Diagnostic value of left ventricular function after adenosine triphosphate loading and at rest in the detection of multi-vessel coronary artery disease using myocardial perfusion imaging

The Impact of Left Ventricle Ejection Fraction Reduction and Transient Ischemic Dilation in Patients With Normal Single-Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging

INTRODUCTION

Coronary artery disease (CAD) is a leading cause of death in developed countries. Non-invasive functional imaging modalities are currently recommended as initial diagnostic tests in patients with an intermediate-high pretest probability of CAD. Single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) creates images of regional myocardial tracer uptake, reflecting relative myocardial blood flow. However, there are other non-perfusion predictors of CAD, such as transient ischemic dilatation (TID) and reduced post-stress left ventricle ejection fraction (LVEF). Available data regarding these parameters is controversial. The aim of our study was to evaluate the incidence of significant CAD in patients with non-perfusion high-risk markers of ischemia despite a normal SPECT-MPI.

METHODS

Single-center, observational, retrospective, and longitudinal study. Inclusion criteria were age ≥18 years, normal SPECT-MPI, and availability of gated study for LVEF and volume analysis. Exclusion criteria were any known cardiomyopathy or congenital heart disease and known CAD. Non-perfusion high-risk markers: LVEF reduction ≥5% on post-stress images; TID (defined as a stress/rest left ventricle volume ratio ≥ 1.15), including end-systolic, end-diastolic, and mean volumes. The primary endpoint was the identification of significant CAD (stenosis >70% on an epicardial coronary artery or >50% on the left main artery) on invasive coronary angiography.

RESULTS

A total of 197 patients met the inclusion criteria. Mean age was 64 ± 12.6 years and 59.4% (n = 117) of patients were male. Overall, 26% of patients had LVEF reduction ≥5% on stress study; 24.9% had a stress/rest end-systolic volume ratio ≥ 1.15; 7.1% had a stress/rest mean volume ratio ≥ 1.15; 7.1% had a stress/rest end-diastolic volume ratio ≥ 1.15. Time-to-primary endpoint was significantly lower in patients with LVEF reduction ≥5% on stress study (67.99 (95% CI 60.49-75.49) vs. 77.56 months (95% CI 75.14-79.99); p = 0.003) and in patients with stress/rest end-systolic volume ratio ≥ 1.15 (68.39 (95% CI 60.69-76.10) vs. 77.31 months (95% ICCI 74.68-79.76); p = 0.013).

CONCLUSION

In patients with normal perfusion on SPECT-MPI, the incidence of significant CAD was significantly higher in those with LVEF reduction ≥ 5% on stress study and in those with a stress/rest end-systolic volume ratio ≥ 1.15, during a follow-up period of five years.

Clinical Feasibility of Simultaneous Acquisition Rest (99m)Tc/Stress (201)Tl Dual-Isotope Myocardial Perfusion Single-Photon Emission Computed Tomography With Semiconductor Camera

BACKGROUND

The aim of this study was to evaluate the clinical feasibility of simultaneous acquisition of rest (99m)Tc-tetrofosmin/stress (201)Tl dual-isotope single-photon emission computed tomography with a semiconductor gamma camera.

METHODS AND RESULTS

Ninety-four patients with known or suspected coronary artery disease (CAD) were enrolled in the study. First, patients were injected with (99m)Tc-tetrofosmin (296 MBq) for rest imaging, followed by (201)Tl (74 MBq) injection during 6 min of vasodilator stress test. Immediately after the stress test, the patients underwent the first electrocardiogram (ECG)-gated simultaneous acquisition including rest and stress perfusion scans. Patients were brought back for the second simultaneous acquisition for the comparison of ECG-gated wall motion between stress and rest scan 30 min later. Coronary angiography was performed in all the patients within 3 months of this protocol. Sensitivity, specificity and accuracy on a per patient basis to detect significant coronary artery stenosis (≥75%) were 88.6%, 79.2% and 86.2%, respectively. Per coronary vessel, sensitivity, specificity and accuracy were as follows: 84.9%, 80.5% and 83% in the left anterior descending coronary artery; 75%, 93.1% and 86.2% in the left circumflex coronary artery; and 74.2%, 85.7% and 81.9% in the right coronary artery.

CONCLUSIONS

Simultaneous acquisition of rest (99m)Tc-tetrofosmin/stress (201)Tl dual-isotope protocol had high diagnostic accuracy for significant CAD. (Circ J 2016; 80: 689-695).

Heart function disturbances in chronic kidney disease - echocardiographic indices

INTRODUCTION

In chronic kidney disease (CKD) patients left ventricular (LV) diastolic dysfunction occurs frequently and is associated with heart failure (HF) and higher mortality. Left ventricular systolic dysfunction is associated with coronary artery disease (CAD) and is a major determinant of prognosis. The aim of this study was to assess indices of LV diastolic dysfunction in CKD patients.

MATERIAL AND METHODS

Study included 118 CKD patients. All patients underwent transthoracic echocardiography. Diastolic function based on E and A, E/A ratio and pulmonary vein flow velocities as well as EF%, deceleration time, RA, LA volume were assessed. In dialysis patients examination was carried out before and after dialysis.

RESULTS

In CKD patients the stage of renal failure was associated with the significant increase in LV mass (268.0 ±47.6 CKD I/II vs. 432.7 ±122.4 CKD V/dialysis, p < 0.0001), systolic LV (37.3 ±4.5 vs. 51.2 ±8.9, p < 0.0001) and diastolic LV (CKD I-II 44.7 ±4.1 vs. CKD III 48.5 ±6.7 vs. CKD IV 47.1 ±5.6; p = 0.004) dimensions and in the size of the LA (40.4 ±2.0 vs. 41.9 ±2.7 vs. 42.3 ±3.2 vs. 44.8 ±3.1; p < 0.0001). The increase the E/E' ratio between groups of patients (6.7 ±1.5 vs. 8.9 ±2.4 vs. 11.5 ±4.0 vs. 13.5 ±5.0; p < 0.0001) was seen in this study. The reduction in deceleration time (247.2 ±34.5 in CKD I/II vs. 197.4 ±61.0 in CKD IV, p = 0.0005) along with the decrease in estimated glomerular filtration rate was also observed in this study.

CONCLUSIONS

Early identification of factors involved is necessary to prevent this devastating process. Many indexes of contractility are used and each of them has imperfections. It seems that TVI, E, E/A and E/E' are good instruments for the early detection of left ventricular hypertrophy and diastolic dysfunction.

Left ventricular functional changes after adenosine vasodilator stress evaluated by gated single-photon emission computed tomography

OBJECTIVES

Gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging is useful in assessing left ventricular (LV) myocardial perfusion and function. This study evaluated the LV functional changes after adenosine vasodilator stress, using gated SPECT.

METHODS

The study population consisted of 70 patients who underwent adenosine-mediated stress and rest SPECT. All patients underwent coronary angiography. Semi-quantitative assessment of perfusion was analyzed and produced the summed rest score (SRS), the summed stress score (SSS) and the summed difference score (SDS). The global LV function parameters [ejection fraction (EF), end-diastolic volume (EDV), end-systolic volume (ESV)] and regional LV function [the summed motion score (SMS) and the summed thickening score (STS)] were quantified by gated SPECT.

RESULTS

Patients were divided into 2 groups: group 1 comprised 16 patients with worsening of LVEF (LVEFrest-LVEFado ≥5%), and group 2 comprised the other 54 patients. Compared with group 2, patients in group 1 had a significantly higher SSS and SDS (9.1 ± 6.8 vs. 5.6 ± 4.5 and 6.6 ± 3.8 vs. 3.6 ± 4.0, respectively; p < 0.05) and the severity of coronary artery stenosis was more serious (p < 0.05).

CONCLUSION

Worsening of LVEF after adenosine-induced vasodilator stress, as shown by (99m)Tc-MIBI gated SPECT, is a valuable nonperfusion marker of significant CAD.

Impaired renal function is a major determinant of left ventricular diastolic dysfunction: assessment by stress myocardial perfusion imaging

Objective

Relationships between myocardial scintigraphic parameters and renal function have not been fully determined. We investigated correlations between estimated glomerular filtration rate (eGFR) and left ventricular (LV) diastolic function using stress electrocardiographic (ECG)-gated myocardial single photon emission computed tomography (SPECT).

Methods

We enrolled 136 consecutive patients with suspected coronary artery disease (CAD) who were assessed using technetium-99m stress ECG-gated myocardial SPECT. We evaluated SPECT images using 17-segment defect scores graded on a 5-point scale, summed stress score, summed rest score and summed difference score (SDS). The parameters for assessing LV diastolic function were peak filling rate (PFR), 1/3 mean filling rate and time to peak filling. The CAD was defined as SDS ≥2. Chronic kidney disease (CKD) was defined as eGFR <60 mL/min/1.73 m². Patients were assigned to the following four groups (no CAD/no CKD: control group, n = 68; CAD/no CKD: CAD group, n = 24; no CAD/CKD: CKD group, n = 34; CAD/CKD: CAD + CKD group, n = 10).

Results

The PFR was significantly impaired after stress in the CKD and CAD + CKD groups compared with controls (p < 0.001 for both). Furthermore, PFR at rest positively correlated with eGFR (r = 0.29, p < 0.001) and inversely correlated with SDS (r = −0.18, p < 0.05). Multivariate stepwise regression analysis independently associated eGFR with PFR (β coefficient = 0.260, p = 0.002).

Conclusions

Our data suggest that impaired renal function is a significant determinant of LV diastolic dysfunction in patients with suspected CAD.

Direct quantification of left ventricular motion and thickening changes using rest-stress myocardial perfusion SPECT

Changes in myocardial wall motion and thickening during myocardial perfusion SPECT are typically assessed separately from gated studies for the presence of stress-induced functional abnormalities. We sought to develop and validate a novel approach for automatic quantification of rest-stress myocardial motion and thickening changes (MTCs).

METHODS

Endocardial surfaces at the end-diastolic and end-systolic frames for rest-stress studies were registered automatically to each other by matching ventricular surfaces. Myocardial MTCs were computed, and normal limits of change were determined as the mean and SD for each polar sample. Normal limits were used to quantify the MTCs for each map, and the accumulated sample values were used for abnormality assessments in segmental regions. A hybrid method was devised by combining the total perfusion deficit (TPD) and MTC for each vessel territory. Normal limits were obtained from 100 subjects with low likelihood of coronary artery disease. For validation, 623 subjects with correlating invasive angiography were studied. All subjects underwent a rest-stress (99m)Tc-sestamibi exercise or adenosine test and coronary angiography within 3 months of myocardial perfusion SPECT. All MTC and TPD measurements were derived automatically. The diagnostic accuracy for detection of coronary artery disease for MTC plus TPD was compared with TPD alone.

RESULTS

Segmental normal values were between -1.3 and -4.1 mm for motion change and between -30.1% and -9.8% for thickening change. MTC combined with TPD achieved 61% sensitivity for 3-vessel-disease (3VD), 63% for 2-vessel-disease (2VD), and 90% for 1-vessel-disease (1VD) detection, compared with 32% for 3VD (P < 0.0001), 53% for 2VD (P < 0.001), and 90% for 1VD (P = 1.0) detection using the TPD-alone method. The specificity for the combined method was 71% for 3VD, 72% for 2VD, and 47% for 1VD detection versus 90% for 3VD (P < 0.0001), 80% for 2VD (P < 0.001), and 50% for 1VD detection (P = 0.0625) for the TPD-alone method. The accuracy of 3VD detection by MTC plus TPD was higher (69%) than the accuracy of TPD plus change in ejection fraction (63%) (P < 0.004).

CONCLUSION

We established normal limits and a novel method for computation of regional functional changes between the rest and poststress studies. Compared with TPD alone, the combination of TPD with MTC improved the sensitivity for the detection of 3VD and 2VD.

Postischemic myocardial stunning is superior to transient ischemic dilation for detecting multivessel coronary artery disease

BACKGROUND

Although poststress myocardial stunning is regarded as a marker for severe coronary artery disease (CAD), no study has yet compared the diagnostic value of poststress stunning with transient ischemic dilation (TID) of the left ventricle (LV) for detecting multivessel CAD.

METHODS AND RESULTS

A total of 271 patients with suspected or known CAD underwent adenosine triphosphate (ATP) loading and at-rest gated single-photon emission computed tomography. We assessed myocardial perfusion with a 20-segment model, and analyzed the changes in LV volumetric analysis induced by ATP and an automatically derived TID ratio. In 147 patients with multivessel CAD, the prevalence of multi-territorial ischemia was higher, and the post-ATP increase in end-systolic volume (ESV) and TID ratio were greater, than in the 124 with insignificant or single-vessel CAD (P<0.0001, for all cases). The receiver-operating characteristic curves analysis revealed cutoff values for ESV of 5 ml and a TID ratio of 1.11. Multivariate logistic regression analysis revealed that the combination of a poststress increase in ESV of ≥5 ml and multi-territorial ischemia best identified multivessel CAD, with a sensitivity of 78% and a specificity of 84%, whereas the TID ratio was not shown to be an independent predictor.

CONCLUSIONS

Post-ATP stress myocardial stunning is superior to the TID ratio for detecting multivessel CAD.

Assessment of left ventricular dyssynchrony in patients with coronary artery disease during adenosine stress using ECG-gated myocardial perfusion single-photon emission computed tomography

OBJECTIVES

Some investigators have reported that left ventricular (LV) mechanical systolic and diastolic dyssynchrony occurs in coronary artery disease (CAD) patients without earlier myocardial infarction and narrow QRS complex duration. However, earlier studies evaluated LV dyssynchrony only at rest. The purpose of this study was to investigate LV dyssynchrony in CAD patients with preserved ejection fraction during adenosine stress using electrocardiogram-gated myocardial perfusion single-photon emission computed tomography (SPECT).

METHODS

The study population included 18 CAD patients and 18 control subjects. CAD patients had significant stenosis in their coronary arteries by coronary angiogram without earlier myocardial infarction. SPECT images were acquired at rest and during stress with adenosine. The regional time to end systole (TES), time to peak ejection, the time from 0 to peak filling during the whole diastolic period (TPF1), and the time from end systole to peak filling during the whole diastolic period (TPF2) were obtained by using the Quantitative Gated SPECT software. The maximal difference (MD), which is the difference between the earliest and latest temporal parameter among 17 segments, was considered to represent LV dyssynchrony.

RESULTS

MD-TES and MD-TPF1 during stress were significantly greater than those of rest in CAD patients (MD-TES: stress=242+/-107 ms, rest=164+/-79 ms; P=0.005, MD-TPF1: stress=249+/-121 ms, rest=164+/-88 ms; P=0.015) but there were no significant differences in control patients.

CONCLUSION

LV dyssynchrony was shown in CAD with preserved ejection fraction during adenosine stress.

Sex-specific approach to gated SPECT volumetric analysis after stress and at rest to detect high-risk coronary artery disease

OBJECTIVES

To determine the role of quantitative analysis of poststress and resting left ventricular function using sex-specific criteria to detect high-risk coronary artery disease (CAD) as defined by the Duke CAD Prognostic Index.

METHODS AND RESULTS

Stress technetium-99m-sestamibi-gated single-photon emission computed tomography and coronary angiography were performed in 407 consecutive patients (300 men, 107 women) with suspected CAD. The cut-off point for high-risk CAD was defined as a Duke CAD Prognostic Index of 42. The stress-to-rest ratios of end-diastolic volume (rEDV) and end-systolic volume (rESV) were analyzed. In 102 patients with high-risk CAD, the summed difference scores, rEDV and rESV, were greater than in 305 patients with low-risk to intermediate-risk CAD. The receiver operating characteristic curves revealed that the optimal cut-off points for rEDV and rESV to detect high-risk CAD were 1.10 and 1.11, respectively. Sex-specific rEDV was 1.08 in men, 1.11 in women, and sex-specific rESV was 1.09 in men and 1.20 in women. Multivariate discriminant analysis showed that the combination of sex-specific rEDV, sex-specific rESV, and summed difference scores greater than or equal to 8 best identified high-risk CAD, with a sensitivity of 75% and specificity of 76%.

CONCLUSION

The addition of a sex-specific approach to left ventricular functional analysis using gated single-photon emission computed tomography on conventional perfusion analysis, may help better identify patients with high-risk CAD as defined by the Duke CAD Prognostic Index.

Prognostic value of post-ischemic stunning as assessed by gated myocardial perfusion single-photon emission computed tomography: a subanalysis of the J-ACCESS study

BACKGROUND

To determine the prognostic value of post-ischemic stunning, the Japanese assessment of cardiac event and survival study by quantitative gated myocardial single-photon emission computed tomography (SPECT) (J-ACCESS) study was reevaluated.

METHODS AND RESULTS

Of the 4,031 patients of the J-ACCESS, the present study evaluated 1,089 who completed gated SPECT both after stress and at rest. To assess post-ischemic stunning, the following measurements (left ventricular volumes after stress minus volumes at rest) were made: Deltaend-systolic volume (DeltaESV), Deltaenddiastolic volume (DeltaEDV) and Deltaejection fraction (DeltaEF). Myocardial stunning defined either as DeltaESV >or=5 ml, DeltaEDV >or=5 ml or DeltaEF <or=5% was observed in 21%, 22%, or 26%, respectively. During a 3-year follow-up, 101 cardiac events occurred. Kaplan-Meier survival estimation indicated worse event-free survival rates in patients with dilated ESV, dilated EDV, LVEF <or=45%, DeltaESV >or=5 ml or DeltaEDV >or=5 ml than in those without, whereas DeltaEF <or=5% did not predict events. Multivariate analysis demonstrated that LVEF <or=45% was the independent predictor for cardiac events. Nevertheless, DeltaEDV >or=5 ml was also an independent parameter, in addition to LVEF <or=45%, to predict the combined endpoint of cardiac death, myocardial infarction, and revascularization, but excluding heart failure.

CONCLUSIONS

These results indicate that post-ischemic stunning, as assessed by gated SPECT, is a marker for poor prognosis, particularly for ischemic cardiac events.

Results of interventional treatment of stress positive coronary artery disease

The aim of this study was to define the impact of percutaneous coronary intervention (PCI) including stenting in patients with stress-positive stable coronary artery disease on long-term prognosis and symptoms. A group of 1,018 patients were identified from the angiographic and single-photon emission computed tomographic (SPECT) databases (technetium-99m sestamibi or tetrofosmin at rest and during stress) January 1, 2000, to December 31, 2003, to have significant coronary artery disease (>50% diameter stenosis on quantitative coronary angiography) and positive SPECT findings. Two hundred sixty-six patients were medically treated. Seven hundred fifty-two patients with positive SPECT findings who underwent PCI were matched to 266 patients of similar age, gender, number and location of stenotic arteries, left ventricular function, and size of SPECT perfusion defect who underwent medical treatment. Clinical events (death, nonfatal myocardial infarction, and revascularization) as well as clinical symptoms (angina or dyspnea, Canadian Cardiovascular Society class II to IV) were determined after a follow-up period of 6.4 +/- 1.2 years. In 524 of the 532 patients (98%), clinical follow-up was obtained. There were no differences between the PCI and medical groups in the frequencies of death (13.5% vs 10.9%) and myocardial infarction (5.3% vs 5.6%) during follow-up. PCI patients had more revascularization procedures <1 year after choice of treatment modality (14.7% vs 6.0%, p <0.002). During the subsequent follow-up period (>1 year), the 2 groups did not differ in the frequency of revascularization procedures. At the end of follow-up, patients in the PCI group complained less frequently of angina pectoris (38% vs 49%, p = 0.014). In conclusion, in patients with stress-positive stable coronary artery disease, PCI including stenting did not reduce mortality or rate of nonfatal myocardial infarction. The PCI group complained less frequently of angina pectoris at long-term follow-up.