Clinical significance of reverse redistribution on thallium-201 single-photon emission computed tomography in patients with acute myocardial infarction

A reverse perfusion pattern during Technetium-99m stress myocardial perfusion imaging does not predict flow limiting coronary artery disease

BACKGROUND

A reverse redistribution pattern during myocardial perfusion imaging is most widely described using thallium (Tl-201), when stress images exhibit greater perfusion than rest. Technetium (Tc-99 m) radiopharmaceuticals may also yield a reverse perfusion (RP) pattern, but its significance is uncertain. This study tested the hypothesis that RP correlates with the presence and location of flow limiting coronary stenosis(es).

METHOD

We reviewed 842 consecutive Tc-99 m tetrofosmin SPECT stress studies performed at a cardiothoracic centre over a 15 month period. 69 (8.2%) demonstrated RP. Thirty-three patients (age 32-79 mean 56, 17 female) had undergone cardiac catheterisation within 12 months of the scan. Correlation was sought between the presence and location of angiographic stenoses and RP pattern.

RESULTS

10/33 (30.3%) had significant (>60%) coronary stenosis(es); 5 single-vessel, 2 two-vessel and 3 three-vessel disease (3VD). Stenosis location correlated poorly with the RP territory (LAD/Anterior 5/17, RCA/Inferior 1/10, Cx/lateral 0/4 (p = 0.57)). Of the 6 patients with a lesion in the RP territory, 3 had 3VD; 2 of these had a simultaneous reversible defect. All 5 patients with previous myocardial infarction had a simultaneous fixed defect. However only 3/12 with co-existent reversible defects had significant disease.

CONCLUSION

The reverse perfusion pattern is a poor predictor of flow limiting coronary disease, and does not correlate with stenosis location in those with significant lesions. Such patients should not undergo invasive investigation purely on the basis of this result.

Clinical significance of reverse redistribution on resting thallium-201 imaging in patients with vasospastic angina

To evaluate the clinical significance of reverse redistribution (RR) of resting 201Tl single photon emission computed tomography (SPECT) in patients with vasospastic angina (VSA), we performed left ventriculography, coronary angiography and resting 201Tl-SPECT in 22 patients with VSA. Left ventriculography showed abnormal wall motion in 17 of 22 patients (77%) and 37 of 154 segments. Thirty-one of these 37 segments (84%) were within the area perfused by coronary arteries showing acetylcholine-induced vasospasm. On 201Tl images, abnormal findings were observed in 11 of 22 patients (50%), and among them, 7 patients (32%) had RR. Seven of 37 segments (19%) having abnormal regional wall motion had RR of 201TI, and in 6 of these 7 segments (86%), accumulation of 123I-BMIPP was found to be reduced. We conclude that repetitive brief myocardial ischemia may cause myocardial injuries in patients with VSA, and that the presence of RR of 201Tl indicates the presence of myocardial injury in these patients.

Effects of metabolically ischemic, but viable, myocardium on QT dispersion in patients with acute myocardial infarction: a study with resting I-123-BMIPP/thallium-201 myocardial single-photon emission computed tomography

In chronic Q-wave myocardial infarction, QT dispersion is closely correlated with infarct size, but this correlation has not been evaluated for acute myocardial infarction (AMI). The effects of abnormal fatty acid metabolism on QT dispersion were examined in 123 patients with AMI who underwent resting iodine-123-15-iodophenyl 3-methyl pentadecanoic acid (BMIPP)/thallium-201(201Tl) myocardial single photon emission computed tomography (SPECT) and electrocardiographic analysis in the subacute phase. The relationship between BMIPP and 201Tl was defined as match when the total defect score for BMIPP was equal to or smaller than that for 201Tl, and as mismatch when the total defect score for BMIPP was larger than that for 201Tl. Twenty-six patients (21%) demonstrated BMIPP-201Tl match and 97 (79%) demonstrated mismatch. Infarct size was closely correlated with QT dispersion (r=0.67, p<0.001) in patients with BMIPP-201Tl match, but weakly correlated (r=0.30, p<0.005) in patients with BMIPP-201Tl mismatch. For small infarctions, QT dispersion was significantly larger in patients with BMIPP-201Tl mismatch than in those with BMIPP-201Tl match (62+/-24 ms vs 41+/-18 ms, p=0.03), but did not differ between the 2 groups for large infarctions. This study shows that QT dispersion is influenced by infarct size and by the presence of metabolically ischemic but viable myocardium in patients with AMI.

Reverse redistribution of thallium-201 myocardial single photon emission tomography and contractile reserve

The present study investigated the contractile reserve of myocardium exhibiting reverse redistribution (RRD) of thallium-201 (201Tl) after acute myocardial infarction. Forty patients experiencing their first acute myocardial infarction underwent resting 201Tl single-photon emission computed tomography (SPECT) and low-dose (5-10 microgxkg(-1)xmin(-1)) dobutamine stress echocardiography (DSE) within 4 weeks after the onset of infarction. The left ventricle was divided into 13 segments for analysis. The severity of defects in 201Tl SPECT and the extent of wall motion abnormality in DSE were visually assessed and scored. The sum of each defect score and wall motion score of infarct-related segments were defined as total defect score (TDS) and total wall motion score (TWM), respectively. Quantitative analysis of 201Tl uptake was also performed. Resting 201Tl SPECT revealed RRD in 16 patients (group RRD), fixed defect (FIX) in 23 patients (group FIX), and redistribution in one. There was a significant difference in improvement of TWM between rest and stress in TWM in both the RRD and FIX groups (p<0.0001, each case). The improvement of TWM with dobutamine was significantly greater in RRD than in FIX (1.6+/-1.0 vs 0.6+/-0.7, p=0.001). There was a positive correlation between the magnitude of RRD and improvement of TWM with dobutamine (r=0.48, p=0.002). Myocardium exhibiting RRD on 201Tl SPECT in patients with acute myocardial infarction has greater contractile reserve than that exhibiting a fixed defect.

Reverse redistribution: fact or fiction?

It has been well documented that it is not uncommon for a thallium-201 perfusion defect to develop or become more evident on delayed exercise thallium scintigraphic imaging, as compared with the initial image immediately following stress. The pathophysiology and clinical significance of the phenomenon are currently unclear. Literature on this subject is reviewed, and it is concluded that reverse redistribution of 201Tl in the post-myocardial infarction patient is indeed a "fact". In this context it represents a low-risk condition and may imply successful thrombolysis, patent infarct-related coronary artery, improved wall motion at the infarct site and retained myocardial viability in that segment.