CT attenuation correction improves quantitative risk prediction by cardiac SPECT in obese patients

Purpose This study aimed to compare the predictive value of CT attenuation-corrected stress total perfusion deficit (AC-sTPD) and non-corrected stress TPD (NC-sTPD) for major adverse cardiac events (MACE) in obese patients undergoing cadmium zinc telluride (CZT) SPECT myocardial perfusion imaging (MPI).Methods The study included 4,585 patients who underwent CZT SPECT/CT MPI for clinical indications (chest pain: 56%, shortness of breath: 13%, other: 32%) at Yale New Haven Hospital (age: 64 +/- 12 years, 45% female, body mass index [BMI]: 30.0 +/- 6.3 kg/m(2), prior coronary artery disease: 18%). The association between AC-sTPD or NC-sTPD and MACE defined as the composite end point of mortality, nonfatal myocardial infarction or late coronary revascularization (> 90 days after SPECT) was evaluated with survival analysis.Results During a median follow-up of 25 months, 453 patients (10%) experienced MACE. In patients with BMI >= 35 kg/m(2) (n = 931), those with AC-sTPD >= 3% had worse MACE-free survival than those with AC-sTPD < 3% (HR: 2.23, 95% CI: 1.40 - 3.55, p = 0.002) with no difference in MACE-free survival between patients with NC-sTPD >= 3% and NC-sTPD < 3% (HR:1.06, 95% CI:0.67 - 1.68, p = 0.78). AC-sTPD had higher AUC than NC-sTPD for the detection of 2-year MACE in patients with BMI >= 35 kg/m(2) (0.631 versus 0.541, p = 0.01). In the overall cohort AC-sTPD had a higher ROC area under the curve (AUC, 0.641) than NC-sTPD (0.608; P = 0.01) for detection of 2-year MACE. In patients with BMI >= 35 kg/m(2) AC sTPD provided significant incremental prognostic value beyond NC sTPD (net reclassification index: 0.14 [95% CI: 0.20 - 0.28]).Conclusions AC sTPD outperformed NC sTPD in predicting MACE in patients undergoing SPECT MPI with BMI >= 35 kg/m(2). These findings highlight the superior prognostic value of AC-sTPD in this patient population and underscore the importance of CT attenuation correction.