Influence of exercise-induced coronary artery spasm on thallium-201 initial distribution and washout kinetics in patients with variant and classic angina pectoris

Clinical usefulness of myocardial scintigraphy in patients with vasospastic angina

BACKGROUND

Myocardial scintigraphy is defined as class IIb in the Japanese Circulation Society guideline for diagnosis of vasospastic angina (VSA). However, Caucasian guidelines had no classification of cardiac scintigraphy for diagnosis of VSA.

OBJECTIVES

To clarify the clinical usefulness of myocardial scintigraphy, we analyzed the sensitivity and specificity of each cardiac scintigraphy.

METHODS

We extracted the 136 papers of myocardial scintigraphy from the PubMed database from 1980 to 2018 in patients with VSA. Finally we analyzed the 88 papers including 33 papers of^201-thallium (Tl), 10 papers of ¹²³I beta-methyl 15-para-iodophenyl 3(R, S)-methylpentadecanoic acid (BMIPP), 9 papers of ¹²³I-metaiodobenzylguanidine (MIBG), 4 papers of ^99mTc-sestamibi (MIBI: methoxy-isobutyl-isonitrile), and 2 papers of tetrofosmin to investigate the sensitivity and specificity of each tracer.

RESULTS

Tl, BMIPP, or MIBG cardiac scintigraphy were useful to diagnose patients with VSA, because sensitivity was 57-73%. Specificity was 55-83%. Sensitivity of left circumflex artery was significantly lower than other vessels. BMIPP imaging may be helpful for clinical course of VSA. However, myocardial scintigraphic abnormal findings may not always show the ischemic memory due to coronary artery spasm.

CONCLUSIONS

Recent cardiologists do not perform hyperventilation tests or MIBG scintigraphy for diagnosis of coronary spasm. After understanding the flow of the times, cardiologists should use Tl or BMIPP myocardial scintigraphy for VSA as one of supplementary tools in the real world.

Expression of CD28 by bone marrow stromal cells and its involvement in B lymphopoiesis

Young mice lacking CD28 have normal numbers of peripheral B cells; however, abnormalities exist in the humoral immune response that may result from an intrinsic defect in the B cells. The goal of this study was to assess whether CD28 could be involved in the development of B cells. CD28 mRNA was detected preferentially in the fraction of bone marrow enriched for stromal cells. Flow cytometry and RT-PCR analysis demonstrated that CD28 was also expressed by primary-cultured stromal cells that supported B lymphopoiesis. Confocal microscopy revealed that in the presence of B-lineage cells, CD28 was localized at the contact interface between B cell precursors and stromal cells. In addition, CD80 was detected on 2-6% of freshly isolated pro- and pre-B cells, and IL-7 stimulation led to induction of CD86 on 15-20% of pro- and pre-B cells. We also observed that stromal cell-dependent production of B-lineage cells in vitro was greater on stromal cells that lacked CD28. Finally, the frequencies of B-lineage precursors in the marrow from young (4- to 8-wk-old) CD28(-/-) mice were similar to those in wild-type mice; however, older CD28(-/-) mice (15-19 mo old) exhibited a 30% decrease in pro-B cells and a 50% decrease in pre-B cells vs age-matched controls. Our results suggest that CD28 on bone marrow stromal cells participates in stromal-dependent regulation of B-lineage cells in the bone marrow. The localization of CD28 at the stromal cell:B cell precursor interface suggests that molecules important for T cell:B cell interactions in the periphery may also participate in stromal cell:B cell precursor interactions in the bone marrow.

Clandestine ischemia in patients with vasospastic angina

BACKGROUND

Coronary vasospasms generally occur at rest, but can also be triggered by physical exercise. Anginal pain and ST-segment elevation may be seen during exercise-stress tests. ST-segment depression, due to nonocclusive vasospasms, has also been found to occur. When the result of a test is positive, scintigraphy usually reveals perfusion defects. True silent or clandestine ischemia (normal result of exercise test with perfusion defects) in these patients is very uncommon.

OBJECTIVE

To stress the need for suspecting occurrence of coronary vasospasms in order to perform a proper diagnosis.

METHODS

Eight patients with angina were selected for this study. They had negative results of exercise tests with perfusion defects detected by thallium-201 tomography, normal coronary arteries and vasospasms. Maximal exercise-stress tests with thallium-201 tomography were performed. Sizes of perfusion defects were quantified by examining polar maps. Coronary angiography and then an intracoronary ergonovine test were performed for each patient.

RESULTS

Significant defects were seen in territory of the right coronary artery, the left anterior descending artery, or both. Lung:heart ratio was normal in every case. The coronary arteries were normal and vasospasms were elicited with ergonovine in all the patients. Correspondence between the location of perfusion defects and angiographic spasms was generally observed. After treatment with calcium antagonists and nitrates all of them improved and defects detected by thallium tomography were no longer found when tests were repeated.

CONCLUSIONS

Some patients with vasospastic angina may have normal results of exercise-stress tests and reversible perfusion defects detectable by scintigraphy. This finding must lead one to perform coronary angiography without administration of nitroglycerine beforehand and an ergonovine test if the coronary arteries are normal.