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Sharir T. What is the value of motion and thickening in gated myocardial perfusion SPECT? J Nucl Cardiol 2018; 25:754-757. [PMID: 29476455 DOI: 10.1007/s12350-018-1239-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 02/05/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Tali Sharir
- Nuclear Cardiology Department, Assuta Medical Center, 96 Igal Alon, C Building, 67891, Tel Aviv, Israel.
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheba, Israel.
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2
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Sharir T, Brodkin B, Kovalski G. Combined assessment of myocardial perfusion and left ventricular function by nuclear cardiology: The value of high-efficiency SPECT. J Nucl Cardiol 2016; 23:1262-1265. [PMID: 27311451 DOI: 10.1007/s12350-016-0570-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 05/31/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Tali Sharir
- Department of nuclear cardiology, Assuta Medical Centers, 96 Igal Alon, C Building, 67891, Tel Aviv, Israel.
| | - Boris Brodkin
- Department of nuclear cardiology, Assuta Medical Centers, 96 Igal Alon, C Building, 67891, Tel Aviv, Israel
- Department of cardiology, Barzilai Medical Center, Ashkelon, Israel
- Ben Gurion University of the Negev, Beersheba, Israel
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3
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Kurata A, Kawaguchi N, Kido T, Inoue K, Suzuki J, Ogimoto A, Funada JI, Higaki J, Miyagawa M, Vembar M, Mochizuki T. Qualitative and quantitative assessment of adenosine triphosphate stress whole-heart dynamic myocardial perfusion imaging using 256-slice computed tomography. PLoS One 2013; 8:e83950. [PMID: 24376774 PMCID: PMC3871670 DOI: 10.1371/journal.pone.0083950] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 11/11/2013] [Indexed: 11/18/2022] Open
Abstract
Background The aim of this study was to investigate the correlation of the qualitative transmural extent of hypoperfusion areas (HPA) using stress dynamic whole-heart computed tomography perfusion (CTP) imaging by 256-slice CT with CTP-derived myocardial blood flow (MBF) for the estimation of the severity of coronary artery stenosis. Methods and Results Eleven patients underwent adenosine triphosphate (0.16 mg/kg/min, 5 min) stress dynamic CTP by 256-slice CT (coverage: 8 cm, 0.27 s/rotation), and 9 of the 11 patients underwent coronary angiography (CAG). Stress dynamic CTP (whole–heart datasets over 30 consecutive heart beats in systole without spatial and temporal gaps) was acquired with prospective ECG gating (effective radiation dose: 10.4 mSv). The extent of HPAs was visually graded using a 3-point score (normal, subendocardial, transmural). MBF (ml/100g/min) was measured by deconvolution. Differences in MBF (mean ± standard error) according to HPA and CAG results were evaluated. In 27 regions (3 major coronary territories in 9 patients), 11 coronary stenoses (> 50% reduction in diameter) were observed. In 353 myocardial segments, HPA was significantly related to MBF (P < 0.05; normal 295 ± 94; subendocardial 186 ± 67; and transmural 80 ± 53). Coronary territory analysis revealed a significant relationship between coronary stenosis severity and MBF (P < 0.05; non-significant stenosis [< 50%], 284 ± 97; moderate stenosis [50–70%], 184 ± 74; and severe stenosis [> 70%], 119 ± 69). Conclusion The qualitative transmural extent of HPA using stress whole-heart dynamic CTP imaging by 256-slice CT exhibits a good correlation with quantitative CTP-derived MBF and may aid in assessing the hemodynamic significance of coronary artery disease.
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Affiliation(s)
- Akira Kurata
- Department of Diagnostic and Therapeutic Radiology, Ehime University Graduate School of Medicine, Ehime, Japan
- * E-mail:
| | - Naoto Kawaguchi
- Department of Diagnostic and Therapeutic Radiology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Teruhito Kido
- Department of Diagnostic and Therapeutic Radiology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Katsuji Inoue
- Department of Integrated Medicine and Informatics, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Jun Suzuki
- Department of Integrated Medicine and Informatics, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Akiyoshi Ogimoto
- Department of Integrated Medicine and Informatics, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Jun-ichi Funada
- Department of Cardiology, National Hospital Organization, Ehime National Hospital, Ehime, Japan
| | - Jitsuo Higaki
- Department of Integrated Medicine and Informatics, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Masao Miyagawa
- Department of Diagnostic and Therapeutic Radiology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Mani Vembar
- CT Clinical Science, Philips Healthcare, Cleveland, Ohio, United States of America
| | - Teruhito Mochizuki
- Department of Diagnostic and Therapeutic Radiology, Ehime University Graduate School of Medicine, Ehime, Japan
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4
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ACR Appropriateness Criteria® Chronic Chest Pain—High Probability of Coronary Artery Disease. J Am Coll Radiol 2011; 8:679-86. [DOI: 10.1016/j.jacr.2011.06.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 06/22/2011] [Indexed: 01/02/2023]
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5
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Eryonucu B, Bilge M, Güler N. Comparison of heart rate variability and treadmill exercise score in patients with stable coronary artery disease. Int J Angiol 2011. [DOI: 10.1007/bf01616980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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6
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Nakata T, Hashimoto A, Wakabayashi T, Kusuoka H, Nishimura T. Prediction of new-onset refractory congestive heart failure using gated myocardial perfusion SPECT imaging in patients with known or suspected coronary artery disease subanalysis of the J-ACCESS database. JACC Cardiovasc Imaging 2010; 2:1393-400. [PMID: 20083074 DOI: 10.1016/j.jcmg.2009.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Revised: 09/16/2009] [Accepted: 09/22/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the predictive value of perfusion/function parameters measured by gated myocardial perfusion single-photon emission computed tomography (SPECT)in combination with clinical variables in patients with known or suspected coronary artery disease to predict refractory heart failure (HF). BACKGROUND The increasing number of HF patients requires the establishment of a prophylactic strategy that can identify patients at high risk of HF due to coronary artery disease. METHODS We analyzed clinical and stress/rest-gated SPECT data from the multicenter, prospective, and observational J-ACCESS (Japanese Assessment of Cardiac Events and Survival Study by Quantitative Gated SPECT) database of 3,835 known or suspected coronary artery disease patients in which new-onset congestive HF symptoms requiring aggressive medical treatment were observed in 71 patients for 3 years. RESULTS The multivariable Cox hazard model revealed that chronic renal dysfunction (hazard ratio(HR): 6.227 [95% confidence interval (CI): 2.920 to 13.279]), the end-systolic volume index (ESVI) (HR:1.019 [95% CI: 1.011 to 1.029]), and moderate to high stress summed score (SSS) (HR: 3.012 [95% CI: 1.757 to 5.181]) independently (p < 0.0001) predicted HF. In addition to the close (p < 0.0001) correlation of ESVI and SSS with HF incidence, the combined tertiles of SSS and ESVI revealed high-risk patients with a maximally 17.3 times greater risk (5.2%/3 years) compared with the minimal risk (0.3%/3 years) at a normal to low SSS and lower ESVI. Chronic renal dysfunction combined with ESVI and SSS categories had the greatest (p < 0.005 to 0.001) incremental prognostic value with a global chi-square value (125.0)over single or other combined risks. CONCLUSIONS Chronic renal dysfunction, greater stress-induced perfusion abnormality, and higher ESVI provide independent and additive information for predicting the risk of refractory HF in known or suspected coronary patients, indicating the efficacy of perfusion/function parameters measured by stress gated perfusion SPECT for identifying patients at greater risk of future refractory HF.
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7
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Mudrick DW, Velazquez E, Borges-Neto S. Does Myocardial Perfusion Imaging Provide Incremental Prognostic Information to Left Ventricular Ejection Fraction? Curr Cardiol Rep 2010; 12:155-61. [DOI: 10.1007/s11886-010-0093-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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8
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Stress-induced ST-segment deviation in relation to the presence and severity of coronary artery disease in patients with normal myocardial perfusion imaging. Coron Artery Dis 2009; 20:41-9. [DOI: 10.1097/mca.0b013e32831a8828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Hashimoto A, Nakata T, Wakabayashi T, Kusuoka H, Nishimura T. Incremental Prognostic Value of Stress/Rest Gated Perfusion SPECT in Patients With Coronary Artery Disease Subanalysis of the J-ACCESS Study. Circ J 2009; 73:2288-93. [DOI: 10.1253/circj.cj-09-0212] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Tomoaki Nakata
- Sapporo Medical University School of Medicine
- Hokkaido Prefectural Esashi Hospital
| | | | | | - Tsunehiko Nishimura
- Graduate School of Medical Science, Kyoto Prefectural University of Medicine
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Petretta M, Costanzo P, Acampa W, Imbriaco M, Ferro A, Filardi PP, Cuocolo A. Noninvasive assessment of coronary anatomy and myocardial perfusion: going toward an integrated imaging approach. J Cardiovasc Med (Hagerstown) 2008; 9:977-86. [PMID: 18799959 DOI: 10.2459/jcm.0b013e328306f311] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Many noninvasive imaging techniques are available for the evaluation of patients with known or suspected chronic coronary artery disease. Among these, computed tomography-based techniques allow the quantification of coronary atherosclerotic calcium and noninvasive imaging of coronary arteries, whereas nuclear cardiology is the most widely used noninvasive approach for the assessment of myocardial perfusion. The available single-photon emission computed tomography flow agents are characterized by a cardiac uptake proportional to myocardial blood flow. In addition, different positron emission tomography tracers may be used for the quantitative measurement of myocardial blood flow and coronary flow reserve. Extensive research is currently being performed in the development of noninvasive coronary angiography and myocardial perfusion imaging using cardiac magnetic resonance. Finally, new multimodality imaging systems have been recently developed, bringing together anatomical and functional information. This review sought to provide a description of the relative merits of noninvasive imaging techniques in the assessment of coronary anatomy and myocardial perfusion in patients with known or suspected coronary artery disease.
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Affiliation(s)
- Mario Petretta
- Department of Clinical Medicine, Cardiovascular and Immunological Sciences, University Federico II, Italy
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Matsumoto N, Sato Y, Suzuki Y, Yoda S, Kunimasa T, Kato M, Tadehara F, Lewin HC, Hyun MC, Saito S. Usefulness of rapid low-dose/high-dose 1-day 99mTc-sestamibi ECG-gated myocardial perfusion single-photon emission computed tomography. Circ J 2007; 70:1585-9. [PMID: 17127804 DOI: 10.1253/circj.70.1585] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The clinical usefulness of a rapid rest low-dose/stress high-dose (dose ratio =1:5) (99m)Tc-sestamibi myocardial perfusion single-photon emission computed tomography (SPECT) protocol for the detection of coronary artery disease was evaluated. METHODS AND RESULTS In 89 patients, rest images were obtained immediately after the injection of (99m)Tc-sestamibi (256.1+/-28.4 MBq) followed by drinking water (400 ml). Exercise or vasodilator stress test was performed immediately after the completion of rest imaging with the injection of (99m)Tc-sestamibi (1312.3 +/-167.6 MBq). Prior to the post-stress imaging, patients were asked again to drink water (400 ml) in order to eliminate subdiaphragmatic tracer activity. The myocardial count ratio (stress/rest) of (99m)Tc-sestamibi was calculated. Image quality was scored using a 4-point scale system (4= excellent, 3= good, 2= poor, 1= unacceptable). Coronary angiography was performed in 56 patients within 1 month of the SPECT scan. All patients successfully performed the protocol and total examination time was 108+/-7 min. The myocardial count ratio of (99m)Tc-sestamibi was always greater than 6. The image quality was satisfactory both at rest (3.4+/-0.9) and after stress (3.9+/-0.2). The sensitivity and specificity to detect coronary artery stenosis >50% was 84% and 97%, respectively. CONCLUSIONS This rapid one-day (99m)Tc-sestamibi protocol provides adequate image quality and diagnostic accuracy for detecting coronary artery disease.
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Affiliation(s)
- Naoya Matsumoto
- Department of Cardiology, Nihon University School of Medicine, Tokyo, Japan
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12
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Williams KA, Schuster RA, Williams KA, Schneider CM, Pokharna HK. Correct spatial normalization of myocardial perfusion SPECT improves detection of multivessel coronary artery disease. J Nucl Cardiol 2003; 10:353-60. [PMID: 12900739 DOI: 10.1016/s1071-3581(03)00496-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND This study sought to improve the detection of multivessel coronary artery disease (CAD) with the use of rest and exercise single photon emission computed tomography (SPECT) perfusion scintigraphy by developing a processing scheme, which provides proper regional normalization of the images for interpretation. When SPECT perfusion images are interpreted, one area of myocardium serves as "normal." We hypothesized that if this "normal" region changes location from rest to stress, the stress images must be adjusted for proper interpretation. By taking into account the level of tracer activity in this "normal" area on the resting images, we could more accurately identify patients with multivessel CAD. Methods and results Dual-isotope rest (thallium 201) and exercise dobutamine or adenosine stress (technetium 99m sestamibi) perfusion SPECT studies were examined in 258 patients with 2- or 3-vessel CAD on coronary arteriography performed within 6 months of each other (mean interval, 19 days). If a shift in regional location of the "normal" segment from rest to stress was present, the images were (1) interpreted in the usual fashion for the number of vessels with ischemia (PRE-NORM) and (2) reinterpreted after quantitative normalization (ie, adjusting the display window until the intensity of the "normal" segment was matched at rest and stress [POST-NORM]). Interpretation was performed with blinding to arteriographic results. An angiographic stenosis was defined as luminal diameter stenosis greater than 50%. Three control groups comprising (1) single-vessel CAD (n = 119), (2) no significant angiographic CAD (n = 118), and (3) a normalcy group of low pre- and post-test probability of CAD (n = 44) were also studied to determine the incidence of false-positive results induced by the renormalization technique. A shift in the "normal" segment occurred in 81 studies of 258 patients (31%), 80 of which were read as abnormal PRE-NORM (sensitivity, 99%); however, for their 216 stenosed vessels, only 143 were detected PRE-NORM (vessel sensitivity, 66%; accuracy, 65%). The mean POST-NORM change in the display was 11%. POST-NORM, all 82 patients' studies were interpreted as abnormal (sensitivity, 100%), and 196 of 216 vascular territories were abnormal (vessel sensitivity, 91%; accuracy, 83%; both P <.0001 vs PRE-NORM). In the single-vessel disease, no significant disease, and normalcy groups, 19 of 119, 15 of 118, and 11 of 44 patients, respectively, demonstrated a shift in the peak pixel location. However, there were no significant changes in single-vessel sensitivity, angiographic specificity, or normalcy in these patients. CONCLUSIONS With multivessel CAD, the "normal" region on SPECT often changes in location from rest to stress, potentially masking the extent and severity of multivessel ischemia. Renormalization of the images to match their resting level before image interpretation allows diagnosis of contralateral ischemia and strikingly improves the detection of multivessel CAD, without a substantive loss in specificity.
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Affiliation(s)
- Kim A Williams
- Department of Medicine, University of Chicago, 5758 S. Maryland Avenue, MC9025, Chicago, IL 60637, USA
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Abstract
In recent years, the characteristics of patients who suffer acute myocardial infarction without complications during hospitalization have changed. In addition, the range of non-invasive studies available for evaluating left ventricular systolic function, residual myocardial ischemia, and myocardial viability in these patients has improved. Left ventricular systolic function and residual ischemia should be evaluated in all patients before release. The non-invasive technique used (exercise test, echocardiography, nuclear cardiology, magnetic resonance imaging) depends on availability, experience, and results at each institution. Coronary arteriography should be performed in patients with significant ischemia or severe left ventricular systolic dysfunction in non-invasive studies. In these cases coronary angiography must be performed to determine if coronary arteries are suitable for revascularization before performing a test of myocardial viability.
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Affiliation(s)
- Jaume Candell Riera
- Servei de Cardiologia. Hospital General Universitari Vall d'Hebron. Barcelona. España.
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Forrester JS, Liebson PR, Parrillo JE, Klein LW. Risk stratification post-myocardial infarction: is early coronary angiography the more effective strategy? Prog Cardiovasc Dis 2002; 45:49-66. [PMID: 12138414 DOI: 10.1053/pcad.2002.123464] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The primary management strategy for the post-myocardial infarction patient continues to be controversial despite published guidelines. In part, this is the consequence of study designs that are not directly applicable to individual patients, but also to the rapidly changing pharmacological and mechanical device armamentarium that rapidly renders clinical trial results obsolete within a few years. This review attempts to highlight those areas where there is consensus as well as to explicate those situations where common clinical practice appears to be in conflict with accepted guidelines.
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Affiliation(s)
- James S Forrester
- Rush Heart Institute, Rush-Presbyterian-St. Lukes Medical Center, Chicago, IL 06012, USA
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15
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Leitha T, Gwechenberger M, Pruckmayer M, Staudenherz A, Bailer H, Kronik G. Does motion analysis in postexercise gated sestamibi SPECT reflect rest left ventricular motion even in severe coronary artery disease? Clin Nucl Med 2001; 26:694-700. [PMID: 11452177 DOI: 10.1097/00003072-200108000-00007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Evidence has suggested that postexercise gated Tc-99m sestamibi SPECT (GSPECT) provides combined information about resting wall motion and exercise perfusion. No data have been published about possible differences in wall motion analysis between postexercise and resting GSPECT. METHODS Fifty patients underwent postexercise (symptom-limited bicycle stress) and rest GSPECT and cardiac catheterization with contrast ventriculography. In 35 patients, additional rest planar Tc-99m RBC radionuclide ventriculography (RNV) was performed. Four observers independently performed left ventricular ejection fraction (LVEF) calculations and visual analysis of regional wall motion (graded in four stages) for all studies. RESULTS The LVEF calculations in GSPECT revealed a statistically significant difference between postexercise (45.8 +/- 15.7%) and rest (48.0 +/- 16.1%; P < 0.05) determination. Postrest GSPECT LVEF showed a better correlation with LVEF determination performed with contrast ventriculography and RNV than did postexercise GSPECT LVEF. The reduced postexercise wall motion could be shown in segments with exercise-induced ischemia and in those with normal regional perfusion but not in segments with irreversibly abnormal perfusion. CONCLUSIONS Postexercise GSPECT provides reliable information regarding global wall motion even in severe coronary artery disease, but regional wall motion is underestimated compared with rest GSPECT, because of an imprecise surface detection algorithm in ischemic wall segments and possibly postexercise stunning in severe coronary artery disease.
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Affiliation(s)
- T Leitha
- University Clinic Nuclear Medicine, Vienna, Austria.
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Bestetti A, Di Leo C, Alessi A, Triulzi A, Tagliabue L, Tarolo GL. Post-stress end-systolic left ventricular dilation: a marker of endocardial post-ischemic stunning. Nucl Med Commun 2001; 22:685-93. [PMID: 11403181 DOI: 10.1097/00006231-200106000-00013] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Several studies have shown the accuracy of gated single photon emission computed tomography (SPECT) using thallium-201 and technetium tracers in the assessment of myocardial perfusion and function. Gated SPECT has been successfully utilized to detect post-stress left ventricular ejection fraction (LVEF) reduction resulting from post-ischemic stunning in patients with coronary obstruction. The aim of this study was to evaluate whether the post-stress LVEF impairment could be related to the post-stress end-systolic ventricular dilation resulting from post-ischemic endocardial stunning. Two hundred and eighty-two consecutive patients were studied by conventional diagnostic 2 day stress/rest gated SPECT following injection of 925 MBq of 99mTc-tetrofosmin using a dual-headed SPECT camera. One hundred and forty-seven of these patients (52%) showed reversible perfusion defects, 69 (24%) permanent defects and the remaining 66 (24%) had normal perfusion. One hundred and thirty-eight of these patients had a history of myocardial infarction (MI) and 19% underwent coronary angiography without an intervening cardiac event. Perfusion was analysed on ungated images using 20 segments scored on a five-point scale (0, normal; 4, no uptake), while wall thickening (WT) was assessed visually on stress/rest end-systolic images using a four-point score (0, normal; 3, absence of WT). LVEF and volumes were calculated using an automatic algorithm. The post-stress and rest ratios were determined for both end-diastolic (EDV) and end-systolic (ESV) volume. Normal values for all these parameters were obtained using data from 149 patients with a low likelihood (<5%) of coronary artery disease (CAD). In 50 of the 147 (34%) of patients with reversible perfusion defects, post-stress LVEF was >5% lower than rest values (stunned group), while the remaining 97 patients did not show a significant LVEF change (group 2A). The percentage of patients who developed exercise-induced angina, the percentage of patients who underwent coronary angiography and the segmental summed perfusion and WT scores were significantly higher in the stunned group compared with group 2A. Only ESV increased significantly post-stress, and this increase occurred only in stunned patients. Both EDV and ESV ratios were significantly higher in the stunned group compared with normal controls (P=0.008 and P<0.000001, respectively) and with the subgroup 2A (P=0.011 and P<10(-12), respectively). The ESV stress/rest ratio correlated significantly with the summed WT difference score by univariate analysis in stunned patients. It can be concluded that the post-stress ESV dilation, obtained by stress/rest gated SPECT, seems to be due to endocardial post-ischemic stunning. The stunned patients showed more severe clinical, angiographic, perfusion and function parameters.
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Affiliation(s)
- A Bestetti
- Cattedra di Medicina Nucleare, Università degli Studi di Milano c/o Ospedale S. Paolo-Milano, Italy.
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Candell-Riera J, Llevadot J, Santana C, Castell J, Aguadé S, Armadans L, Bermejo B, Oller G, García-del-Castillo H, Soler-Peter M, Soler-Soler J. Prognostic assessment of uncomplicated first myocardial infarction by exercise echocardiography and Tc-99m tetrofosmin gated SPECT. J Nucl Cardiol 2001; 8:122-8. [PMID: 11295688 DOI: 10.1067/mnc.2001.109928] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND We evaluate the prognostic value of stress echo and gated single photon emission computed tomography (SPECT) after a first uncomplicated acute myocardial infarction. METHODS AND RESULTS We used predischarge maximal subjective exercise echocardiography and gated SPECT with technetium 99m tetrofosmin to prospectively study 103 patients younger than 70 years with a first acute myocardial infarction. During a 12-month follow-up period, 2 patients died, 9 had heart failure, and 29 had ischemic complications (4 reinfarction and 25 angina). Predictive variables for heart failure in multivariate analysis were ejection fraction evaluated by echocardiography (odds ratio [OR] 8.5, P =.016) or by gated SPECT (OR 10.7, P =.009). Predictive variables for ischemic complications in multivariate analysis were less than 5 metabolic equivalents (METS) in exercise test (OR 5.2, P =.007) and greater than 15% ischemic extent in the polar map (OR 3.6, P =.04) of SPECT. CONCLUSIONS Exercise echocardiography and Tc-99m tetrofosmin gated SPECT were predictive for heart failure, but exercise SPECT was the only test with predictive power for ischemic complications.
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Affiliation(s)
- J Candell-Riera
- Hospital General Universitari Vall d'Hebron, Barcelona, Spain
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Berman DS, Hayes SW, Shaw LJ, Germano G. Recent advances in myocardial perfusion imaging. Curr Probl Cardiol 2001; 26:1-140. [PMID: 11252891 DOI: 10.1053/cd.2001.v26.112583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- D S Berman
- University of California-Los Angeles School of Medicine, Department of Nuclear Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Kymes SM, Bruns DE, Shaw LJ, Gillespie KN, Fletcher JW. Anatomy of a meta-analysis: a critical review of "exercise echocardiography or exercise SPECT imaging? A meta-analysis of diagnostic test performance". J Nucl Cardiol 2000; 7:599-615. [PMID: 11144475 DOI: 10.1067/mnc.2000.109027] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Accurate diagnosis of coronary heart disease has the potential to contribute substantially to cost-effective delivery of health services. Recent work by Fleischmann et al (JAMA 1998;280:913-20) represents an effort to summarize the accuracy of exercise echocardiography and exercise single photon emission computed tomography (SPECT). METHODS AND RESULTS A critique of the previous work was constructed, obtaining the 44 articles used. These articles were reviewed and summarized with established techniques for meta-analysis. The studies summarized by Fleischmann et al were found to be significantly heterogeneous (echocardiography and SPECT, both P<.001). In the SPECT cohort, combination of different radioisotopes and reading techniques, and inclusion of reports using experimental techniques, were sources of heterogeneity. In the echocardiography cohort, experimental techniques and an individual series were identified. When the sample was stratified for sources of heterogeneity, it was found that there was no significant difference in diagnostic accuracy between the echocardiography and SPECT techniques used in current clinical practice. Meta-regression with summary receiver operating characteristic curve techniques, after adjustment of the model for multicolinearity and outliers, revealed that there were no significant differences between SPECT as used in current clinical practice and echocardiography. CONCLUSION The report by Fleischmann et al contains serious flaws that limit its validity and generalizability.
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Affiliation(s)
- S M Kymes
- Saint Louis University School of Medicine, USA.
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Tausig A, Knesewitsch P, Brinkbäumer K, Tatsch K, Hahn K. Is a low-dose Tc-99m-MIBI protocol suitable for first-pass RNV? Nucl Med Commun 2000; 21:965-70. [PMID: 11130339 DOI: 10.1097/00006231-200010000-00012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Tc-99m-labelled radiopharmaceuticals, such as Tc-99m-sestamibi (Tc-99m-MIBI), offer the opportunity to measure myocardial perfusion and function with one injection only. The aim of this study was to evaluate whether first-pass (FP) radionuclide ventriculography (RNV) consecutively followed by myocardial perfusion single photon emission computed tomography (SPECT) may be performed according to a low-dose MIBI 1-day protocol using a multi-crystal gamma camera. Two hundred and seventy consecutive, predominantly obese [61% with a body mass index (BMI) of >25 kg x m(-2)] patients (169 male, 101 female), referred for myocardial perfusion SPECT with Tc-99m-MIBI [4 MBq x kg(-1) (>300 MBq) at stress; 9 MBq x kg(-1) (> 650 MBq) at rest], were studied with FP RNV prior to SPECT. Bicycle ergometry (29%), dobutamine (6%) or dipyridamole stress (65%) was performed. Adequate count (ct) statistics for FP RNV were defined as follows: (1) > 2000 cts within the background-corrected, end-diastolic (ED), left ventricular (LV) region of interest (ROI) of the representative cycle; and (2) >4 heart beats with > 1000 cts within the ED LV ROI (> 50% of maximal cts). A net mean dose of 318+/-64 MBq (4.3+/-1.1 MBq x kg(-1)) was injected during stress and 674+/-55 MBq (9.1+/-1.7 MBq x kg(-1)) during rest. There was no statistical difference among the three stress modalities concerning the net dose. Two hundred and fifty-six out of 270 (95%) stress and a basis for reliable all 270 (100%) rest FP RNV studies showed adequate count statistics as functional analysis. The 14 patients with insufficient count statistics were all obese and had received less than the planned dose. For the vast majority of patients, even a low-dose 1-day protocol with Tc-99m-MIBI is suitable for the assessment of FP RNV prior to SPECT. A minimum of 300 MBq and 4 MBq x (kg body weight)(-1) should be administered in order to obtain technically adequate results even in obese patients.
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Affiliation(s)
- A Tausig
- Department of Nuclear Medicine, University of Munich, Germany.
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21
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Lewin HC, Hachamovitch R, Harris AG, Williams C, Schmidt J, Harris M, Van Train K, Siligan G, Berman DS. Sustained reduction of exercise perfusion defect extent and severity with isosorbide mononitrate (Imdur) as demonstrated by means of technetium 99m sestamibi. J Nucl Cardiol 2000; 7:342-53. [PMID: 10958276 DOI: 10.1067/mnc.2000.106966] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The impact of long-acting nitrates on the extent and severity of stress-induced myocardial ischemia is not well described, especially after long-term treatment. METHODS Forty patients with chronic stable angina and reversible ischemia on an exercise stress myocardial perfusion single photon emission computed tomography (ex-SPECT) were prospectively studied in a 6-week period. At baseline, rest thallium-201/exercise stress technetium 99m sestamibi SPECT was performed, followed by treatment with extended-release isosorbide 5-mononitrate (5-ISMN, Imdur). Follow-up ex-SPECT was performed 5 days and 6 weeks after the initiation of therapy with extended-release 5-ISMN. The exercise treadmill testing (ETT) protocol and exercise duration of the follow-up studies were the same as that of the baseline ETT. Defect extent and severity were analyzed both by means of an automated quantitative method, with CEqual software, and visually, with a 20-segment scoring system (which was also used to derive a summed stress score [SSS]). RESULTS In the 6-week study period, significant reductions occurred in both the extent and the severity of exercise-induced ischemia by means of quantitative SPECT (13.8% [P<.0003] and 12.7% [P<.0003], respectively). There was no significant change in these variables between stages 2 (day 5) and 3 (6 weeks), indicating no development of tolerance to the nitrate effect. Similar reductions were noted by means of the visual analysis (SSS reduction of 13.0% [P<.002]) in the entire study period. CONCLUSIONS Patients with chronic-stable-angina treated with a long-acting nitrate demonstrate improvement in myocardial perfusion defect extent and severity in an extended period by means of both visual and quantitative analysis of sequential exercise testing to the same rate-pressure product end point.
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Affiliation(s)
- H C Lewin
- Department of Imaging, Cedars-Sinai Medical Center, The CSMC Burns and Allen Research Institute, University of California Los Angeles, USA
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Kang X, Berman DS, Lewin HC, Cohen I, Friedman JD, Germano G, Hachamovitch R, Shaw LJ. Incremental prognostic value of myocardial perfusion single photon emission computed tomography in patients with diabetes mellitus. Am Heart J 1999; 138:1025-32. [PMID: 10577431 DOI: 10.1016/s0002-8703(99)70066-9] [Citation(s) in RCA: 141] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous studies have shown that myocardial perfusion single photon emission computed tomography (SPECT) provides incremental prognostic information in the general population, but the prognostic efficacy of nuclear testing in patients with diabetes mellitus is unclear. METHODS We conducted a study with 1271 consecutively registered patients with diabetes and 5862 patients without diabetes with known or suspected coronary artery disease undergoing rest thallium 201/stress technetium 99m sestamibi dual-isotope myocardial perfusion SPECT with exercise or adenosine pharmacologic testing. Patients were followed up for at least 1 year. The successful follow-up rate was 92.4% for patients with diabetes and 94.0% for subjects without diabetes. The mean follow-up period was 23.7 +/- 7.7 months for the former group and 21.5 +/- 6.1 months for the latter. RESULTS Over the follow-up period, patients with diabetes had significantly higher rates of hard events (cardiac death or nonfatal myocardial infarction) (4.3% per year versus 2.3% per year, P <.001) and higher total event rates (hard events and late revascularization) (9.0% per year versus 5.3% per year, P <. 001) compared with rates among patients without diabetes. Cox proportional hazards analysis revealed that nuclear testing added incremental value over clinical and historical variables among patients with diabetes (global chi(2) increased 46% for the exercise group [n = 619] and 88% for the adenosine group [n = 461]; both P <. 001). The event rates rose significantly as a function of summed stress score and summed difference score among both patients with diabetes and patients without diabetes (P <.001). The patients with diabetes with normal scans had relatively low hard event rates (1% to 2% per year), those with mildly abnormal scans had intermediate hard event rates (3% to 4% per year), and those with moderately to severely abnormal scans had relatively high hard event rates (>7% per year). CONCLUSIONS The results of this study indicated that exercise and adenosine stress myocardial perfusion SPECT are valuable for risk stratification and management of patients with diabetes.
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Affiliation(s)
- X Kang
- Department of Imaging (Division of Nuclear Medicine), Artificial Intelligence in Medicine Program, Burns & Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Kelion AD, Banning AP, Ormerod OJ. Does exercise radionuclide angiography still have a role in clinical cardiac assessment? J Nucl Cardiol 1999; 6:540-6. [PMID: 10548150 DOI: 10.1016/s1071-3581(99)90027-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Quantitative imaging involves first, a set of measurements that characterize an image. There are several variations of technique, but the basic measurements that are used for single photon emission computed tomography (SPECT) perfusion images are reasonably standardized. Quantification currently provides only relative tracer activity within the myocardial regions defined by an individual SPECT acquisition. Absolute quantification is still a work in progress. Quantitative comparison of absolute changes in tracer uptake comparing a stress and rest study or preintervention and postintervention study would be useful and could be done, but most commercial systems do not maintain the data normalization that is necessary for this. Measurements of regional and global function are now possible with electrocardiography (ECG) gating, and this provides clinically useful adjunctive data. Techniques for measuring ventricular function are evolving and promise to provide clinically useful accuracy. The computer can classify images as normal or abnormal by comparison with a normal database. The criteria for this classification involve more than just checking the normal limits. The images should be analyzed to measure how far they deviate from normal, and this information can be used in conjunction with pretest likelihood to indicate the level of statistical certainty that an individual patient has a true positive or true negative test. The interface between the computer and the clinician interpreter is an important part of the process. Especially when both perfusion and function are being determined, the ability of the interpreter to correctly assimilate the data is essential to the use of the quantitative process. As we become more facile with performing and recording objective measurements, the significance of the measurements in terms of risk evaluation, viability assessment, and outcome should be continually enhanced.
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Affiliation(s)
- D D Watson
- Heart Center, Department of Radiology, University of Virginia Health Sciences Center, Charlottesville 22908, USA
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25
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Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM, Grunwald MA, Levy D, Lytle BW, O'Rourke RA, Schafer WP, Williams SV, Ritchie JL, Cheitlin MD, Eagle KA, Gardner TJ, Garson A, Russell RO, Ryan TJ, Smith SC. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). J Am Coll Cardiol 1999; 33:2092-197. [PMID: 10362225 DOI: 10.1016/s0735-1097(99)00150-3] [Citation(s) in RCA: 367] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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26
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Kang X, Berman DS, Lewin H, Miranda R, Erel J, Friedman JD, Amanullah AM. Comparative ability of myocardial perfusion single-photon emission computed tomography to detect coronary artery disease in patients with and without diabetes mellitus. Am Heart J 1999; 137:949-57. [PMID: 10220646 DOI: 10.1016/s0002-8703(99)70421-7] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Diabetics generally have more frequent and extensive silent myocardial ischemia than nondiabetics, increasing the importance of noninvasive detection of coronary artery disease (CAD) in this cohort. However, little is known regarding the diagnostic accuracy of myocardial perfusion single-photon emission computed tomography (SPECT) in patients with diabetes. This study was undertaken to compare the diagnostic value of rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion SPECT in patients with and without diabetes. METHODS Of the 203 patients with diabetes and 260 patients without diabetes who underwent dual-isotope myocardial perfusion SPECT with exercise or pharmacologic stress testing, 138 diabetics (12% type 1 diabetics) and 188 nondiabetics had coronary angiography within 6 months of the nuclear test, and 65 diabetics and 72 nondiabetics had a low likelihood (<10%, mean 6% +/- 3% and 6% +/- 3%) of CAD. RESULTS The angiographic data showed that patients with diabetes had less incidence of 1-vessel disease and a higher incidence of 3-vessel/left main artery disease than patients without diabetes (P <.05). The overall sensitivity and specificity, respectively, of SPECT for detecting CAD with the criterion of >/=50% diameter stenosis were 86% (95 of 111) and 56% (15 of 27) in diabetics, 86% (122 of 142) and 46% (21 of 46) in nondiabetics (P = not significant). With the criterion of >/=70% diameter stenosis the corresponding results were 90% (86 of 96) and 50% (21 of 42) in diabetics, and 91% (108 of 119) and 43% (30 of 69) in nondiabetics, respectively (P = not significant). The normalcy rate for low likelihood patients was 89% (58 of 65) in diabetics and 90% (65 of 72) in nondiabetics (P = not significant). The sensitivity and specificity for individual vessel detection were also similar in patients with and without diabetes (P = not significant) except for a lower sensitivity and a higher specificity for detecting left anterior descending coronary artery disease in the diabetic group (P <.05). CONCLUSION Dual-isotope myocardial perfusion SPECT has comparable accuracy for the diagnosis of CAD in diabetic and nondiabetic patients.
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Affiliation(s)
- X Kang
- Departments of Imaging (Division of Nuclear Medicine) and Medicine(Division of Cardiology), Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Massardo T, González P, Humeres P, Chamorro H, Ayala F, Yovanovich J, Avendaño P. Simultaneous assessment of function and perfusion during dipyridamole-handgrip Tc-99m sestamibi imaging in chronic coronary artery disease. Ann Nucl Med 1999; 13:121-5. [PMID: 10355958 DOI: 10.1007/bf03164889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The main goal of this work was to know the value of ventricular function in addition to perfusion Tc-99m sestamibi images in the assessment of coronary artery disease (CAD) when using dipyridamole (DIP) associated to isometric exercise. We analyzed 52 patients with suspected CAD; 40 of them had coronary lesions > or = 50% and 12 patients without CAD, conforming study and control groups, respectively. Twenty-eight patients had prior myocardial infarction. A two-day sestamibi protocol was employed with i.v. DIP-handgrip and rest injections, acquiring ECG-gated first pass and planar perfusion images. Sensitivity for perfusion images was 85% and specificity was 91.7%. There was no change between rest and DIP ejection fraction (EF) in controls. CAD patients presented a significant EF decrease with DIP (p: 0.0015). Patients with ischemia in perfusion images had larger EF decrease (p: 0.0001). For the analysis, an EF drop > or = 5% and any wall motion abnormality (WMA) were considered as having an abnormal response to DIP. CAD sensitivity improved significantly to 92.5% when adding EF drop and to 90% when adding WMA parameters, but specificity decreased to 75% with EF drop, and to 58.3% with WMA. In conclusion, first pass parameters from DIP-isometric exercise in addition to perfusion images are not a significant help in the assessment of CAD.
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Affiliation(s)
- T Massardo
- Nuclear Medicine Center, University of Chile Clinical Hospital, Santiago.
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Affiliation(s)
- G F Fletcher
- Division of Cardiovascular Diseases, Mayo Clinic Jacksonville, USA
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29
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Caner B, Beller GA. Are technetium-99m-labeled myocardial perfusion agents adequate for detection of myocardial viability? Clin Cardiol 1998; 21:235-42. [PMID: 9562932 PMCID: PMC6656293 DOI: 10.1002/clc.4960210402] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/1997] [Accepted: 10/21/1997] [Indexed: 11/07/2022] Open
Abstract
The noninvasive assessment of myocardial viability in patients with coronary artery disease and depressed left ventricular function has proven clinically useful for identifying those patients with ischemic cardiomyopathy who benefit most from coronary revascularization. Thallium-201 (201Tl) imaging at rest has been the radionuclide imaging technique most often utilized for distinguishing viable myocardium from scar. However, new technetium-99m (99mTc) perfusion agents such as 99mTc-sestamibi and 99mTc-tetrofosmin have emerged as alternatives to 201Tl for imaging of regional myocardial perfusion. Whether these new agents, which have better physical properties for imaging with a gamma camera than 201Tl, are valid for use in assessing myocardial viability is still uncertain. Recent clinical studies have demonstrated that these agents, when imaged using quantitative SPECT, can identify patients with myocardial hibernation who exhibit improved regional systolic function following revascularization. Experimental laboratory studies have shown that the uptake of 99mTc-sestamibi and 99mTc-tetrofosmin in ischemic myocardium is only slightly lower than the uptake of 201Tl. These 99mTc-labeled agents remain bound intracellularly in mitochondria of viable myocytes under conditions of myocardial stunning and short-term hibernation, producing severe myocardial asynergy. With respect to determination of viability, the inferior wall region is at times problematic since attenuation of 99mTc-sestamibi and 99mTc-tetrofosmin is greatest in this area. Demonstration of preserved systolic thickening on ECG-gated SPECT images is indicative of viability in the instance of decreased regional 99mTc counts due to attenuation and not scar. Administration of nitrates prior to tracer injection improves the sensitivity for identifying viable myocardial segments using rest imaging with 99mTc-sestamibi or 99mTc-tetrofosmin. Thus, it appears that the new 99mTc perfusion imaging agents can be successfully employed for the determination of myocardial viability in the setting of severe regional dysfunction and chronic coronary artery disease. The greater the myocardial uptake of these agents in the resting state, the greater the probability of improved systolic function after coronary revascularization.
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Affiliation(s)
- B Caner
- Department of Medicine, University of Virginia, Charlottesville 22908, USA
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30
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DePuey EG, Port S, Wackers FJ, Rozanski A, Botvinick EH, Dae MW, Tamaki N. Nonperfusion applications in nuclear cardiology: report of a task force of the American Society of Nuclear Cardiology. J Nucl Cardiol 1998; 5:218-31. [PMID: 9588675 DOI: 10.1016/s1071-3581(98)90206-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- E G DePuey
- St. Luke's-Roosevelt Hospital and Columbia University College of Physicians and Surgeons, New York, NY, USA
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31
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Amanullah AM, Berman DS, Hachamovitch R, Kiat H, Kang X, Friedman JD. Identification of severe or extensive coronary artery disease in women by adenosine technetium-99m sestamibi SPECT. Am J Cardiol 1997; 80:132-7. [PMID: 9230147 DOI: 10.1016/s0002-9149(97)00306-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
To assess the ability of adenosine technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography (SPECT) to identify high-risk women with severe or extensive coronary artery disease (CAD), we studied 130 consecutive women who underwent adenosine sestamibi myocardial perfusion SPECT and catheterization within 2 months. Severe (> or = 50% stenosis of left main coronary artery, > or = 90% stenosis in the proximal left anterior descending or in > or = 2 coronary arteries) or extensive (> or = 70% stenosis in 3 vessels) CAD was present in 54 patients, whereas 76 had no CAD or mild to moderate CAD. Semiquantitative visual SPECT analysis used 20 segments and a 5-point scoring system (0 = normal, 4 = absent uptake). Among the clinical, hemodynamic and nuclear variables analyzed, univariate predictors of severe or extensive CAD included a higher prescan likelihood of CAD, history of myocardial infarction, a higher heart rate at rest, a lower increase in heart rate during adenosine infusion, a higher summed stress score, summed reversibility score, and multivessel scan abnormality. Multivariate logistic analysis of the most predictive clinical (prescan likelihood of CAD), hemodynamic (increase in heart rate during adenosine infusion), and scan variables (summed stress score) revealed summed stress score (chi-square = 32; p <0.0001) and prescan likelihood of CAD (chi-square = 6.4; p <0.05) as the only independent predictors of severe or extensive CAD. Based on these logistic models, we determined the probability for the presence of severe or extensive CAD in patients with low, intermediate, and high prescan likelihood of CAD across the range of values of a summed stress score. This revealed that there were incremental increases in the probability for severe or extensive CAD both as a function of prescan likelihood of CAD and summed stress score. A severely abnormal scan (summed stress score > 8) during adenosine technetium-99m sestamibi myocardial perfusion SPECT had a high sensitivity of 91% and a moderately high specificity of 70% for identifying high-risk women with severe or extensive CAD. These results coupled with the previously defined prognostic significance of these findings suggest this test to be a useful diagnostic tool for the evaluation of CAD in women.
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Affiliation(s)
- A M Amanullah
- Department of Medicine, Cedars-Sinai Medical Center, the CSMC Burns & Allen Research Institute, and the University of California-Los Angeles School of Medicine, 90048, USA
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Amanullah AM, Berman DS, Kiat H, Friedman JD. Usefulness of hemodynamic changes during adenosine infusion in predicting the diagnostic accuracy of adenosine technetium-99m sestamibi single-photon emission computed tomography (SPECT). Am J Cardiol 1997; 79:1319-22. [PMID: 9165150 DOI: 10.1016/s0002-9149(97)00132-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Whether adenosine myocardial perfusion single-photon emission computed tomography (SPECT) remains accurate for detecting coronary artery disease (CAD) in the absence of peripheral hemodynamic changes is unknown. To assess the hemodynamic correlates of perfusion defects, we studied 222 consecutive patients (age 71 +/- 11 years) without prior myocardial infarction or revascularization who underwent adenosine technetium (Tc)-99m sestamibi myocardial perfusion SPECT and cardiac catheterization within 6 months of adenosine study. The SPECT protocol used separate acquisition of rest thallium-201 and adenosine Tc-99m sestamibi, which was semiquantitatively analyzed in 20 segments with a visual 5-point scoring system (0 = normal, 4 = absent uptake). The overall sensitivity, specificity, and predictive accuracy of adenosine Tc-99m sestamibi SPECT for detecting significant CAD were 93% (159 of 171), 73% (37 of 51), and 88% (196 of 222), respectively. The study population was grouped into 6 categories as a function of peripheral hemodynamic changes: (1) increase in heart rate by < or = 10 beats/min (n = 135); (2) increase in heart rate by > 10 beats/min (n = 87); (3) decrease in systolic blood pressure by < or = 10 mm Hg (n = 108); (4) decrease in systolic blood pressure by > 10 mm Hg (n = 114); (5) increase in heart rate by < or = 10 beats/min and decrease in systolic blood pressure by < or = 10 mm Hg (n = 72); and (6) increase in heart rate by > 10 beats/min or decrease in systolic blood pressure by > 10 mm Hg (n = 150). The sensitivity, specificity, and predictive accuracy of adenosine sestamibi SPECT were similar in all 6 categories. The prevalence of left main or multivessel CAD and extent of scan abnormality were also similar among all groups. Thus, the diagnostic accuracy of adenosine Tc-99m sestamibi SPECT is high in patients with or without peripheral hemodynamic evidence of adenosine effect.
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Affiliation(s)
- A M Amanullah
- Department of Medicine, Cedars-Sinai Medical Center, the CSMC Burns and Allen Research Institute, University of California--Los Angeles School of Medicine, 90048, USA
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Tamaki N, Tadamura E, Kudoh T, Hattori N, Inubushi M, Konishi J. Recent advances in nuclear cardiology in the study of coronary artery disease. Ann Nucl Med 1997; 11:55-66. [PMID: 9212883 DOI: 10.1007/bf03164811] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A variety of new radiopharmaceutical agents have been introduced to probe myocardial function in vivo. This review will introduce these new techniques which have recently been available in Japan. Tc-99m perfusion imaging agents provide excellent myocardial perfusion images which may enhance diagnostic accuracy in the study of coronary artery disease. In addition, greater photon flux from the tracer permits simultaneous assessment of regional perfusion and function with use of first-pass angiography or ECG-gated acquisition. Positron emission tomography enables metabolic assessment in vivo. Preserved FDG uptake indicates ischemic but viable myocardium which is likely to improve regional dysfunction after revascularization. In addition, FDG-PET seems to be valuable for selecting a high risk subgroup. Recently I-123 BMIPP, a branched fatty acid analog, has been clinically available in Japan. Less uptake of BMIPP than thallium is often observed in the ischemic myocardium. Such perfusion metabolic mismatch which seems to be similarly observed in FDG-PET is identified in the stunned or hibernating myocardium with regional dysfunction. Both of them are likely to recover afterwards. Severe ischemia is identified as reduced BMIPP uptake at rest, suggesting its role as an ischemic memory imaging. I-123 MIBG uptake in the myocardium reflects adrenergic neuronal function in vivo. In the study of coronary artery disease, neuronal denervation is often observed around the infarcted myocardium and post ischemic region as well. More importantly, reduced MIBG uptake in these patients can identify high risk for ventricular arrhythmias and assess severity of congestive heart failure. These new techniques will provide insights into new pathological states in the ischemic heart disease and enable to select optimal treatment in these patients.
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Affiliation(s)
- N Tamaki
- Department of Nuclear Medicine, Hokkaido University School of Medicine, Sapporo, Japan
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Crnac J, Schmidt MC, Theissen P, Sechtem U. Assessment of myocardial perfusion by magnetic resonance imaging. Herz 1997; 22:16-28. [PMID: 9088937 DOI: 10.1007/bf03044567] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Magnetic resonance imaging (MRI) has proven useful for anatomic and functional evaluation of the heart. However, until recently assessment of myocardial perfusion has not been possible by MRI. Using newly developed ultrafast imaging sequences, images can be acquired rapidly with a high temporal resolution, which is a prerequisite for imaging the initial passage of a bolus of MR-contrast medium through the myocardium. Only gadolinium chelates, which rapidly diffuse out of vascular space, are currently approved for clinical use. The first pass of a bolus of one of these agents through hypoperfused myocardium distal to a coronary artery stenosis enhances this area less as compared to normally perfused areas. This different myocardial enhancement is often visible when looking at the series of MR images. However, intensity differences are rapidly decreasing as MR-contrast media are diluted in the systemio circulation after the first pass and diffuse to the interstitium. Therefore, only the first pass is of interest for MR-perfusion imaging. Additional and often more precise information can be derived by measuring parameters of the signal intensity time curve such as mean transit time, maximum signal intensity increase, upslope, downslope, and delay before reaching maximum signal intensity. Temporal resolution is the crucial factor in MR-perfusion imaging because it takes only 20 to 60 seconds for the contrast medium to pass through the myocardium. Therefore, this dynamic process must be imaged with a high temporal resolution. Moreover, image acquisition must be fast enough to minimize motion artefacts and to maximize the spatial coverage of the ventricle. Ultrafast gradient echo techniques and echo planar imaging are in principle capable to fulfill these demands. While ultrafast gradient echo sequences enable one to acquire a maximum of 2 slices per heartbeat, echo planar sequences need only 30 to 50 msec to completely acquire one image and are thus able to image the entire ventricle within one heartbeat. However, they are also more susceptible to image artefacts. As gradients capable of producing high quality echo planar images are not widely available, ultrafast gradient echo techniques are commonly used for MR-perfusion imaging. A good correlation between quantitative estimates of myocardial perfusion by MRI after injection of an intravascular contrast agent and microsphere measurements has been shown in animal experiments but quantitative MR perfusion measurements have not yet been performed in humans. Clinical studies have until now focused on visual and parametric analysis of signal intensity time curves. From these studies, sensitivities and specifities in the range of 60 to 90% as compared to x-ray coronary angiography and scintigraphy were reported despite the fact that only parts of the left ventricular myocardium could be assessed. However, a generally accepted method of acquiring and analysing MR perfusion images does not yet exist. Therefore, future improvements of hardware and pulse-sequences as well as the development of new blood pool contrast agents are necessary before MR-perfusion imaging will become a widely accepted and clinically useful diagnostic procedure.
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Affiliation(s)
- J Crnac
- Klinik III für Innere Medizin, Universität zu Köln
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35
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Gunning MG, Underwood SR. Recent advances in myocardial perfusion scintigraphy. Clin Radiol 1996; 51:677-83. [PMID: 8893634 DOI: 10.1016/s0009-9260(96)80237-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Nallamouthu N, Araujo L, Russell J, Heo J, Iskandrian AE. Prognostic value of simultaneous perfusion and function assessment using technetium-99m sestamibi. Am J Cardiol 1996; 78:562-4. [PMID: 8806344 DOI: 10.1016/s0002-9149(96)00366-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This study examines the prognostic value of simultaneous perfusion and function assessment in 412 patients. The exercise perfusion pattern was a stronger predictor of events (mostly acute nonfatal myocardial infarcts) than resting ejection fraction.
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Verzijlbergen JF, Zwinderman AH, Ascoop CA, van der Wall EE, Niemeyer MG, Pauwels EK. Comparison of technetium-99m sestamibi left ventricular wall motion and perfusion studies with thallium-201 perfusion imaging: in search of the combination of variables with the highest accuracy in predicting coronary artery disease. EUROPEAN JOURNAL OF NUCLEAR MEDICINE 1996; 23:550-9. [PMID: 8698061 DOI: 10.1007/bf00833391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Measurements of myocardial perfusion and ventricular function are expected to provide additional information in the detection of coronary artery disease (CAD). The purpose of this study was threefold: (1) to determine to what extent technetium-99m sestamibi wall motion yields different information compared with 99mTc-sestamibi and thallium-201 perfusion; (2) to test which information unique to either study is of value in diagnosing CAD; and (3) to assess the combination of variables with the highest diagnostic accuracy. Perfusion and wall motion scores (at rest and during exercise) obtained from visual and quantitative planar 201Tl and 99mTc-sestamibi scintigraphy of 60 patients with suspected CAD were compared with the angiographic results by means of a polytomous logistic regression model and the diagnostic values were compared with one another. All univariate variables were significantly related to the probability of CAD and its extent. Comparative studies revealed a large degree of correlation between 201Tl stress and redistribution variables. The rest 99mTc-sestamibi and wall motion studies contained partially different information. Stepwise logistic regression analysis showed the strongest diagnostic power for the combination of 201Tl visual analysis of the stress images with quantitative redistribution images (sensitivity 93%, specificity 71%). The diagnostic power was similar for all combinations of visual and quantitative analyses of the exercise and redistribution images. The strongest diagnostic power of the 99mTc-sestamibi variables was the score of the diastolic stress image (sensitivity 91%, specificity 79%). Comparable sensitivity and specificity estimates were found when both optimal models were compared. Wall motion studies did not have additional diagnostic power. Although 99mTc-sestamibi wall motion studies, both at rest and during exercise, provide information in addition to the 99mTc-sestamibi or 201Tl myocardial perfusion variables, the information does not enhance the diagnostic power with regard to the prediction of CAD.
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Affiliation(s)
- J F Verzijlbergen
- Department of Nuclear Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
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Hachamovitch R, Berman DS, Kiat H, Cohen I, Cabico JA, Friedman J, Diamond GA. Exercise myocardial perfusion SPECT in patients without known coronary artery disease: incremental prognostic value and use in risk stratification. Circulation 1996; 93:905-14. [PMID: 8598081 DOI: 10.1161/01.cir.93.5.905] [Citation(s) in RCA: 570] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND We evaluated the incremental prognostic value, the role in risk stratification, and the impact on patient management of myocardial perfusion single-photon emission computed tomography (SPECT) in a population of patients without prior myocardial infarction, catheterization, or revascularization. METHODS AND RESULTS We examined 2200 consecutive patients who at the time of their dual-isotope SPECT had not undergone catheterization, coronary artery bypass surgery, or percutaneous transluminal coronary angioplasty and had no known history of previous myocardial infarction. Follow-up was performed at a mean of 566 +/- 142 days (97% complete) for hard events (cardiac death and myocardial infarction) and for referral to cardiac catheterization or revascularization within 60 days after nuclear testing. Examination of clinical, exercise, and nuclear models by use of pre-exercise tolerance test (ETT), post-ETT, and nuclear information using a stepwise Cox proportional hazards model and receiver-operating characteristic curve analysis revealed that nuclear testing added incremental prognostic value after inclusion of the most predictive clinical and exercise variables (global chi2 = 12 for clinical variables; 31 for clinical + exercise variables; 169 for nuclear variables; gain in chi2, P < .0001 for all; receiver-operating characteristic areas: 0.66 +/- 0.04 for clinical, 0.73 +/- 0.04 for clinical + exercise variables, 0.87 +/- 0.03 for nuclear variables, P = .03 for gain in area with exercise variables; P < .001 for increase with nuclear variables). Multiple logistic regression analysis revealed that scan information contributed 95% of the information regarding referral to catheterization with further additional information provided by presenting symptoms and exercise-induced ischemia. Referral rates to early catheterization and revascularization paralleled the hard event rates in all scan categories - very low referral rates in patients with normal scans and significant increases in referral rates as a function of worsening scan results. Even after stratification by clinical and exercise variables such as the Duke treadmill score, pre- and post-ETT likelihood of coronary artery disease, presenting symptoms, sex, and age, the nuclear scan results further risk-stratified the patient subgroups, thus demonstrating clinical incremental value. CONCLUSIONS In a patient population with no evidence of previous coronary artery disease at overall low risk (1.8% hard event rate), myocardial perfusion SPECT adds incremental prognostic information and risk-stratifies patients even after clinical and exercise information is known. It appears that referring physicians use this test in an appropriate manner in selecting patients to be referred to catheterization or revascularization.
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Affiliation(s)
- R Hachamovitch
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA
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