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Open Access Highly Accessed Research article

Area of ischemia assessed by physicians and software packages from myocardial perfusion scintigrams

Lars Edenbrandt123, Peter Höglund4, Sophia Frantz1, Philip Hasbak5, Allan Johansen6, Lena Johansson2, Annett Kammeier7, Oliver Lindner7, Milan Lomsky2, Shinro Matsuo8, Kenichi Nakajima8, Karin Nyström3, Eva Olsson9, Karl Sjöstrand3, Sven-Eric Svensson10, Hiroshi Wakabayashi8 and Elin Trägårdh1*

Author Affiliations

1 Clinical Physiology and Nuclear Medicine, Skåne University Hospital, Lund University, Inga Marie Nilssons gata 49, 205 02 Malmö, Sweden

2 Department of Molecular and Clinical Medicine, Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden

3 EXINI Diagnostics AB, Lund, Sweden

4 Competence Center for Clinical Research, Skåne University Hospital, Lund, Sweden

5 Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark

6 Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark

7 Institute of Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North Rhine-Westphalia, University Hospital of Ruhr University Bochum, Bad Oeynhausen, Germany

8 Department of Nuclear Medicine, Kanazawa University, Kanazawa, Japan

9 Department of Medical and Health Sciences, Linköping University and Department of Clinical Physiology, County Council of Östergötland, Linköping, Sweden

10 Department of Clinical Physiology, Blekingesjukhuset, Karlskrona, Sweden

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BMC Medical Imaging 2014, 14:5  doi:10.1186/1471-2342-14-5

Published: 31 January 2014



The European Society of Cardiology recommends that patients with >10% area of ischemia should receive revascularization. We investigated inter-observer variability for the extent of ischemic defects reported by different physicians and by different software tools, and if inter-observer variability was reduced when the physicians were provided with a computerized suggestion of the defects.


Twenty-five myocardial perfusion single photon emission computed tomography (SPECT) patients who were regarded as ischemic according to the final report were included. Eleven physicians in nuclear medicine delineated the extent of the ischemic defects. After at least two weeks, they delineated the defects again, and were this time provided a suggestion of the defect delineation by EXINI HeartTM (EXINI). Summed difference scores and ischemic extent values were obtained from four software programs.


The median extent values obtained from the 11 physicians varied between 8% and 34%, and between 9% and 16% for the software programs. For all 25 patients, mean extent obtained from EXINI was 17.0% (± standard deviation (SD) 14.6%). Mean extent for physicians was 22.6% (± 15.6%) for the first delineation and 19.1% (± 14.9%) for the evaluation where they were provided computerized suggestion. Intra-class correlation (ICC) increased from 0.56 (95% confidence interval (CI) 0.41-0.72) to 0.81 (95% CI 0.71-0.90) between the first and the second delineation, and SD between physicians were 7.8 (first) and 5.9 (second delineation).


There was large variability in the estimated ischemic defect size obtained both from different physicians and from different software packages. When the physicians were provided with a suggested delineation, the inter-observer variability decreased significantly.

Ischemic heart disease; Myocardial perfusion imaging; Intra-observer variability; Software tools