A simplified method of quantitating organ uptake using a gamma camera

A simplified method of absolute quantitation of activity in any region of the body is presented utilizing a series of views acquired with a scintillation camera linked to a computer. An accuracy of +/- 6% may be achieved. No additional programming needs to be added to the standard nuclear medicine computer software and a knowledge of the attenuation coefficients involved and the shape or position of the organs examined is not presupposed or estimated. Attention correction is performed using a transmission image as one of the sequence of camera. The phantom measurements used to evaluate the technique are described and some clinical results presented.

Myocardial cell damage during attacks of vasospastic angina in the absence of persistent electrocardiographic changes

We have investigated whether vasospastic anginal attacks might be associated with myocardial cell damage even when permanent ORS or ST-T changes are absent. We obtained serum time-activity curves of creatine kinase MB, of myoglobin, and of alpha hydroxybutyrate dehydrogenase in 15 patients with vasospastic angina admitted to our Coronary Care Unit (CCU). A slight but consistent rise and fall of both myoglobin and creatine kinase MB was observed in 7 patients (4 presented a definitive myocardial uptake of 99mTc pyrophosphate, and I had a faint deposition). A similar pattern was observed for myoglobin alone in 3 patients (1 presented a negative myocardial scan), while no consistent changes were found in the remaining 5 patients (2 presented a faint deposition of 99mTc pyrophosphate). No significant change of alpha hydroxybutyrate dehydrogenase was observed in any of the patients. The coherent rise and fall of the levels of myocardial cytosolic components after prolonged episodes of vasospastic angina suggests that cell damage may occur even in the absence of persistent QRS and ST-T changes.

Prostacyclin does not affect insulin secretion in humans

The effects of Prostacyclin (PGI2) infusion on insulin secretion and glucose tolerance were investigated in 7 healthy subjects. PGI2 infusion caused no statistically significant changes of either glucose or insulin concentration, over the range 2.5-20 ng/Kg/min. A constant PGI2 infusion (10 ng/Kg/min) did not inhibit acute insulin responses to a glucose (20 g i.v.) pulse (response before PGI2 = 612 +/- 307%; during PGI2 = 515 +/- 468%, mean +/- SD, mean change 3-5 min insulin, % basal; P=NS). Glucose disappearance rates were similar after the first and second glucose pulse. Thus, in contrast to PGE2, PGI2 does not affect insulin secretion nor glucose disposal at doses producing platelet and vascular changes. It is hypothesized that an altered PGI2/PGE2 balance in diabetes may represent a link between vascular, platelet and metabolic changes.

Pathogenetic mechanisms of angina pectoris: expanding views

Images

Thallium-201 scintigraphy for diagnosis of old myocardial infarction: comparison with electrocardiographic, ventriculographic, and coronary arteriographic findings

Myocardial scintigraphy with 201Tl was performed at rest in a selected group of 36 patients with unequivocal clinical and electrocardiographic evidence of old myocardial infarction. The scintigraphic findings were correlated with electrocardiographic pattern, and with regional left ventricular wall motion and the severity of coronary artery disease defined by contrast angiography. Detection was dependent on the extent of the infarct but was independent of QRS morphology and of the severity of coronary disease. When positive, 201Tl scintigraphy was often a more precise method than the electrocardiogram for localising and delineating the extent of the infarct. Furthermore, the perfusion defect corresponded in location and extent to abnormalities of left ventricular wall motion. The site or severity of coronary artery disease could not be determined from the 201Tl scintigram.

Sequence of events in angina at rest: primary reduction in coronary flow

To investigate the events that lead to acute myocardial ischemia we monitored continuously the ECG, the left ventricular (four patients) or aortic (two patients) pressure and the great cardiac vein oxygen saturation (CSO2S) by a fiberoptic catheter in six patients with frequent anginal attacks at rest. We recorded 137 transient ischemic episodes (10 with chest pain) characterized by ST-segment elevation in 28 episodes, depression in three episodes and by pseudonormalization of previously inverted or flat T waves in 106 episodes. The onset of electrocardiographic and hemodynamic changes was preceded by a large drop in CSO2S in all 135 episodes with ST-T changes in the anterior leads but not in two episodes with ST elevation on inferior leads. The fall in CSO2S, consistently followed by signs of left ventricular function impairment and never preceded by any detectable increase in the hemodynamic determinants of myocardial oxygen consumption, probably reflects a reduction in regional perfusion. Thus, a reduction in coronary flow may cause transient ischemia in patients with angina at rest. These episodes may be associated with variable, often minor electrocardiographic changes and occasionally with anginal pain.

Some clinical considerations regarding the relation of coronary vasospasm to coronary atherosclerosis: a hypothetical pathogenesis

This study explores the relation between coronary arterial spasm and the development of coronary atherosclerosis. The clinical history and coronary angiographic and electrocardiographic data in 212 consecutive patients with ischemic heart disease were correlated. These patients were classified into four groups: Group 1, patients without angiographic evidence of atherosclerosis; Group 2, patients with single vessel disease; Group 3, patients with double vessel disease; and Group 4, patients with significant narrowing of major coronary arteries. Although spontaneous angina occurred in all four groups, it was more common (55 percent) in the patients in Group 1, who were predominantly female and young. Spontaneous angina was confirmed in Group 1 with several techniques, including thallium-201 scintigraphy, ergonovine administration and electrocardiography during attacks of pain. Prior myocardial infarction was present with similar frequency in all four groups. A patient is discussed whose spontaneously occurring coronary arterial spasm later progressed to fixed arteriosclerotic narrowing requiring coronary bypass surgery. These observations and a review of the literature lend support to the hypothesis that coronary arterial spasm can be a possible antecedent leading to the later development of fixed atherosclerotic coronary arterial obstruction.

Xenon studies of myocardial blood flow: theoretical, technical, and practical aspects

External detection by a single collimator of the washout curve of 133Xe following its intracoronary injection was used in humans following its validation in animals. However, additional experimental studies showed that the straightforward application of the theoretical principles on which the technique should be based resulted in uncorrected values. Special empirical modifications in the analysis of the washout curves were required in order to obtain a fair agreement between calculated and experimental flow values. Furthermore, studies in humans indicate that reappearance of indicator into the counting field due to recirculation and diffusion retention of the tracer in epicardial fat alter the precordial washout curve leading to underestimation of coronary blood flow. This method has found a second wave of applicatin in humans for the study of regional myocardial perfusion using a gamma camera. The amount of new information on regional myocardial perfusion provided by this approach is quite considerable; however, the interpretation of the values obtained in these studies requires particular attention in view of the limitations outlined above.

Management of unstable angina at rest by verapamil. A double-blind cross-over study in coronary care unit

A therapeutic trial with verapamil, a calcium-antagonist drug, was performed in 12 patients admitted to our coronary care unit because of frequent daily attacks of angina at rest attributed to coronary vasospasm. After a 48-hour run-in period, oral verapamil 480 mg/day and placebo were administered alternately during 4 randomised 48-hour periods. Transient ischaemic attacks with ST segment elevation or depression, with or without pain, were documented by continuous electrocardiographic monitoring. The number of attacks during the run-in and 2 placebo periods were 128, 123, and 130, respectively, and 31 and 23 during the 2 treatment periods (P less than 0.006 and P less than 0.003). This drug therefore appears to be effective in the management of patients with frequent attacks of angina at rest.

Coronary vasospasm as a possible cause of myocardial infarction. A conclusion derived from the study of "preinfarction" angina

To investigate the pathogenesis of myocardial infarction we undertook a systematic study of patients with angina at rest, a syndrome known to evolve frequently into infarction. Among 187 consecutive patients, 37 had infarction, all in the area that showed electrocardiographic changes during angina. In all 76 patients who underwent hemodynamic monitoring, 201thallium myocardial scintigraphy or angiography during angina, a vasospastic origin of the attacks was documented. In six patients with infarction shortly after these studies and in two in whom the infarction developed during hemodynamic monitoring or during angiography the onset of infarction was indistinguishable from the onset of anginal attacks. One patient in whom spasm was observed at the onset of infarction died six hours later; at post-mortem examination, a fresh laminar thrombus was found at the site of the spasm. After infarction, complete thrombotic occlusion of the branch shown to undergo vasospasm was documented in two patients by angiography.

Possibilities, limitations, and technique for the study of regional myocardial perfusion in man by Xenon-133

The theoretical possibilities and the practical limitations of the Xenon-133 (133Xe) method for the study of regional myocardial perfusion in man are discussed. The techniques for data acqusition and processing developed over the past 5 years are described in detail. Illustrative examples of experimental findings are reported. The practical interpretation of the data, at the light of the influence of injection site, initial tracer distribution, constancy of counting geometry, spatial resolution, and Xenon retention in fat, is presented.

Coronary vasospasm in angina pectoris

Coronary angiography was performed during 34 angina attacks in thirty patients admitted because of recurrent angina at rest. Nineteen (seventeen with S-T segment elevation and two S-T depression) had angiograms during a spontaneous attack, eleven (nine with S-T elevation and two with S-T depression) during an attack induced by intravenous ergonovine maleate. Control coronary angiograms showed a wide range of atherosclerotic obstruction, from normal vessels to severe triple-vessel disease. During the anginal attack, all patients with S-T segment elevation had vasospasm localised to one of the major branches, often resulting in complete occlusion. Attacks with S-T segment depression were seen only in patients with double or triple vessel disease, and here the vasospasm generally affected coronary branches without causing complete occlusion. When appropriately searched for, vasospastic angina seems to be common.

Regional myocardial perfusion in patients with atherosclerotic coronary artery disease, at rest and during angina pectoris induced by tachycardia

We studied regional myocardial perfusion by scintigraphic computer-assisted analysis of initial distribution, washout rates, and residual activity of 133Xe injected into the left coronary artery of four patients with normal arteriograms and 14 patients with coronary stenosis. At rest, residual activity in poststenotic regions was always greater than in control regions, but initial washout rates were not slower. During angina, following xenon injections, the amount of indicator distributed to the poststenotic regions was markedly reduced; the increase of the initial washout rates was smaller than in control regions relative to rest, and residual activity was higher. Initial washout rates did not differ as much as from those of normal myocardium because in severe ischemia too little indicator is deposited initially in these regions to produce a change of any magnitude. Indeed, when angina was induced immediately after the xenon injection, poststenotic washout rates became much slower during angina than at rest, a finding that implicates functional factors in impairing poststenotic myocardial perfusion during angina.

Pathophysiologic studies of the pulmonary and coronary circulations in man

Studies of the pulmonary circulation in normal man, performed with external radiation detectors, have shown that pulmonary blood volume is about 10% of total blood volume. Pulmonary blood volume was unchanged in patients with acute or chronic left atrial hypertension and in normal persons during expansion of total blood volume in spite of marked increases in pulmonary vascular pressures. However, pulmonary blood volume was greatly increased in patients with polycythemia rubra vera and a large total blood volume and in patients with a left to right shunt but normal pulmonary intravascular pressure. Studies of regional myocardial perfusion with injection of xenon-133 solution into the left coronary artery revealed localized areas of ischemia distal to stenotic lesions even when the patient was at rest. During angina produced by pacing, more severe ischemia occurred, thus suggesting that functional factors reduce local perfusion below resting levels. In patients with "variant" angina, intravenous injection of thallium-201 chloride during spontaneous attacks has revealed large cold areas in myocardial scintigrams not present under control conditions, thus suggesting severe transmural reduction of perfusion in heart muscle corresponding to S-T segment elevation in the electrocardiogram.

Systemic and coronary haemodynamic effects of the new hypotensive drug L 6150

The acute systemic and coronary haemodynamic effects of a new hypotensive drug L 6150 (3-hydrazino-6-[N,N-bis(2-hydroxyethyl)amino]pyridazine) have been studied in six patients with renal or essential hypertension. The drug, administered intravenously at a dose of 2-9 mg, caused a marked hypotension and increase of cardiac output in five cases. Though left ventricular work was reduced or unchanged after the drug, myocardial blood flow increased markedly, coronary resistance decreased and coronary A-V oxygen difference decreased by about 50% indicating coronary vasodilation. When compared with the available data on the effects of hydrazinophthalazine, L 6150 appeared to have qualitatively similar effects, but a somewhat greater direct coronary vasodilator effect.

Transient transmural reduction of myocardial blood flow demonstrated by thallium-201 scintigraphy, as a cause of variant angina

In previous studies we demonstrated that variant angina could not be attributed to increased myocardial demands. In order to investigate whether a reduction of regional myocardial blood supply could be responsible for these ischemic episodes, we studied regional myocardial perfusion in six patients admitted to our coronary care unit. Myocardial scintigrams, obtained 5-7 min following i.v. injection of 1 mCi of thallium-201, performed during an episode of ST-segment elevation, showed transmural deficits of tracer uptake in the heart wall corresponding to the leads showing ST-segment elevation. These regional deficits ahd disappeared by 2 hours because of late uptake in previously ischemic myocardium. One week later, following injections performed in the absence of acute ischemia, no deficit was apparent. Tracer uptake in ischemic areas was 60% to 85% of that observed a week later. After adjusting for thallium-201 kinetics and counting geometry promblems., these scintigrams actually represent large underestimations of actual flow reduction. Thus variant angina appears to be caused by massive transmural reduction of myocardial blood supply.

Methods for the study of regional myocardial perfusion in patients with atherosclerotic coronary artery disease: findings at rest after nitroglycerin and during angina pectoris

In patients with ischemic heart disease the evaluation of regional myocardial perfusion by 133Xenon intracoronary injection using a gamma camera computer system allows the detection of regional alterations of myocardial perfusion. While at rest a minority of the patients studied shows large alterations, during pacing induced angina a severe reduction of regional myocardial perfusion can be evidenced both in initial distribution scintigrams, when the injection is performed during angina, and on the washout curves when angina is induced immediately after the injection, during the course of the washout.