CZT camera systems may provide better risk stratification for low-risk patients



The photon sensitivity and spatial resolution of single-photon emission-computed tomography (SPECT) has been significantly improved by solid-state camera systems using cadmium zinc telluride (CZT) detectors. While the diagnostic accuracy of these systems is well established, there is little evidence directly comparing the prognostic utility to conventional NaI cameras.

Methods and Results

Retrospective analysis of patients undergoing SPECT between 2008 and 2012. Visual SPECT assessment was performed utilizing the 17-segment model to determine summed stress scores (SSS). We identified 12,830 consecutive patients, mean age 63.2 ± 13.7 and 56.1% male, 5072 of whom underwent CZT and 7758 NaI imaging. During a median follow-up duration of 7.0 years (IQR 5.5-8.2), a total of 2788 (21.7%) patients died. Compared to SSS 0, minimal perfusion abnormality (SSS 1-3) was associated with increased all-cause mortality with CZT camera (adjusted HR 1.32, P = .017) and NaI camera (adjusted HR 1.29, P = .001, interaction P = .803). Increasing stress abnormality was associated with a similar increase in risk with CZT or NaI imaging (interaction P > .500). In a propensity matched analysis, patients with normal perfusion stress perfusion assessed with a CZT was associated with decreased mortality compared to normal perfusion assessed by a NaI camera system (hazard ratio .88, 95% CI .78-.99, P = .040).


Increasing stress perfusion abnormality was associated with similar increase in all-cause mortality with CZT or NaI cameras. CZT and NaI camera systems provide similar risk stratification, however, normal myocardial perfusion may be associated with a more benign prognosis when assessed with a CZT camera system.

This is a preview of subscription content, log in to check access.

Figure 1
Figure 2
Figure 3



Body mass index


Coronary artery bypass grafting


Coronary artery disease


Cadmium zinc telluride


Hazard ratio


Interquartile range


Left ventricle


Left ventricular ejection fraction


Myocardial perfusion imaging


Sodium iodide


Percutaneous coronary intervention


Standard deviation


Summed rest score


Summed stress score


Single-photon emission computed tomography


Transient ischemic dilation


  1. 1.

    Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ et al. J Am Coll Cardiol 2014;64:1929-49.

    Article  Google Scholar 

  2. 2.

    Berman DS, Kang X, Hayes SW, Friedman JD, Cohen I, Abidov A et al. Adenosine myocardial perfusion single-photon emission computed tomography in women compared with men: Impact of diabetes mellitus on incremental prognostic value and effect on patient management. J Am Coll Cardiol 2003;41:1125-33.

    Article  Google Scholar 

  3. 3.

    Hachamovitch R, Rozanski A, Hayes SW, Thomson LE, Germano G, Friedman JD et al. Predicting therapeutic benefit from myocardial revascularization procedures: Are measurements of both resting left ventricular ejection fraction and stress-induced myocardial ischemia necessary? J Nucl Cardiol 2006;13:768-78.

    Article  Google Scholar 

  4. 4.

    Romero-Farina G, Candell-Riera J, Aguadé-Bruix S, Ferreira-González I, Cuberas-Borrós G, Pizzi N et al. Warranty periods for normal myocardial perfusion stress SPECT. J Nucl Cardiol 2015;22:44-54.

    Article  Google Scholar 

  5. 5.

    Slomka PJ, Patton JA, Berman DS, Germano G. Advances in technical aspects of myocardial perfusion SPECT imaging. J Nucl Cardiol 2009;16:255-76.

    Article  Google Scholar 

  6. 6.

    Garcia EV, Faber TL, Esteves FP. Cardiac dedicated ultrafast SPECT cameras: New designs and clinical implications. J Nucl Med 2011;52:210-17.

    Article  Google Scholar 

  7. 7.

    Slomka P, Miller RJ, Hu L-H, Germano G, Berman D. Solid-state detector SPECT myocardial perfusion imaging. J Nucl Med 2019;60 (9):1194-204.

    CAS  Article  Google Scholar 

  8. 8.

    Bocher M, Blevis IM, Tsukerman L, Shrem Y, Kovalski G, Volokh L. A fast cardiac gamma camera with dynamic SPECT capabilities: Design, system validation and future potential. Eur J Nucl Med Mol Imaging 2010;37:1887-902.

    Article  Google Scholar 

  9. 9.

    Gimelli A, Bottai M, Giorgetti A, Genovesi D, Kusch A, Ripoli A et al. Circ Cardiovasc Imaging 2011;4:51-8.

    Article  Google Scholar 

  10. 10.

    Duvall WL, Croft LB, Ginsberg ES, Einstein AJ, Guma KA, George T et al. Reduced isotope dose and imaging time with a high-efficiency CZT SPECT camera. J Nucl Cardiol 2011;18:847-57.

    Article  Google Scholar 

  11. 11.

    Sharir T, Ben-Haim S, Merzon K, Prochorov V, Dickman D, Ben-Haim S et al. High-speed myocardial perfusion imaging: Initial clinical comparison with conventional dual detector anger camera imaging. JACC Cardiovasc Imaging 2008;1:156-63.

    Article  Google Scholar 

  12. 12.

    Nkoulou R, Pazhenkottil AP, Kuest SM, Ghadri JR, Wolfrum M, Husmann L et al. Semiconductor detectors allow low-dose-low-dose 1-day SPECT myocardial perfusion imaging. J Nucl Med 2011;52:1204-9.

    Article  Google Scholar 

  13. 13.

    Nudi F, Iskandrian AE, Schillaci O, Peruzzi M, Frati G, Biondi-Zoccai G. Diagnostic accuracy of myocardial perfusion imaging with CZT technology. Systemic review and meta-analysis of comparison with invasive coronary angiography. JACC Cardiovasc Imaging 2017;10:787-94.

    Article  Google Scholar 

  14. 14.

    Berman DS, Kiat H, Friedman JD, Wang FP, van Train K, Matzer L et al. Separate acquisition rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion single-photon emission computed tomography: A clinical validation study. J Am Coll Cardiol 1993;22:1455-64.

    CAS  Article  Google Scholar 

  15. 15.

    Berman DS, Abidov A, Kang X, Hayes SW, Friedman JD, Sciammarella MG et al. Prognostic validation of a 17-segment score derived from a 20-segment score for myocardial perfusion spect interpretation. J Nucl Cardiol 2004;11:414-23.

    Article  Google Scholar 

  16. 16.

    Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, Laskey WK et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the council on clinical cardiology of the American Heart Association. Circulation 2002;105:539-42.

    Article  Google Scholar 

  17. 17.

    Hachamovitch R, Hayes SW, Friedman JD, Cohen I, Berman DS. Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation 2003;107:2900-7.

    Article  Google Scholar 

  18. 18.

    Miller RJH, Hu LH, Gransar H, Betancur J, Eisenberg E, Otaki Y et al. Transient ischaemic dilation and post-stress wall motion abnormality increase risk in patients with less than moderate ischaemia: Analysis of the REFINE SPECT registry. Eur Heart J Cardiovasc Imaging 2019;21:567-75.

    Article  Google Scholar 

  19. 19.

    Otaki Y, Betancur J, Sharir T, Hu LH, Gransar H, Liang JX et al. 5-Year prognostic value of quantitative versus visual MPI in subtle perfusion defects: Results from REFINE SPECT. JACC Cardiovasc Imaging 2019;13:774-85.

    Article  Google Scholar 

  20. 20.

    Slomka PJ, Berman DS, Germano G. Normal limits for transient ischemic dilation with 99mTc myocardial perfusion SPECT protocols. J Nucl Cardiol 2017;24:1709-11.

    Article  Google Scholar 

  21. 21.

    Joergensen T, Hansson SH. Evaluation of the left ventricular ejection fraction with gated IQ-SPECT myocardial perfusion imaging. J Nucl Med Tech 2015;43:193-200.

    Article  Google Scholar 

  22. 22.

    Nakazato R, Berman DS, Gransar H, Hyun M, Miranda-Peats R, Kite FC et al. Prognostic value of quantitative high-speed myocardial perfusion imaging. J Nucl Cardiol 2012;19:1113-23.

    Article  Google Scholar 

  23. 23.

    Engbers EM, Timmer JR, Mouden M, Knollema S, Jager PL, Ottervanger JP. Prognostic value of myocardial perfusion imaging with a cadmium-zinc-telluride SPECT camera in patients suspected of having coronary artery disease. J Nucl Med 2017;58:1459-63.

    CAS  Article  Google Scholar 

  24. 24.

    Yokota S, Mouden M, Ottervanger JP, Engbers E, Knollema S, Timmer JR et al. Prognostic value of normal stress-only myocardial perfusion imaging: A comparison between conventional and CZT-based SPECT. Eur J Nucl Med Mol Imaging 2016;43:296-301.

    Article  Google Scholar 

  25. 25.

    Elze MC, Gregson J, Baber U, Williamson E, Sartori S, Mehran R et al. Comparison of propensity score methods and covariate adjustment: Evaluation in 4 cardiovascular studies. J Am Coll Cardiol 2017;69:345-57.

    Article  Google Scholar 

  26. 26.

    Lima R, Peclat T, Soares T, Ferreira C, Souza AC, Camargo G. Comparison of the prognostic value of myocardial perfusion imaging using a CZT-SPECT camera with a conventional anger camera. J Nucl Cardiol 2017;24:245-51.

    Article  Google Scholar 

  27. 27.

    Abidov A, Hachamovitch R, Hayes SW, Friedman JD, Cohen I, Kang X et al. Are shades of gray prognostically useful in reporting myocardial perfusion single-photon emission computed tomography? Circ Cardiovasc Imaging 2009;2:290-98.

    Article  Google Scholar 

  28. 28.

    Usher-Smith JA, Sharp SJ, Griffin SJ. The spectrum effect in tests for risk prediction, screening, and diagnosis. BMJ 2016;353:3139.

    Article  Google Scholar 

  29. 29.

    Lauer MS, Blackstone EH, Young JB, Topol EJ. Cause of death in clinical research: Time for a reassessment? J Am Coll Cardiol 1999;34:618-20.

    CAS  Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Daniel S. Berman MD.

Ethics declarations


Drs. Berman, and Slomka participate in software royalties for QPS/QGS software at Cedars-Sinai Medical Center.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The authors of this article have provided a PowerPoint file, available for download at SpringerLink, which summarises the contents of the paper and is free for re-use at meetings and presentations. Search for the article DOI on

The authors have also provided an audio summary of the article, which is available to download as ESM, or to listen to via the JNC/ASNC Podcast.


The work was supported in part by the Dr. Miriam and Sheldon G. Adelson Medical Research Foundation.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file3 (M4A 7696 kb)

Supplementary file1 (DOCX 23 kb)

Supplementary file2 (PPTX 321 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Miller, R.J.H., Han, D., Rozanski, A. et al. CZT camera systems may provide better risk stratification for low-risk patients. J. Nucl. Cardiol. (2020).

Download citation


  • myocardial perfusion imaging
  • CZT