MIBI) SPECT
DOI: 10.1097/MNM.0000000000001335
 Incremental value of regional wall motion abnormalities Liu et al. 277
MPI can provide information on perfusion, global and
regional function through one-step station with high
reproducibility and repeatability [6–8]. Previous stud-
ies [9–12] have shown that regional wall motion (WM)
changes after stress add incremental diagnostic value for
detection of severe CAD.
However, stress testing cannot be applied to all patients,
especially in patients with suspected acute coronary syn-
drome (ACS), or other people with exercise and drug
test contraindications such as severe heart failure. There
are about 2.5 million patients with ACS [13] and a large
number of suspected ACS patients in the real world of
China every year. It is especially important to improve
the ability of rest-only SPECT MPI to detect obstructive
CAD. In addition, our previous research [14] has found
that reduced wall thickening exists in normal perfusion
segments on resting MPI in patients with MI. Previous
studies have found that 30% of suspected CAD patients
have abnormal resting perfusion [15] and a decrease of
10–20% in subendocardial blood flow would be adequate
for inducing severe regional dysfunction [16]. Therefore,
the goal of the present study was to determine whether
regional WM abnormalities based on rest-only 99mTc-
MIBI ECG-gated SPECT MPI had incremental diag-
nostic value for detecting obstructive CAD in suspected
CAD patients.
Methods
Patient enrollment
We retrospectively studied 2038 consecutive patients
who performed ECG-gated SPECT MPI at the Third
Affiliated Hospital of Soochow University between
March 2015 and November 2018. Inclusion criteria: sus-
pected CAD patients, rest-only 99mTc-MIBI ECG-gated
SPECT MPI was performed, coronary angiography was
performed within 3 months of SPECT MPI. Three hun-
dred eleven patients were initially enrolled. Exclusion
criteria were severe valve disease (n = 9), hypertrophic or
dilated cardiomyopathy (n = 15), significant arrhythmia
(n = 21) and poor overall image quality (n = 11). Finally,
there were 255 patients with suspected CAD in this
study. The enrolled population all had stress contraindi-
cations [17], including 62 patients with suspected ACS,
61 patients with asthma, 53 patients with systolic blood
pressure >200  mmHg before examination, 41 patients
with limb movement disorders also combined with
second- or third-degree atrioventricular block without
a functioning pacemaker, 38 patients with decompen-
sated heart failure. This was an observational study and
the data were analyzed anonymously, so there was no
informed consent.
Resting image acquisition
99m
Tc-MIBI (740–925  MBq) was injected intravenously
at rest, and ECG-gated SPECT MPI was initiated 60–90
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
minutes later. Acquisitions were performed using a dual-
head 90° gamma camera (Symbia T16; Siemens Medical
Systems, Erlangen, Germany) equipped with a paral-
lel-hole collimator with low energy and high resolution.
A 20% symmetric energy window around the 140-KeV
photopeak and eight frames per R-R cycle were used for
image acquisition. Sixty-four images covering 180° were
obtained with a 64 × 64 matrix and 1.45 magnification.
The ‘beat-length acceptance window’ was ± 20% of the
expected R-R duration. Projection data were filtered
with a Butterworth filter (order, 5; cutoff frequency, 0.4)
and then reoriented to obtain left ventricle (LV) short-
axis, horizontal long-axis, and vertical long-axis images
through filtered back projection. No attenuation correc-
tion was used in this study.
Quality control
We performed quality control procedures in the pro-
cess of original image acquisition, reconstruction, and
image quantification, including observing whether the
myocardial radioactive uptake was good, whether there
was leakage of imaging agent injection, and whether
there was a radioactive focus outside the heart. We
also checked the original image to see if there was any
movement and checked the gated quality control curve,
sinogram and linogram in the tomographic processing.
Patients who did not meet the above quality control
requirements were excluded. The adjustment of the
tomographic axis was performed automatically, supple-
mented by manual adjustment. The long-axis direction
should be parallel to the longest axis of the LV. Image
quantification was performed automatically by the soft-
ware. When the automatic delineation was not good,
we would make appropriate manual adjustments to
ensure accurate sampling of the myocardial boundary
contours.
Image analysis
A 17-segment model of the LV was used for scoring
resting perfusion by a dedicated software package
(QPS 2009; Cedars-Sinai Medical Center, Los Angeles,
California, USA), with a five-point scoring system for
defect severity (0 = normal perfusion; 1 = mildly reduced;
2 = moderate reduction; 3 = severe reduction; 4 = absent
perfusion) [18].The summed rest score (SRS) was the
sum of all perfusion scores on the rest scan. The QGS
software package was used to quantitatively measure
end-diastolic volume, end-systolic volume, LV ejection
fraction (LVEF) and summed motion score (SMS) from
resting ECG-gated SPECT MPI. A scale of 0–5 was used
for grading WM (0 = normal, 1 = mildly hypokinetic,
2 = moderately hypokinetic, 3 = severely hypokinetic,
4 = akinetic, 5 = dyskinetic) [19]. To allow for statistical
correlation with angiographic findings, the 17 segments
for both perfusion and WM were divided into the terri-
tories of left anterior descending coronary artery (LAD),
278  Nuclear Medicine Communications  2021, Vol 42 No 3

left circumflex coronary artery (LCX) and right coronary Results

artery (RCA), as previously described [20]. In this study, Patient characteristics
SRS ≥4 exhibited in two consecutive segments in one This study group consisted of 255 patients with sus-
territory was considered abnormal [15]. SMS ≥ 2 exhib- pected CAD. Subsequent coronary angiography con-
ited in two consecutive segments in one territory was firmed that 94 (36.9%, 94/255) patients had obstructive
considered as WM abnormality [19]. CAD (stenosis ≥70%). Of the 94 patients with obstruc-
tive CAD, 28 (29.8%, 28/94) patients had one vessel
Coronary angiography disease, 30 (31.9%, 30/94) patients had two vessels
All coronary angiograms were visually interpreted disease and 36 (38.3%, 36/94) had three vessels dis-
by experienced cardiologists. Obstructive CAD was ease. Compared with the patients without obstructive
defined as ≥70% narrowing of the inner diameter of CAD, there were no significant differences in age,
the LAD, LCX, RCA or their main branches and ≥50% BMI and smoking history. Subjects with obstructive
narrowing of the left main coronary artery on coronary CAD were more commonly male, more likely to have
angiography [9]. hypertension and diabetes, and had a higher EDV
and ESV. Myocardial perfusion and function abnor-
Statistical analysis malities as expressed by SRS, LVEF and SMS in
IBM SPSS (Version 25.0, Chicago, Illinois, USA) was obstructive CAD group were significantly more severe
used for all statistical analysis in this study. Continuous (Table 1).
data with normal distribution were expressed as the
mean value ± SD and the parameters with skewed dis- Incremental value of regional wall motion
tribution were presented as median P50 (P25, P75). abnormalities to rest perfusion alone for detecting
Categorical variables were described as percentages. obstructive coronary artery disease patients
Unpaired t-test or Mann–Whitney U test was performed The sensitivity of the combination of perfusion and
to compare the continuous parameters between two regional WM abnormalities was significantly higher than
groups. The comparison of categorical variables was perfusion alone for detection of obstructive CAD (46.8%
made with chi-square analysis. The global chi-square vs. 30.9%; respectively, P < 0.001), with similar specificity
value by likelihood ratio test was used in the whole (91.9% vs. 95.0%; P = 0.063) (Table 2). Perfusion abnor-
cohort to compare the overall performance of perfu- malities correctly identified 29 of the 94 patients with
sion vs. combined perfusion and WM for detection of obstructive CAD and failed to identify 65. Combination
obstructive CAD patients. P < 0.05 was considered to be of WM and perfusion abnormalities correctly identified
statistically significant. 44 patients with obstructive CAD, and failed to identify
50. Of the 161 patients without obstructive CAD, adding
Table 1   Characteristics of patients with suspected coronary
WM abnormalities to perfusion resulted in 5 misdiagno-
artery disease (n = 255) ses (13 vs. 8). The model of association of perfusion and
Without obstructive With obstructive
WM had incremental global chi-square value (50.71 vs.
Variables CAD (n = 161) CAD (n = 94) P value 31.40, P < 0.001) for detecting obstructive CAD than per-
fusion alone (Fig. 1).
Age (years old) 60.9 ± 9.3 62.7 ± 9.0 0.126
Male (%) 98 (60.9) 72 (76.6) 0.010
BMI (kg/m m2) 25.1 ± 3.0 24.6 ± 3.0 0.260 Of 94 obstructive CAD patients, combination of WM
Hypertension (%) 103 (64.0) 72 (76.6) 0.036 and perfusion abnormalities correctly recognized 44
Diabetes (%) 26 (16.1) 35 (37.2) <0.001
Hyperlipidemia (%) 64 (39.8) 21 (22.3) 0.004 (46.8%, 44/94) patients. Among them, 26 (59.1%, 26/44)
Smoking >1 year (%) 58 (36.0) 41 (43.6) 0.230 patients had abnormal perfusion and WM, 15 (34.1%,
Medical treatment (%)
 ACEI 82 (50.9) 56 (59.6) 0.181
15/44) only had WM abnormalities and three (6.8%,
  Beta blockers 100 (62.1) 79 (84.0) <0.001 3/44) had perfusion abnormalities alone (Fig. 2). In 26
  Calcium channel blockers 97 (60.2) 48 (51.1) 0.153
Gated SPECT
  EDV (ml) 86.9 ± 25.3 100.2 ± 47.2 0.013 Table 2  The diagnostic efficacy of perfusion alone and
  ESV (ml) 31.5 ± 15.0 46.3 ± 39.2 0.001 combination of perfusion and wall motion for detecting
  LVEF (%) 65.4 ± 8.6 58.3 ± 12.4 <0.001 obstructive coronary artery disease in patients with suspected
 SRS 1.0 (0.0 ~ 2.0) 2.0 (0.0 ~ 7.0) <0.001 coronary artery disease (n = 255)
 SMS 0.0 (0.0 ~ 0.0) 1.0 (0.0 ~ 9.3) <0.001
Coronary angiography (%) Perfusion Perfusion + WM
  One vessel disease 28 (29.8)
  Two vessel disease 30 (31.9) Sensitivity 30.9 46.8
  Three vessel disease 36 (38.3) Specificity 95.0 91.9
PPV 78.4 77.2
ACEI, angiotensin-converting enzyme inhibitor; CAD, coronary artery disease; NPV 70.2 74.7
EDV, end-diastolic volume; ESV, end-systolic volume; LVEF, left ventricular ejec- Accuracy 71.4 75.3
tion fraction; SMS, summed motion score; SPECT, single-photon emission com-
puterized tomography; SRS, summed rest score. NPV, negative predictive value; PPV, positive predictive value; WM, wall motion.

Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Incremental value of regional wall motion abnormalities Liu et al. 279
patients with abnormal perfusion and WM, 44 territo-
ries showed abnormal perfusion. Among the 44 abnor-
mal perfusion territories, 42 (95.5%, 42/44) territories
also showed abnormal WM, showing good consistency.
In addition, combination of regional WM and perfu-
sion abnormalities had 13 (8.1%, 13/161) misdiagnosed
patients which stenosis <70%. The clinical and coro-
nary angiography results of these patients are exposed
(Table 3).
Incremental value of regional wall motion
abnormalities to rest perfusion alone for detecting
severe coronary stenosis in overall, left anterior
descending coronary artery, left circumflex coronary
artery and right coronary artery territories
The sensitivity for detecting severe coronary stenosis
was higher for association of perfusion and WM than for
perfusion alone in overall territories (36.7% vs. 20.4%,
respectively, P < 0.001), with slightly reduced specificity
(94.7% vs. 97.2%; P < 0.001). In LAD territories, the sen-
sitivity of combination WM and perfusion for detecting
severe coronary stenosis increased from 27.6% to 40.2%
(P = 0.001) compared to perfusion, with no significant
difference in specificity (92.3% vs. 95.2%; P = 0.063). In
LCX territories, the sensitivity of association WM and
perfusion was higher than perfusion (22.6% vs. 11.3%;
P = 0.016), with no significant difference in specificity
(96.9% vs. 97.9%; P = 0.500). In RCA territories, the sen-
sitivity of combination WM and perfusion for detecting
severe coronary stenosis increased from 19.1% to 48.9%
Fig. 1
Incremental value of combined WM and perfusion (expressed on
y-axis as global chi-square values) over perfusion alone for detecting
obstructive CAD patients. CAD, coronary artery disease; WM, wall
motion.
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
(P < 0.001) compared to perfusion and the specific-
ity was slightly reduced (94.7% vs. 98.1%; P = 0.016)
(Fig. 3).
Incremental value of combination of regional wall
motion and rest perfusion for detecting obstructive
coronary artery disease in patients with multivessel
disease
The association of WM and perfusion abnormalities had
higher sensitivity (56.1% vs. 25.0%; P < 0.001) for detect-
ing obstructive CAD in patients with multivessel disease
than in patients with single-vessel disease, with similar
specificity. Combination of WM and perfusion abnormal-
ities correctly identified 37 (56.1%, 37/66) patients with
multivessel disease and seven (25.0%, 7/28) patients with
single-vessel disease (Fig. 4). A patient example is shown
(Fig. 5).
Discussion
The present study confirmed that combination of
regional WM abnormalities and perfusion by rest-only
99m
Tc-MIBI ECG-gated SPECT MPI had incremen-
tal value for detecting obstructive CAD in suspected
patients. The sensitivity of the association of regional
WM and perfusion abnormalities was significantly
higher than perfusion for detecting obstructive CAD
(46.8% vs. 30.9%; P < 0.001), without a significant loss in
specificity. The global chi-square value of combination
of perfusion and regional WM abnormalities increased
Fig. 2
Distribution of perfusion and WM in patients with suspected CAD
(n = 255). CAD, coronary artery disease; WM, wall motion.
280  Nuclear Medicine Communications  2021, Vol 42 No 3

Table 3  Individual analysis of abnormal wall motion/perfusion in patients without obstructive coronary artery disease (n = 13)

Patient Age (years)/gender Rest perfusion WM Coronary angiography Clinical diagnosis

Patient 1 37/M Abnormal (LAD) Abnormal (LAD) Normal CMD

Patient 2 50/M Normal Abnormal (LAD) Intimal irregularity (LAD, RCA)
Patient 3 34/M Normal Abnormal (LAD) Coronary muscle bridge (LAD)
Patient 4 64/F Normal Abnormal (LAD, RCA) Normal CMD
Patient 5 66/M Normal Abnormal (LAD, RCA) Coronary muscle bridge (LAD)
Patient 6 73/F Normal Abnormal (LAD) 30–50% stenosis (LAD)
Patient 7 74/F Abnormal (LAD) Normal 60% stenosis (LAD), 50% stenosis (LCX)
Patient 8 80/M Abnormal (LAD) Normal 30% stenosis (LCX), 60% stenosis (RCA)
Patient 9 60/M Abnormal (LCX) Normal 50% stenosis (LAD),30% stenosis (LCX, RCA)
Patient 10 55/M Abnormal (LAD) Normal 60% stenosis (LAD), 40% stenosis (RCA)
Patient 11 41/M Abnormal (LAD) Normal 30% stenosis (LAD) CMD
Patient 12 68/F Abnormal (LCX) Normal 20–30% stenosis (LAD)
Patient 13 54/M Abnormal (LAD) Normal Coronary muscle bridge (LAD)

CAD, coronary artery disease; CMD, coronary microvascular dysfunction; LAD, left anterior descending coronary artery; LCX, left circumflex coronary artery; RCA, right
coronary artery; WM, wall motion.

Fig. 3

The sensitivity and specificity of perfusion alone and combination of perfusion and WM for detecting severe coronary stenosis in overall, LAD,
LCX and RCA territories. LAD, left anterior descending coronary artery; LCX, left circumflex coronary artery; RCA, right coronary artery; WM, wall
motion. *P < 0.05 compared with perfusion alone.

from 31.40 to 50.71 (P < 0.001) compared to perfusion
alone. The sensitivity of combination of perfusion and
WM for detecting obstructive CAD in patients with
multivessel disease was higher than in patients with
single-vessel disease (56.1% vs. 25.0%; P < 0.001), with
similar specificity.
It is well known that SPECT MPI is a widely used
noninvasive method for detecting myocardial ischemia.
Abnormal (reduced perfusion/defect) stress MPI and
resting MPI partially or completely returned to normal
indicate myocardial ischemia. At rest, even if the cor-
onary arteries are significantly narrowed, myocardial
blood flow can still be normal. The increase in myocar-
dial blood flow under stress is limited by the reduction
of coronary flow reserve of the diseased blood vessel,
showing abnormal perfusion. However, many patients
with stress contraindications cannot perform stress ECG-
gated SPECT MPI. Taban Sadeghi et al. [15] evaluated
the value of resting MPI in suspected CAD with atypical
chest pain in the emergency room and found that 30%
of the enrolled patients had abnormal resting perfusion.
Similar to this research, our study found that 30.9% of
obstructive CAD patients had abnormal resting MPI and
the sensitivity of combined regional WM abnormality was
further increased to 46.8%. On the other hand, despite the
combined regional WM, the sensitivity of resting MPI to
diagnose obstructive CAD was not high. Therefore, we
still advocate that suspected CAD patients without stress
contraindications need to perform stress MPI.
Shirai et al. [12] have proved that the combined assess-
ment of worsening of LV regional WM and perfusion data
in exercise 201Tl gated SPECT MPI had incremental

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 Incremental value of regional wall motion abnormalities Liu et al. 281

value for detection of multivessel CAD. We have found
that combination of WM and perfusion abnormalities by
rest-only 99mTc-MIBI gated SPECT MPI had higher sen-
sitivity for detecting obstructive CAD in patients with
Fig. 4
multivessel disease than in patients with single-vessel
disease, with similar specificity. First, the possible mech-
anism was that the territories of abnormal WM were
increased with the growth of the number of severe cor-
onary stenosis, although multivessel disease was prone
to balanced ischemia. Second, single-vessel disease may
have collateral circulation to maintain normal perfusion
and WM, while patients with multivessel disease have
reduced myocardial blood flow in multiple territories and
insufficient collateral circulation compensation, resulting
in abnormal perfusion or WM.

In our study, 15 (16.0%, 15/94) obstructive CAD had

The sensitivity and specificity of combination of perfusion and WM
for detecting obstructive CAD in patients with single-vessel and mul-
tivessel disease. CAD, coronary artery disease; WM, wall motion. *P <
0.05 compared with perfusion alone.
regional WM dysfunction but normal perfusion. Several
possible mechanisms may contribute to these findings.
First, the possible mechanism for normal perfusion but
abnormal WM was balanced ischemia in multivessel
CAD. The degree of ischemia may be underrated due to
relatively balanced global hypoperfusion of LV without
absolute quantification of myocardial regional blood flow,
even under stress [11]. Second, the regional myocardial
dysfunction in normal perfusion may be explained by the
close relation between regional myocardial function and
subendocardial blood flow [16,21]. Pantely et al. [16] have
found that a decrease of 10–20% in subendocardial blood
flow usually does not cause a visible perfusion defect, but

Fig. 5

A patient example. A 60-year-old patient was admitted to the hospital with repeated chest pain for half a month. Each pain lasted for 3–5 minutes.
The examination showed that the high-sensitivity cardiac troponin I (hs-cTnI) was slightly increased (0.0520 ng/ml; normal standard: 0–0.0400 ng/
ml) and the electrocardiogram (ECG) was normal. The patient was diagnosed with suspected acute coronary syndrome (ACS) and received rest-
only ECG-gated single-photon emission computerized tomography (SPECT) myocardial perfusion imaging (MPI). (a) Rest ECG-gated SPECT
MPI images, the three rows from top to bottom are left ventricular (LV) short-axis, vertical long-axis and horizontal long-axis images, respectively.
There are no abnormalities in resting MPI. (b) Rest perfusion score map shows the score of left anterior descending coronary artery (LAD) territory,
left circumflex coronary artery (LCX) territory and right coronary artery (RCA) territory are 2, 1 and 0, respectively, which are considered as normal
perfusion. (c) Wall motion score map shows the score of LAD, LCX and RCA territories are 12, 0 and 1, respectively, indicating an abnormality in
LAD territory. (d) Subsequently coronary angiography was performed: LAD, 90% narrowing of the near-mid (black arrow); left main coronary artery
(LM), negative; LCX, negative; RCA, 50–70% narrowing of the near-mid. This figure shows the incremental value of regional wall motion abnormal-
ities for detecting obstructive disease in suspected CAD patients, while the rest perfusion is normal. CAD, coronary artery disease.

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282  Nuclear Medicine Communications  2021, Vol 42 No 3
would be adequate for inducing severe regional dysfunc-
tion. Third, previous studies [22–24] have confirmed that
myocardial ischemia in patients’ daily lives may cause
myocardial stunning, which leads to normal perfusion but
reduced regional WM. Lastly, the compensation of coro-
nary blood flow can maintain normal perfusion in some
territories supplied by stenotic vessels at rest. In addition,
95.5% abnormal perfusion or abnormal WM vascular ter-
ritories were consistent in 26 obstructive CAD patients
with abnormal perfusion and WM. The possible mecha-
nism was that severe stenosis leads to long-term chronic
ischemia in the dominated territories, leading to abnor-
mal perfusion and WM.
Lewis et al. [25] reported that WM abnormalities detected
by resting echocardiography were associated with severe
(≥70%) coronary artery stenosis in 252 patients who had
no history of MI. In 77 abnormal WM separate regions,
60 regions (78%) were supplied by coronary vessels with
≥70% stenosis. Similar to this study, Pärkkä et al. [26]
showed that abnormal WM obtained from resting mag-
netic resonance cine imaging can be used to detect CAD.
By analyzing regional WM, 11 out of 30 subjects were
determined to have CAD. However, echocardiography
relies on the operator’s skills and conventional echocardi-
ography cannot obtain myocardial perfusion parameters.
MRI is expensive and contraindicated in patients with
claustrophobia and pacemakers. ECG-gated SPECT
MPI can obtain perfusion and regional function param-
eters noninvasively through one-step station, with high
reproducibility and repeatability.
Gallagher et al. [27] reported that the sensitivity of com-
puted tomography (CT) coronary angiography was 86%,
and the specificity was 92% for the detection of ACS
in low-risk chest pain patients. According to the latest
ESC guidelines, both CT coronary angiography and
MPI are class I recommendations for people with sus-
pected CAD. CT coronary angiography is considered for
patients with contraindications to stress MPI. However,
CT coronary angiography requires the use of iodinated
contrast agents, which is related to the risk of allergies
and nephrotoxicity. In addition, extensive coronary cal-
cification, irregular heart rate, severe obesity, inability
to cooperate with breath-holding, etc. may affect the
image quality of CT coronary angiography. Therefore,
CT coronary angiography and MPI are complementary
in the diagnosis of CAD. Assuming a patient with renal
failure and suspected ACS, resting MPI may be a good
choice. In addition, CT coronary angiography provides
anatomical stenosis, while ECG-gated SPECT MPI can
obtain relative myocardial perfusion and regional func-
tion noninvasively.
In this study, we confirmed that combination of regional
WM and perfusion abnormalities by resting ECG-gated
SPECT MPI had incremental diagnostic value for detect-
ing obstructive CAD over perfusion alone, although the
overall sensitivity was not high. Therefore, we believe
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
that regional WM abnormalities based on rest-only 99mTc-
MIBI ECG-gated SPECT MPI has the potential to help
perfusion to identify high-risk CAD in patients with con-
traindications to stress testing.
Limitation
Several limitations of this study should be considered.
First, all enrolled patients had stress contraindications
and were only a small part of patients in clinical work.
We still maintain that suspected CAD patients without
stress contraindications need to undergo stress MPI.
Second, the enrolled population included multiple
stress contraindications and we did not perform sub-
group analysis due to the number limitation. Third, we
did not implement regadenoson or dobutamine stress
MPI in 61 asthma patients, because regadenoson is
not available and dobutamine stress MPI is rarely con-
ducted in China. Other than that, the sample size of this
study was small, a large sample and prospective research
is needed.
Conclusion
Regional WM abnormalities at rest, as shown by rest-only
99m
Tc-MIBI ECG-gated SPECT MPI, has incremen-
tal diagnostic value over perfusion alone for detecting
obstructive CAD in suspected CAD patients.
Acknowledgements
This research was supported by the National Natural
Science Foundation of China (81871381, PI: Y.W.), Key
Laboratory of Changzhou High-tech Research Project
(CM20193010, PI: Y.W.), Chinese National Natural
Science Foundation for Young Scholars (81701737, PI:
J.W.), Social Development Foundation of Changzhou
Science and Technology Bureau, Jiangsu Province,
China (CE20175029, PI: J.W.), Chinese National Natural
Science Foundation for Young Scholars (81701734, PI:
X.S.), Chinese National Natural Science Foundation for
Young Scholars (81901777, PI: F.Z.), and Science and
Technology Project for Youth Talents of Changzhou
Health Committee (QN201920, PI: F.Z.).
Conflicts of interest
There are no conflicts of interest.
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