Myocardial viability: methods of assessment and clinical relevance

Myocardial hibernation is hypoperfused dysfunctional myocardium that has the potential to recover function after coronary revascularization. Although recovery of regional function after revascularization is the gold standard for assessing the diagnostic accuracy of various techniques, improvements of EF, symptoms, and survival are fundamental end points. Despite important differences in the markers of viability by positron-emission tomography, single-photon emission tomography, two-dimensional echocardiography, and magnetic resonance imaging, their positive and negative predictive values in nonrandomized studies are fairly comparable. Assessment of myocardial viability may be clinically important in many patients but especially in those with EF < 30% and congestive heart failure. The degree of improvement in EF after coronary revascularization depends on the extent of hibernation, the suitability of coronary structure for revascularization, the lack of perioperative infarction, the completeness of revascularization, and the long-term patency of grafts.

Dynamic planar myocardial perfusion imaging in patients with one-vessel disease with intracoronary injection of technetium 99m teboroxime during papaverine-induced coronary hyperemia

This study examined the imaging results and kinetics of technetium 99m teboroxime after its intracoronary injection during papaverine-induced coronary hyperemia in patients with one-vessel disease before and after coronary angioplasty. Thirteen patients with > or = 90% diameter stenosis of either the left anterior descending or the left circumflex coronary artery were included. Two patients were excluded because of ventricular tachycardia during papaverine injection in one patient and unsuccessful angioplasty in the second patient. One mCi of technetium 99m teboroxime was injected into the left main coronary artery during coronary hyperemia induced by intracoronary injection of papaverine. Dynamic acquisition in a frame mode (20 sec/frame) was performed for 5 minutes in the left anterior oblique projection with a multicrystal gamma camera before and after successful angioplasty. Ischemic:normal count ratio increased from 0.75 +/- 0.4 before to 1.00 +/- 0.50 after angioplasty (p < 0.1). The T 1/2 of teboroxime was 6.5 +/- 1.5 min in the normal zone and 7.2 +/- 1.9 min in the ischemic zone (p, NS). Perfusion defects were visible in the territory of the stenosed coronary artery in 9 of 11 patients before angioplasty and in 7 of 11 patients after angioplasty. The image quality was excellent in all studies. Thus this study shows that performing dynamic imaging with intracoronary injection of technetium 99m teboroxime is feasible. This technique may be useful to study the impact of angioplasty on coronary flow and tracer kinetics.

Comparison of left ventricular performance in healthy young women and men during exercise

BACKGROUND

Previous studies show sex-related differences in left ventricular (LV) response to exercise. It is not clear, however, whether these differences are also seen in younger healthy subjects.

METHODS AND RESULTS

This study examined the changes in LV performance during dynamic upright exercise in 11 healthy men and 19 healthy young women according to the Bruce protocol and an individualized ramp protocol. There were no significant differences between the two protocols for either men or women in heart rate, blood pressure, LV ejection fraction (EF) (measured by ambulatory nuclear detector), and measured oxygen consumption. The peak oxygen consumption was higher in men than in women (44 +/- 13 vs 36 +/- 9 ml/kg/min; p < 0.05), but the peak heart rate, systolic blood pressure, and EF were similar. The change in EF (from rest to exercise) was 19% +/- 8% in men and 19% +/- 11% in women with the Bruce protocol (difference not significant) and 26% +/- 9% in men and 19% +/- 6% in women with the ramp protocol (difference not significant). At peak exercise, both men and women showed an increase in end-diastolic volume (29% +/- 14% vs 23% +/- 11%; difference not significant) and a decrease in end-systolic volume (41% +/- 15% vs 43% +/- 21%) (difference not significant). The increase in cardiac output during exercise was due to an increase in heart rate and stroke volume in both men and women. At submaximal exercise, however, the decrease in end-systolic volume was less in women than in men (p < 0.05).

CONCLUSIONS

There are no sex-related differences in compensatory mechanism during dynamic exercise in healthy subjects. The changes in contractility and LV volume are not affected by the exercise protocol.

Prognostic value of simultaneous perfusion and function assessment using technetium-99m sestamibi

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.

Early postoperative rise in defibrillation threshold in patients with nonthoracotomy defibrillation lead systems: attenuation with biphasic shock waveforms

INTRODUCTION

In patients with non-thoracotomy defibrillation lead (NTL) systems coupled with monophasic shock waveforms, the defibrillation threshold (DFT) rises early after implantation. There is little information regarding features predictive of the DFT rise, or DFT changes early after implantation of NTL systems coupled with biphasic shock waveforms.

METHODS AND RESULTS

DFT measurements were performed serially at implantation, prior to hospital discharge (mean 4 +/- 3 days), and at follow-up (mean 49 +/- 22 days) in 146 patients with an NTL system. Factors were assessed for association with a "clinically important" early postimplantation DFT rise, defined as a rise of > or = 2 energy steps (2 to 4 J per step; > or = 5 J total). A clinically important early postimplantation DFT rise occurred in 48 patients (33%). Univariate predictors of the rise included the monophasic shock waveform, the Medtronic Transvene lead system, the presence of a subcutaneous defibrillation patch, and the number of shocks delivered during the implantation procedure. However, the only independent predictor of a clinically important DFT rise was the monophasic shock waveform (F = 18, P < 0.001). For the monophasic patient group (n = 79), the incidence of a DFT rise was 53% (n = 42). For the biphasic patient group (n = 67), the incidence of a DFT rise was 9% (n = 6). The clinical characteristics of the monophasic and biphasic groups were not significantly different, nor were their DFTs at implantation. Among a subgroup of 18 consecutive patients who underwent serial DFT testing utilizing both monophasic and biphasic waveforms, the incidence of a clinically important DFT rise with monophasic (n = 9,50%) was higher than with biphasic shocks (n = 3,17%; P = 0.05).

CONCLUSION

NTL systems coupled with biphasic shock waveforms have an attenuated incidence of a clinically important DFT rise early after implantation, relative to patients with NTL systems coupled to monophasic waveforms.

Prognostic value of tomographic rest-redistribution thallium 201 imaging in medically treated patients with coronary artery disease and left ventricular dysfunction

BACKGROUND

Previous studies show that rest-redistribution thallium imaging is useful in the assessment of myocardial viability. The impact of such studies on patient outcome is not well defined. This study examined the prognostic value of tomographic rest-redistribution 201T1 imaging in 81 medically treated patients with coronary artery disease and left ventricular dysfunction.

METHODS AND RESULTS

Rest-redistribution single-photon emission computed tomographic images were obtained and analyzed quantitatively. The segmental thallium uptake (20 segments per patient) was interpreted as normal, reversible defect, mild to moderate fixed defect, or severe fixed defect. The thallium images were abnormal in 80 patients, with no redistribution (no ischemia) in 43 patients and redistribution (ischemia) in 38 patients. The left ventricular ejection fraction was 27% +/- 8% in patients with no redistribution and 26% +/- 7% in patients with redistribution (difference not significant). In patients with no ischemia, there were 7 +/- 5 severe fixed defects and 5 +/- 4 mild to moderate fixed defects per patient. In patients with ischemia there were 7 +/- 4 reversible defects, 3 +/- 3 mild to moderate fixed defects, and 5 +/- 4 severe fixed defects per patient. The number of any abnormal segments was 11 +/- 5 in patients with no ischemia and 14 +/- 4 in patients with ischemia (p = 0.03). During a mean follow-up of 31 +/- 24 months, there were 11 cardiac deaths in patients with no ischemia (26%) and 22 in patients with ischemia (58%); the survival rate was worse in patients with than without ischemia (p < 0.05). Multivariate Cox survival analysis on important clinical, angiographic, and thallium variables showed that the presence of redistribution was an independent predictor of death (x2 = 5; p = 0.03).

CONCLUSIONS

Patients with left ventricular dysfunction and redistribution on rest thallium imaging, a marker of hibernating myocardium, have a higher mortality rate with medical therapy than do patients with a comparable degree of left ventricular dysfunction but with fixed defects only. Thus observations similar to those made with positron emission tomography can be made in a much more straightforward, simple, and probably cost-effective manner with single-photon emission computed tomography.

Prediction of improvement in left ventricular function with iodine-123-IPPA after coronary revascularization

Iodine-123-phenylpentadecanoic acid (IPPA) is a synthetic fatty acid suitable for myocardial imaging. This study is the result of a Phase I/II trial to evaluate IPPA's ability to predict functional recovery in patients undergoing coronary revascularization.

METHODS

Twenty-three patients with documented coronary disease underwent sequential SPECT imaging with IPPA before and radionuclide ventriculography both before and 8 wk after revascularization. Software was developed to evaluate myocardial IPPA metabolism and to determine the fraction of the left ventricle with intermediate metabolism.

RESULTS

There was a significant correlation between initial IPPA uptake and final LVEF. The fractional area of the left ventricle demonstrating IPPA metabolism in the intermediate metabolic range was significantly higher in patients who demonstrated a 5% or greater increase in EF after revascularization (0.90 +/- 0.08 versus 0.78 +/- 0.17, p = 0.04). When only the patients who received complete revascularization were evaluated, there was a more significant difference (improved 0.92 +/- 0.05 versus 0.74 +/- 0.17, p = 0.011). Taking a lower limit of 1 s.d. from the mean, (87%) the six patients who had > or = 5% increase in LVEF after revascularization had more than 87% of the left ventricle in the intermediate metabolic range, whereas seven of ten patients whose change in LVEF was < 5% had less than 87% in the intermediate metabolic range (p = 0.011).

CONCLUSION

In this initial experience, the amount of myocardium in the intermediate metabolic range is associated with improvement in LVEF after revascularization, especially in patients receiving complete revascularization.

Use of a tantalum-178 generator and a multiwire gamma camera to study the effect of the Mueller maneuver on left ventricular performance: comparison to hemodynamics and single photon emission computed tomography perfusion patterns

During the Mueller maneuver, there is a decrease in intrathoracic pressure and an increase in transmural left ventricular pressure. The changes in loading conditions cause transient left ventricular dysfunction. This study examined the effects of the Mueller maneuver on left ventricular performance using tantalum (Ta)-178 (half-life 9.3 min) and a multiwire gamma camera. First-pass radionuclide angiograms were obtained at baseline and during Mueller maneuver in 41 patients aged 58 +/- 10 years. In 34 patients, stress single photon emission computed tomography (SPECT) myocardial perfusion imaging with thallium-201 or sestamibi was also performed. Hemodynamic measurements during the Mueller maneuver (n = 10) showed a decrease in systemic pressure (139 +/- 25 mm Hg vs 123 +/- 24 mm Hg, p < 0.001) and pulmonary artery pressure (24 +/- 6 mm Hg vs 14 +/- 12 mm Hg, p = 0.01) and an increase in heart rate (67 +/- 10 bpm vs 75 +/- 14 beats/min, p = 0.001). Among the 34 patients who had perfusion imaging, the left ventricular ejection fraction remained unchanged or increased in 17 patients (group 1) (48% +/- 19% vs 49% +/- 21%, p not significant) and decreased (> or = 5%) in 17 patients (group 2) (55% +/- 13% vs 40% +/- 16%, p = 0.001). The stress SPECT images showed no or only fixed defects in 11 (65%) patients in group 1 and 3 (18%) patients in group 2 (p = 0.02), and reversible defects in 6 (35%) patients in group 1 and 14 (82%) patients in group 2 (p = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Implications of increased lung thallium uptake during exercise single photon emission computed tomography imaging

Increased lung thallium uptake during exercise is an important marker of patients who are at high risk and have CAD; however, most previous studies were done with planar imaging, and therefore it is unclear whether this conclusion is also true with SPECT imaging. This study examined the lung thallium uptake during exercise SPECT imaging in 1031 patients who also underwent coronary angiography. The lung thallium uptake was increased in 309 patients (group 1) and normal in 722 patients (group 2). Compared with patients in group 2, those in group 1 had more ST segment depression (44% vs 28%, p = 0.01), previous Q-wave myocardial infarction (28% vs 17%, p = 0.0001), larger perfusion defects (24% +/- 11% vs 10% +/- 11%, p = 0.0001), and multivessel CAD by angiography (75% vs 47%, p = 0.0001). Multivariate discriminant analysis identified left ventricular dilation, reversible defects, the size of perfusion abnormality, and the extent of CAD as independent predictors of increased lung thallium uptake. Increased lung thallium uptake was more common in men than women regardless of the extent of CAD: 26% versus 11% in patients with one-vessel, 38% versus 18% in patients with two-vessel, and 51% versus 31% in patients with three-vessel disease (p < 0.001 each). Thus increased lung thallium uptake by SPECT identifies patients with more severe anatomic and functional evidence of CAD. The sex-related difference suggests the need for a sex-specific normal file for quantitative analysis.

Spectroscopic analysis of Tm(3+) in PbO-Bi(2)O(3)-Ga(2)O(3) glass

Tm(3+)-doped heavy metal oxide glasses in the PbO-Bi(2)O(3)-Ga(2)O(3) system were prepared, and their emission characteristics were examined. Three emission bands at the infrared wavelength region were observed, at 1.46, 1.79, and 2.36 µm, which are associated with the (3)H(4) ? (3)F(4), (3)F(4) ? (3)H(6), and (3)H(4) ? (3)H(5), transitions, respectively. Measured fluorescence lifetimes for the first two transitions were 0.160 and 1.035 ms, respectively. Oscillator strengths and intensity parameters suggest that the ionicity of Tm-Obonds in the glass is higher when compared with those in other oxide glass hosts. Higher radiative transition probabilities of the three infrared emissions than those calculated for other glasses appear to provide potentials for future laser applications.

Results of adenosine single photon emission computed tomography thallium-201 imaging in hemodynamic nonresponders

Systolic blood pressure typically decreases during adenosine infusion because of stimulation of A2b receptors, resulting in systemic vasodilation. This study examined the results of adenosine single photon emission computed tomography (SPECT) thallium-201 imaging in patients who did not show such a decrease in blood pressure during peak adenosine effect (nonresponders). The 102 nonresponders and 341 responders had no significant differences in age, gender, history of diabetes mellitus, hypertension, or previous myocardial infarction. The extent of coronary artery disease (CAD) by angiography was also similar. The sensitivity of SPECT thallium-201 imaging in patients with one-vessel disease was 82% in nonresponders and 84% in responders (p value not significant [NS]); in patients with multivessel disease, it was 90% in nonresponders and 94% in responders (p = NS) and for all CAD, it was 87% in non-responders and 91% in responders (p = NS). Thus lack of hemodynamic systemic response during adenosine infusion does not affect sensitivity for detecting CAD.

Impact on exercise single-photon emission computed tomographic thallium imaging on patient management and outcome

BACKGROUND

Stress perfusion imaging is useful in risk stratification of patients with known or suspected coronary artery disease. In the current era of managed health care, there is a need to provide data on patient outcome.

METHODS AND RESULTS

This study examined the impact of exercise single-photon emission computed tomographic (SPECT) thallium imaging on patient management (the subsequent need for coronary angiography and revascularization) and outcome (the occurrence of hard cardiac events defined as cardiac death or nonfatal acute myocardial infarction) in 2700 patients who were being evaluated for diagnostic purposes. None of the patients had previous coronary angiography, coronary revascularization, or Q-wave myocardial infarction. The SPECT images were normal in 2027 patients (group 1) and abnormal in 673 patients (group 2). Within 6 months after thallium imaging 53 patients in group 1 (3%) and 242 patients in group 2 (36%) underwent coronary angiography (p = 0.0001). The patients who underwent coronary angiography had higher pretest probability of coronary disease (group 1) or more perfusion defects (group 2) than patients who did not (p = 0.0001 each). Coronary revascularization within 3 months of coronary angiography was performed in 1 of the 53 patients (2%) in group 1 and in 87 of 242 patients (30%) in group 2 (p = 0.0001). Among the remaining patients who had coronary angiography but were medically treated there were no hard cardiac events in group 1 but there were 15 events in group 2 (p = 0.02).

CONCLUSIONS

The results of exercise SPECT thallium imaging are important in patient management and outcome. Coronary angiography, coronary revascularization and events are rare in patients with normal exercise SPECT thallium images.

Circadian variation of ventricular arrhythmia recurrences after cardioverter-defibrillator implantation in patients with healed myocardial infarcts

Past studies using Holter monitoring and retrospective reviews of death certificates have documented peak occurrence of sudden death and nonsustained ventricular tachycardia (VT) in the morning hours. We used the Ventritex Cadence device (Ventritex, Sunnyvale, California) which documents the date and time of all stored arrhythmias leading to device therapy to evaluate the circadian pattern of sustained ventricular arrhythmia recurrence. Mean follow-up after defibrillator implantation was 628 +/- 285 days. All 390 patients had at least 1 episode (range 1 to 43) of sustained VT documented from analysis of the stored electrograms associated with an arrhythmia event. Stored electrograms were available for review and analysis in 3,041 device detections; 349 stored events were excluded because they did not fulfill the diagnostic criteria for VT or failed to document the onset of the ventricular arrhythmia at the beginning of the recorded event of the arrhythmia episode. Criteria for the diagnosis of VT or ventricular fibrillation were met in 2,692 arrhythmia episodes occurring in 390 patients. There was circadian variation for ventricular arrhythmia recurrence for the whole patient group with the data fit to the sinusoidal density function: f(t) = 126 - 51 x cos (-57 + 2 pi t/24) - 25 x sin (63 + 2 pi t/12) (p < 0.0001). Ventricular arrhythmia occurrence rate was lowest between 2:00 and 3:00 A.M., and highest between 10:00 and 11:00 A.M. In addition, the same circadian pattern was demonstrated regardless of patient age, gender, left ventricular ejection fraction (< 35% or > or = 35%), and VT cycle length (< 300 or > or = 300 ms).(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic value of rest-redistribution tomographic thallium-201 imaging in ischemic cardiomyopathy

The relation between the presence of viable myocardium by rest-redistribution thallium imaging and prognosis is not well defined. This study examined the prognostic value of rest-redistribution single-photon emission computed tomographic imaging with thallium-201 in patients with coronary artery disease (CAD) and left ventricular (LV) dysfunction. Patients were divided into 2 groups: group 1 patients (n = 47) were treated medically and group 2 patients (n = 38) underwent coronary revascularization. The 2 groups were comparable in the extent of CAD and in LV ejection fraction. Thallium images showed normal tracer uptake in 1 group 1 and 3 group 2 patients, fixed defects in 26 group 1 and 18 group 2 patients, and both reversible and fixed defects in 20 group 1 and 17 group 2 patients (p = NS). Based on analysis of 20 segments/patient, reversible defects were seen in 4 +/- 4 segments/patient in group 1 and 5 +/- 5 segments/patient in group 2 (p = NS). Viable myocardium (defined as normal tracer uptake, reversible defects, or mild fixed defects) was seen in 14 +/- 4 segments/patient in group 1 and 15 +/- 5 segments/patient in group 2 (p = NS). During a mean follow-up of 31 months, there were 16 group 1 (34%) and 6 group 2 (16%) deaths. The annual mortality rate was 13% in group 1 and 6% in group 2. Actuarial survival analysis showed better survival in group 2 than in group 1 (p = 0.056). Thus, viable myocardium in patients with CAD and LV dysfunction is associated with poor prognosis with medical therapy. Coronary revascularization improves prognosis.

Optimizing patient selection for coronary angiography

Indications for coronary angiography depend on the patient's clinical presentation. In many situations, coronary angiography may be reserved for patients who have severe symptoms, despite optimal medical therapy, and for patients defined to be at high risk, based on noninvasive stress testing. These patient groups include those with chest pain syndromes, postmyocardial infarction, unstable angina, postcoronary revascularization, severe left ventricular dysfunction, survivors of sudden cardiac death, and those about to undergo major vascular noncardiac surgery.

Relation between diastolic left ventricular function and myocardial blood volume during adenosine-induced coronary hyperemia

Adenosine infusion is accompanied by increases in coronary blood flow and myocardial blood volume. Myocardial blood volume may produce changes in diastolic left ventricular (LV) performance by increasing myocardial turgor. Diastolic dysfunction may also be the result of myocardial ischemia. The relation between changes in LV mass and diastolic function has not been previously investigated. This study examined the relation between changes in LV mass during adenosine-induced coronary hyperemia and LV diastolic function. Serial two-dimensional and Doppler echocardiographic measurements were made before, during, and after adenosine infusion (140 micrograms/min for 6 min) in 21 patients with (group 1) and 10 patients without (group 2) coronary artery disease (CAD). The LV mass and transmitral diastolic filling indexes were determined from digitized images from apical four-chamber view. Adenosine infusion produced a greater increase in LV mass in group 2 than in group 1 (29% +/- 11% vs 9% +/- 6%, p < 0.0002). The ratio of transmitral early (E) to atrial (A) filling velocity (E/A) increased 10% +/- 16% in group 2 and decreased 8% +/- 20% in group 1 (p < 0.02), and the velocity time integral of early filling increased 11% +/- 52% in group 2 and decreased 20% +/- 31% in group 1 (p < 0.04). There was a correlation between the change in E/A ratio and the LV mass (r = 0.53, p < 0.003). Thus adenosine infusion caused a greater increase in LV mass in normal subjects than in patients with CAD. There were also changes in Doppler-derived indexes of diastolic LV function.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of thallium-201 single-photon emission computed tomography and electrocardiographic response during exercise in patients with normal rest electrocardiographic results

OBJECTIVES

This study compared the diagnostic accuracy of exercise thallium-201 single-photon emission computed tomography (SPECT) with the exercise electrocardiographic (ECG) response in patients with normal baseline ECG results.

BACKGROUND

Previous studies comparing exercise thallium imaging with exercise electrocardiography have included patients with abnormal rest ECG results that may have biased the results in favor of thallium imaging.

METHODS

Of 321 patients with a pretest likelihood of coronary artery disease of 70 +/- 29% (mean +/- SD) who underwent exercise stress testing and coronary angiography, 68 had no coronary artery disease; 94 had one-vessel disease; 79 had two-vessel disease; and 80 had three-vessel or left main coronary artery disease.

RESULTS

The diagnostic accuracy of SPECT was higher than that of the ECG response (79% vs. 49%, p < 0.0001). Patients with extensive (left main or three-vessel) coronary artery disease were older and had a lower work load, lower heart rate, greater ST segment depression and more extensive perfusion abnormalities than patients with no disease or one- or two-vessel disease. Multivariate discriminant analysis of exercise and thallium variables identified multivessel thallium abnormalities (F = 35), exercise heart rate (F = 18) and extent of ST segment depression (F = 6) as independent predictors of extensive disease. Of the 80 patients with left main or three-vessel disease, 37 (46%) had > or = 2-mm ST segment depression, 44 (55%) had multivessel SPECT abnormalities, and 61 (76%) had either > or = 2-mm ST depression or multivessel SPECT abnormalities (p = 0.0005 vs. the ECG response; p = 0.01 vs. SPECT).

CONCLUSIONS

In patients with an intermediate to high pretest probability of coronary artery disease and normal baseline ECG results, SPECT is superior to the ECG response in detecting coronary disease. Further, SPECT provides incremental power in identifying patients with extensive (left main or three-vessel) coronary disease.

Assessment of myocardial viability by dynamic tomographic iodine 123 iodophenylpentadecanoic acid imaging: comparison with rest-redistribution thallium 201 imaging

BACKGROUND

This study examined the ability of dynamic 123I-labeled iodophenylpentadecanoic acid (IPPA) imaging to detect myocardial viability in patients with left ventricular (LV) dysfunction caused by coronary artery disease.

METHODS AND RESULTS

Serial 180-degree single-photon emission computed tomographic (SPECT) images (five sets, 8 minutes each) were obtained starting 4 minutes after injection of 2 to 6 mCi 123I at rest in 21 patients with LV dysfunction (ejection fraction [EF] 34% +/- 11%). The segmental uptake was compared with that of rest-redistribution 201Tl images (20 segments/study). The number of perfusion defects (reversible and fixed) was similar by IPPA and thallium (11 +/- 5 vs 10 +/- 5 segments/patient; difference not significant). There was agreement between IPPA and thallium for presence or absence (kappa = 0.78 +/- 0.03) and nature (reversible, mild fixed, or severe fixed) of perfusion defects (kappa = 0.54 +/- 0.04). However, there were more reversible IPPA defects than reversible thallium defects (7 +/- 4 vs 3 +/- 4 segments/patient; p = 0.001). In 14 patients the EF (by gated pool imaging) improved after coronary revascularization from 33% +/- 11% to 39% +/- 12% (p = 0.002). The number of reversible IPPA defects was greater in the seven patients who had improvement in EF than in the patients without such improvement (10 +/- 4 vs 5 +/- 4 segments/patient; p = 0.075).

CONCLUSIONS

123I-labeled IPPA SPECT imaging is a promising new technique for assessment of viability. Reversible defects predict recovery of LV dysfunction after coronary revascularization.

Independent and incremental prognostic value of exercise thallium single-photon emission computed tomographic imaging in women

BACKGROUND

This study examined the independent and incremental prognostic value of exercise thallium single-photon emission computed tomographic imaging in 212 women who also underwent coronary angiography.

METHODS AND RESULTS

The left ventricular ejection fraction was normal (65% +/- 15%). During a mean follow-up of 40 months, 27 women had events (cardiac death or nonfatal myocardial infarction). Univariate Cox survival analysis showed several variables to be different between patients with events and those without events: age, exercise heart rate, the extent of coronary artery disease, reversible thallium defects, number of segments with reversible abnormality, and size of perfusion abnormality. Multivariate survival analysis showed that a large perfusion abnormality and age were the independent predictors of events. Actuarial life-table analysis showed that women with a large thallium abnormality (> or = 15% of the myocardium) had significantly worse event-free survival rates than had women with no or small abnormalities (Mantel-Cox statistic = 16; p = 0.0001).

CONCLUSIONS

Thus exercise thallium-201 single-photon emission computed tomographic imaging provides independent and incremental prognostic information to clinical, exercise, and coronary angiographic results in women. The presence of a larger thallium abnormality identifies women at high risk of cardiac events.

Serial changes in left ventricular function after coronary artery bypass: implications in viability assessment

Improvement in left ventricular (LV) performance after coronary artery bypass surgery remains the gold standard in myocardial viability assessment. The time-related changes, however, are not well known. This study examined the LV ejection fraction (EF) by gated blood pool imaging early (6 +/- 4 days) and late (62 +/- 24 days) after surgery in patients with normal preoperative EF (group 1, n = 12) and those with LV dysfunction (group 2, n = 15). There were no changes in the clinical status between the early and late studies, and all patients had normal sinus rhythm. Group 1 had no significant change in EF (preoperatively 62%, early postoperatively 64%, late postoperatively 63%; p = NS). In group 2, EF was 26% +/- 8% preoperatively; 30% +/- 10% early postoperatively; and 34% +/- 8% late postoperatively (p < 0.05). Postoperatively there was > or = 5% improvement in EF in 4 patients early and 11 patients late (p < 0.05). Patients who showed early improvement continued to do so in the late study but, additionally, 7 patients showed improvement only in the late study. Thus the timing of EF measurement after surgery is important in patients with LV dysfunction but not in patients with normal LV function. Early assessment may underestimate the prevalence and degree of recovery.

Prognostic implications of normal exercise tomographic thallium images in patients with angiographic evidence of significant coronary artery disease

This study examines the prognostic implications of normal exercise tomographic thallium images in medically treated patients with angiographic evidence of coronary artery disease (CAD). There were 97 patients aged 60 +/- 10 years; 52 had 1-, 30 had 2-, and 15 had 3-vessel CAD (> or = 50% diameter stenosis). The exercise test was submaximal in 51 patients (53%); ST-segment depression during exercise occurred in 20 patients (21%), and angina during exercise occurred in 23 patients (24%). Most patients (71%) were receiving antianginal therapy. During a mean follow-up of 32 months, only 3 patients had cardiac events: 2 died of cardiac causes and 1 had nonfatal myocardial infarction (event rate 1.1%/year). None of those 3 patients had positive ST response during exercise. Thus, medically treated patients with CAD (including those with multivessel CAD) have a benign prognosis in the presence of normal exercise thallium images. These results have important implications in patient management and cost of health delivery.

Prognostic significance of silent ischemia

This study examined the prognostic predictors in 521 patients with angiographic evidence of coronary artery disease (CAD). All patients underwent exercise single-photon emission computed tomographic thallium imaging. The patients were divided into those with symptomatic ischemia defined as reversible thallium defects, S-T segment depression (or both) and angina during exercise (n = 210, group 1), and silent ischemia defined as thallium defects or ST segment depression (or both) but no angina during exercise (n = 311, group 2). During a mean follow-up of 24 +/- 21 months, there were 30 cardiac events (death or nonfatal myocardial infarction). The extent of CAD (2.0 +/- 0.8 diseased vessels in group 1 and 2.1 +/- 0.8 diseased vessels in group 2), the left ventricular ejection fraction, the extent of perfusion abnormality (21% +/- 11% in group 1 and 24% +/- 12% in group 2), and the peak heart rate and double product were similar in the two groups. Survival analysis showed no significant difference in the event-free survival in patients with symptomatic or silent ischemia. The 2-year event-free survival rate was 95% in group 1 and 94% in group 2 (difference not significant). The extent of perfusion abnormality and history of diabetes mellitus were the most important predictors of events. Thus the prognosis of medically treated patients with CAD is comparable in those patients with silent or symptomatic ischemia and is dependent on the extent of myocardium at risk rather than presence or absence of angina pectoris during exercise.

Planar and tomographic imaging with technetium 99m-labeled tetrofosmin: correlation with thallium 201 and coronary angiography

This study compared the results of planar and single-photon emission computed tomographic (SPECT) imaging with tetrofosmin with those of 201Tl and coronary angiography. In three normal volunteers the images were normal by both 201Tl and tetrofosmin (planar and SPECT). In 23 patients with coronary artery disease, the images were abnormal in 20 patients by SPECT tetrofosmin, in 19 by planar tetrofosmin, in 20 by SPECT thallium, and in 18 by planar thallium (difference not significant). Both planar and SPECT images were divided into five segments per patient. There were 58 perfusion defects by SPECT tetrofosmin, 50 by planar tetrofosmin (difference not significant), 47 by SPECT thallium, and 42 by planar thallium (difference not significant). Perfusion defects were reversible in 47 segments (36%) by SPECT tetrofosmin, 35 (27%) by planar tetrofosmin, 31 (24%) by SPECT thallium (p < 0.05 vs SPECT tetrofosmin), and 31 (24%) by planar thallium (difference not significant). Among the 23 patients with coronary artery disease, 19 underwent coronary angiography. In these patients there were 32 diseased coronary arteries. Perfusion defects were present in 21 territories (66%) by SPECT tetrofosmin, 19 (59%) by planar tetrofosmin, 20 (63%) by SPECT thallium, and 18 (56%) by planar thallium. There was agreement between thallium and tetrofosmin in 108 of 130 segments (kappa statistics = 0.69 +/- 0.06). The images, especially with SPECT, are better with tetrofosmin than with 201Tl. Thus myocardial imaging with tetrofosmin provides results that are at least as good as those of 201Tl. Slightly more abnormal segments and more reversible defects are detected by tetrofosmin than by thallium imaging, especially with SPECT imaging.

Technetium-labeled myocardial perfusion agents

Since its approval for clinical use in 1975, thallium-201 has been the mainstay for myocardial perfusion imaging to diagnose and manage patients with coronary artery disease. In 1992, 80% of 2.6 million myocardial perfusion imaging studies were done with thallium-201. Thallium-201 has important limitations, however, related to photon energy, half life, and availability. In December 1990, two Tc-99m-labeled agents (sestamibi and teboroxime) were approved for clinical use. There are ongoing clinical trials with other classes of Tc-99m agents. This article describes kinetics and imaging experience with Tc-99m-labeled perfusion agents.

Prognostic value of adenosine single-photon emission computed tomographic thallium imaging in medically treated patients with angiographic evidence of coronary artery disease

BACKGROUND

This study examined the prognostic value of adenosine single-photon emission computed tomographic thallium imaging in medically treated patients with angiographic evidence of coronary artery disease (CAD).

METHODS AND RESULTS

Patients who underwent coronary revascularization within 3 months of this study were excluded. There were 177 patients aged 64 +/- 11 years; 74 had one-vessel, 57 had two-vessel, and 46 had three-vessel CAD (> or = 50% diameter stenosis). During a mean follow-up of 22 +/- 13 months, there were 14 events (cardiac death or nonfatal myocardial infarction). Cox survival analysis with important clinical, catheterization, and scintigraphic variables identified the size of perfusion abnormality as the strongest predictor of events (chi 2 = 9). Life-table analysis showed that patients with perfusion defects of 15% or greater of the myocardium had a worse prognosis than had patients with no or smaller defects (Mantel-Cox statistic = 13; p < 0.001).

CONCLUSIONS

Thus adenosine single-photo emission computed tomographic thallium imaging provides important prognostic data in medically treated patients with CAD. The extent of thallium abnormality is the most important predictor of events.

Sequential dual-isotope SPECT imaging with thallium-201 and technetium-99m-sestamibi

This study examined the results of sequential SPECT dual-isotope imaging with 201Tl and 99mTc-sestamibi in 148 patients, 114 of whom also had coronary angiography and 34 had < 5% pretest probability for coronary artery disease (CAD).

METHODS

Stress thallium/rest sestamibi was used in 82 patients and rest thallium/stress sestamibi in 66 patients. Coronary angiography showed that 17 patients had no CAD, 27 patients had one-vessel CAD, 41 patients had two-vessel CAD and 29 patients had three-vessel CAD. The thallium study (3 mCi) was always done before the sestamibi study (20-25 mCi). The stress was either symptom-limited treadmill exercise testing or adenosine infusion at a rate of 140 micrograms/kg/min for 6 min.

RESULTS

The study was completed within 2 hr. The stress and rest images were normal in 11 of 17 patients (65%) with no CAD by angiography and in 33 of 34 patients with a low pretest probability of CAD (normalcy rate = 97%). The images were abnormal in 75 patients with CAD (77%). The perfusion pattern was compared to wall motion in 485 segments (97 patients) assessed by contrast ventriculography. There were no or reversible perfusion defects in 357 of 386 segments (92%) with no wall motion abnormality.

CONCLUSION

Sequential dual-isotope imaging is feasible and can be completed in a short period of time and may therefore enhance laboratory throughput and patient convenience.

When is myocardial viability an important clinical issue?

Myocardial viability is a clinically important issue in patients after acute myocardial infarction and in patients with left ventricular dysfunction in the presence or absence of symptoms. With these broad criteria, roughly 10% to 20% of patients with coronary artery disease will be suitable candidates for myocardial viability studies. Techniques that predict improvement in regional or global left ventricular function must be able to detect hibernating myocardium. The improvement observed following coronary revascularization represents a complex interaction between compensatory mechanisms, coronary anatomy, surgical outcome and patient selection.

Thallium-201 uptake in keloid tissue masquerading as a pulmonary neoplasm

Tl-201 imaging is useful in the diagnostic work-up of tumors. However, Tl-201 uptake is not specific for tumor and is also noted in other conditions. A case is described in which Tl-201 was taken up by a keloid.

Biokinetics of thallium-201 in normal subjects: comparison between adenosine, dipyridamole, dobutamine and exercise

There are currently four common types of stress used with thallium-201 imaging in the diagnosis of coronary artery disease and risk assessment. The objective of this study was to examine the thallium biokinetics during exercise, adenosine, dipyridamole and dobutamine stress testing in 15 healthy volunteers.

METHODS

Each subject underwent planar 201Tl imaging during maximal treadmill exercise testing, adenosine infusion (140 micrograms/kg/min for 6 min), dipyridamole infusion (142 micrograms/kg/min for 4 min) and dobutamine infusion (40 micrograms/kg/min).

RESULTS

Absolute myocardial thallium activity was greater after pharmacologic testing than exercise, (p < 0.001 each). Thus, the activity was 505 counts/pixel with adenosine, 491 counts/pixel with dipyridamole, 517 counts/pixel with dobutamine and 409 counts/pixel with exercise. The myocardial thallium clearance was lower with pharmacologic testing than exercise; 9.7%/hr with adenosine, 9.9%/hr with dipyridamole, 11.3%/hr with dobutamine and 13%/hr with exercise (p < 0.01 each). The thallium uptake and clearance in the lung and liver were also greater with pharmacologic stress testing than exercise (p < 0.05).

CONCLUSIONS

Thus, thallium biokinetics are different during pharmacologic stress testing with adenosine, dipyridamole and dobutamine than during exercise. Diagnostic criteria for quantitative analysis of myocardial perfusion imaging must therefore be specific for the type of stress used.

Comparison of the treadmill exercise score and single-photon emission computed tomographic thallium imaging in risk assessment

BACKGROUND

This study compared the prognostic value of exercise single-photon emission computed tomographic (SPECT) thallium imaging with that of treadmill exercise score in medically treated patients with coronary artery disease (CAD).

METHODS AND RESULTS

The treadmill exercise score was derived from exercise duration, degree of ST segment depression, and the treadmill anginal index. There were 121 patients with no CAD and 316 patients with angiographically defined CAD (> or = 50% diameter stenosis of one or more vessels). During a mean follow-up of 29 months, there were 35 cardiac deaths or nonfatal myocardial infarctions. Multivariate Cox survival analysis showed the extent of thallium imaging abnormality and CAD to be independent predictors of prognosis. On the other hand, the treadmill exercise score was not a significant predictor even on univariate analysis. The results of thallium uptake were the strongest independent predictors of prognosis and in addition provided incremental prognostic power to coronary angiography (chi 2 = 29 for SPECT, 27 for coronary angiography, and 37 for both).

CONCLUSIONS

Thus exercise SPECT thallium imaging is significantly better than the treadmill exercise score in risk assessment. The size of the perfusion abnormality is an important predicator of prognosis.

Safety profile of adenosine stress perfusion imaging: results from the Adenoscan Multicenter Trial Registry

OBJECTIVES

The purpose of this study was to determine the safety of adenosine infusion at 140 micrograms/kg per min in conjunction with radionuclide imaging in 9,256 consecutive patients.

BACKGROUND

Adenosine produces maximal myocardial hyperemia directly with a rapid onset of action. In addition, when used in conjunction with radionuclide perfusion imaging, it has proven efficacy for the diagnosis of coronary artery disease in patients unable to exercise. Because the ultrashort half-life (< 10s) allows dose titration and rapid reversal of side effects, it may be safer than other available pharmacologic agents.

METHODS

Patients were prospectively entered at 21 clinical sites. Information on safety and adverse events during and immediately after adenosine infusion was maintained in the Adenoscan Multicenter Trial Registry.

RESULTS

The infusion protocol was completed in 80% of patients, required dose reduction in 13% and was terminated early in 7%. Interpretable imaging studies were obtained in 98.7% of patients, and 0.8% of patients received aminophylline. Minor and well tolerated side effects were reported in 81.1% of patients. There were no deaths, one myocardial infarction, seven episodes of severe bronchospasm and one episode of pulmonary edema. Transient atrioventricular (AV) node block occurred in 706 patients (first-degree in 256, second-degree in 378 and third-degree in 72) and resolved spontaneously in most patients (n = 508) without alteration in the adenosine infusion. There were no sustained episodes of AV block. Patients > 70 years of age had an increased risk of developing AV block (age < 70, 7.05% vs. > or = 70, 9.44%, p = 0.001, relative risk 1.37).

CONCLUSIONS

Adenosine infusion is safe. Vasodilator and negative dromotropic side effects are generally well tolerated. Serious side effects are relatively rare, and they reverse with termination of adenosine infusion. Interpretable radionuclide studies were obtained in 98.7% of patients and aminophylline reversal was seldom required.

Pharmacologic stress testing: mechanism of action, hemodynamic responses, and results in detection of coronary artery disease

Pharmacologic stress testing may be used in the diagnosis of coronary artery disease and risk assessment. The stress agents may be divided into those that produce primary coronary vasodilation (dipyridamole, adenosine, or adenosine triphosphate) and those that produce secondary vasodilation as a result of increase in myocardial oxygen demand (dobutamine and arbutamine). Assessment of myocardial perfusion and function can be made by single-photon imaging, positron emission tomography, two-dimensional echocardiography, magnetic resonance imaging, and contrast angiography. For assessment of myocardial perfusion, either thallium 201-labeled or technetium-labeled perfusion imaging agents may be used. This article will focus on the mechanisms of action, hemodynamic responses, and results of pharmacologic imaging in detecting coronary artery disease. The use of pharmacologic stress testing in risk assessment will be discussed in a separate article.

Age- and sex-related differences in the use of coronary angiography in patients undergoing adenosine SPECT thallium imaging

BACKGROUND

Recent reports suggest sex-related differences in the management of patients with coronary artery disease.

METHODS

This study examined the pattern of use of coronary angiography in 535 patients initially referred for adenosine single photon emission computed tomography (SPECT) thallium imaging.

RESULTS

Coronary angiography was carried out more often in patients under 70 years of age than those over 70 years of age [107 out of 322 (33%) versus 50 out of 213 (23%), P < 0.01]. Even in patients with abnormal adenosine SPECT thallium results, coronary angiography was less frequently performed in the elderly [40 out of 130 (31%) versus 82 out of 178 (46%), P < 0.01]. Women underwent coronary angiography less often than men [56 out of 261 (21%) versus 101 out of 274 (37%), P < 0.0002]. This difference was due to differences in patients under 70 years of age [31 out of 138 women (22%) versus 76 of 184 men (41%), P < 0.003)], but not in patients over 70 years of age. In patients with abnormal adenosine thallium image results, the difference between men and women was still present: 37 out of 112 women (33%) versus 85 of 196 men (43%) underwent coronary angiography (P = 0.05). Stepwise discriminant analysis of clinical and scintigraphic variables identified four independent predictors of the need for coronary angiography; the abnormal thallium image results (chi 2 = 33, P < 0.0001); the size of the perfusion abnormality (chi 2 = 7, P < 0.01); sex (chi 2 = 7, P < 0.01) and age (chi 2 = 4, P < 0.05).

CONCLUSION

Coronary angiography is less often performed in women and elderly patients even when initial screening results are abnormal. The relation of this observation to subsequent clinical course and events requires further studies.

Simultaneous assessment of left ventricular perfusion and function with technetium-99m sestamibi after coronary artery bypass grafting

This study examined the left ventricular perfusion and EF by using simultaneous SPECT and first-pass radionuclide angiography with technetium 99m sestamibi in 95 patients after uncomplicated coronary artery bypass grafting. The patients were divided into those with normal EF and no previous myocardial infarction before surgery (group 1, n = 57), and those with abnormal EF or infarction (group 2, n = 38). The SPECT images were normal in 37 patients in group 1 and in 6 patients in group 2 (p < 0.0001). The patients with normal SPECT images had a higher EF after surgery than those with abnormal images (65% +/- 10% vs 50% +/- 14%, p < 0.0001) and was higher in group 1 than in group 2 (64% +/- 8% vs 46% +/- 16%, p < 0.0001). There was a significant correlation between the EF and the extent of perfusion abnormality (r = -0.44, p < 0.0001). The patients with normal SPECT images could not be separated from those with abnormal images based on peak CK, CK-MB, and the electrocardiographic changes. Of the 69 patients with postoperative EF > or = 50%, the perfusion pattern was normal in 41 and abnormal in 28; of the 26 patients with EF < 50%, 24 had abnormal SPECT (p < 0.003). There was no significant change in mean EF after surgery (55% +/- 14% before vs 56% +/- 15% after). Thus simultaneous assessment of left ventricular perfusion and function after coronary artery bypass grafting showed that an abnormal perfusion pattern may exist despite a normal EF. These patients could not be predicted by enzymes or electrocardiographic changes.

Study of myocardial infarct remodeling by single-photon emission computed tomographic imaging

Left ventricular (LV) remodeling after Q-wave anterior acute myocardial infarction (AMI) was examined with single-photon emission computed tomographic thallium imaging. Initial (after adenosine infusion) and 4-hour delayed reinjection images were obtained in 34 patients aged 65 +/- 12 years. Short-axis slices from the delayed images were quantitatively analyzed by measuring the outer and inner diameters, and wall thickness. The results were compared with those in a group of normal subjects. The outer diameter was greater in patients than in normal subjects at the apical, mid- and basal levels (all p < 0.01); the average outer diameter was 16.9 +/- 1.9 mm in patients, and 12.2 +/- 1.3 mm in normal subjects (p < 0.001). Similarly, the inner diameter was greater in patients than in normal subjects at the 3 levels (all p < 0.05); the average inner diameter was 6.5 +/- 1.8 mm in patients, and 4.7 +/- 1.3 mm in normal subjects (p < 0.01). Wall thickness was greater in patients than in normal subjects (5.2 +/- 0.5 vs 3.8 +/- 0.5 mm; p < 0.0001). There were significant correlations between LV dilation and time elapsed (in weeks) since AMI (r = 0.57; p < 0.005), and the size of the perfusion abnormality (r = 0.44; p < 0.03). Thus, LV dilation occurs after Q-wave anterior AMI, and is related to infarct size and duration. These changes can be studied by single-photon emission computed tomographic thallium imaging.

Independent and incremental prognostic value of exercise single-photon emission computed tomographic (SPECT) thallium imaging in coronary artery disease

OBJECTIVES

The objective of this study was to examine the independent and incremental prognostic value of exercise single-photon emission computed tomographic (SPECT) thallium imaging in patients with angiographically defined coronary artery disease.

BACKGROUND

Previous studies showed the importance of exercise thallium-201 in risk stratification. However, most of these studies used planar imaging techniques.

METHODS

Follow-up data were obtained in 316 medically treated patients with coronary artery disease. Cox proportional hazards regression models were used to examine the independent and incremental prognostic values of clinical, exercise, thallium and cardiac catheterization data.

RESULTS

There were 35 events (cardiac death or nonfatal myocardial infarction) at a mean follow-up time of 28 months. Univariate analysis showed that gender (chi-square = 5.1), exercise work load (chi-square = 3.1), extent of coronary artery disease and left ventricular ejection fraction (chi-square = 14.8) and thallium variables (chi-square = 22.7) were prognostically important. The thallium data provided incremental prognostic value to catheterization data (chi-square = 33.7, p < 0.01). The extent of the perfusion abnormality was the single best predictor of prognosis (chi-square = 14). Patients with a large perfusion abnormality had a worse prognosis than that of patients with a mild or no abnormality (Mantel-Cox statistics = 10.6, p < 0.001).

CONCLUSIONS

In medically treated patients with coronary artery disease, exercise SPECT thallium imaging provides independent and incremental prognostic information even when catheterization data are available. The extent of the perfusion abnormality is the single most important prognostic predictor.

The role of nuclear imaging in ischemic heart disease

Assessment of myocardial perfusion during exercise and pharmacologic stress testing is an important factor in the detection of coronary artery disease and in risk assessment. Imaging techniques that examine myocardial perfusion and cellular integrity or myocardial metabolism flow mismatches aid in the detection of reversible causes of left ventricular dysfunction. These techniques are also helpful in managing patients after percutaneous transluminal coronary angioplasty or thrombolytic therapy.

Variations in the size of the ischemic myocardium due to differences in the normal file

The myocardial thallium concentration is different during pharmacologic than exercise stress testing due to differences in coronary blood flow and cardiac output. These differences may affect the quantitative measurement of the size of ischemic myocardium if a stress-specific normal file is not used. This study examined this concept in 34 patients with isolated left anterior descending coronary artery disease. All patients underwent tomographic thallium imaging during adenosine infusion (140 micrograms/kg/min for 6 minutes). The size of the ischemic myocardium was measured from the polar map using two different normal files; one derived from normal subjects undergoing treadmill exercise testing, and the second from normal subjects undergoing adenosine stress testing. The extent perfusion abnormality was 19 +/- 13% using the exercise file, and 11 +/- 10% using adenosine file (difference; 8.1 +/- 1.6%, P = 0.0001), the severity score was 580 +/- 480 using exercise file, and 310 +/- 310 using the adenosine file (P < 0.001). The differences were present in the 20 patients with moderate stenosis (50 to 70% diameter stenosis); 17 +/- 10% versus 7 +/- 7% (P = 0.001), and in the 14 patients with severe stenosis (> 70% diameter stenosis); 24 +/- 16% versus 18 +/- 10% (P = 0.03). Thus, stress-specific normal file should be used for sizing the perfusion abnormality. The use of exercise file overestimates defect size in patients undergoing pharmacologic stress testing.

Identification of extensive coronary artery disease in women by exercise single-photon emission computed tomographic (SPECT) thallium imaging

OBJECTIVES

The aim of this study was to examine the ability of exercise single-photon emission computed tomographic (SPECT) thallium imaging to identify high risk women with left main or three-vessel coronary artery disease using a stepwise discriminant analysis.

BACKGROUND

Previous studies have used statistical methods to identify high risk men with coronary artery disease. Only limited data are available in women.

METHODS

Exercise SPECT thallium imaging and coronary arteriography were performed for evaluation of chest pain in 243 women. Group 1 comprised 58 women with left main or three-vessel coronary disease and group 2 comprised 185 women with no or one- or two-vessel disease. Stepwise discriminant analysis was used to determine predictors of left main or three-vessel disease.

RESULTS

On univariate analysis, women in group 1 were older (p < 0.03) and had a lower exercise work load (p < 0.02), lower exercise heart rate (p < 0.004), higher prevalence rate of diabetes mellitus (p < 0.0003) and more multivessel thallium abnormality (p < 0.0001) compared with women in group 2. On multivariate analysis, only multivessel thallium abnormality (F = 43) and exercise heart rate (F = 6) were independent predictors of left main or three-vessel coronary disease. A model based on these two variables separated the women into three risk groups: 99 patients with 9%, 70 patients with 23% and 74 patients with 45% prevalence of left main or three-vessel disease (p < 0.0001).

CONCLUSIONS

High risk women with left main or three-vessel coronary disease can be identified by exercise SPECT thallium imaging.

Identification of high-risk patients with left main and three-vessel coronary artery disease by adenosine-single photon emission computed tomographic thallium imaging

The purpose of this study was to examine the ability of SPECT imaging with thallium-201 during adenosine-induced coronary hyperemia to detect high-risk patients with left main or three-vessel CAD. There were 339 patients: 102 with either left main or three-vessel CAD (group 1) and 237 with no CAD, one-, or two-vessel disease (group 2). By means of univariate analysis, several variables were found to differ between groups 1 and 2: Q wave myocardial infarction (35% vs 25%, p < 0.05), ST segment depression (35% vs 19%, p < 0.001), age (67 +/- 9 vs 62 +/- 10 years, p < 0.001), resting systolic blood pressure (142 +/- 22 vs 135 +/- 20 mm Hg, p < 0.01), abnormal thallium images (95% vs 74%, p < 0.0001), multivessel thallium abnormality (76% vs 39%, p < 0.0001), extent of thallium abnormality (24 +/- 11% vs 19 +/- 13%, p < 0.0001), and increased lung thallium uptake (39% vs 15%, p < 0.01). According to stepwise discriminant analysis, only three variables were predictors of high risk: multivessel thallium abnormality (chi 2 = 27), increased lung thallium uptake (chi 2 = 10), and ST depression (chi 2 = 5). On the basis of these variables, patients were divided into three groups with different prevalence rates for left main and three-vessel CAD: 63% in 68 patients, 30% in 137 patients, and 13% in 137 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Identification of high-risk patients with left main and three-vessel coronary artery disease using stepwise discriminant analysis of clinical, exercise, and tomographic thallium data

This large-scale study examined the ability of stepwise discriminant analysis of clinical, exercise, and thallium tomographic data to detect high-risk patients with three-vessel or left main disease. There were 834 patients, 229 with three-vessel or left main disease (group 1) and 605 (group 2) with either two-vessel disease (n = 236), one-vessel disease (n = 195), or no coronary artery disease (n = 174). The two groups were different in age, exercise heart rate, ST segment depression during exercise, exercise systolic blood pressure, abnormal thallium scans, reversible perfusion defects, extent of thallium abnormality, number of vascular territories with perfusion abnormalities, left ventricular cavity dilatation, and increased lung thallium uptake. On multivariate stepwise discriminant analysis, only three variables were independent predictors of high risk. These included multivessel thallium abnormality (F = 107, p < 0.001), exercise heart rate (F = 27, p < 0.001), and ST segment depression (F = 8, p < 0.01). Based on these three variables, patients could be stratified into three categories with different prevalences of left main or three-vessel disease; the prevalence was 53% in 239 patients, 24% in 271 patients, and 12% in 324 patients. Thus high-risk patients with left main or three-vessel disease can be identified by exercise thallium tomographic imaging that uses a model based on stepwise discriminant analysis. The thallium data are far more powerful than the clinical or treadmill exercise data.

Effect of adenosine on coronary blood flow and its use as a diagnostic test for coronary artery disease

Myocardial perfusion imaging during adenosine induced coronary hyperaemia is a highly sensitive method for diagnosing coronary artery disease. Most perfusion defects reflect heterogeneity in coronary blood flow in the territories of normal and diseased coronary arteries. Myocardial ischaemia can occur, however, due to subendocardial hypoperfusion and coronary artery steal. Evidence for myocardial ischaemia is more difficult to document in clinical than in experimental studies, and includes abnormalities in the ST segment, wall motion, haemodynamic variables, metabolism, and coronary blood flow responses. Using these indices, myocardial ischaemia may occur in some patients with coronary artery disease but it is not a prerequisite for the development of perfusion abnormalities and for the diagnosis of coronary artery during adenosine stress testing.

The treadmill exercise score revisited: coronary arteriographic and thallium perfusion correlates

The treadmill exercise score has been used to stratify patients into low-, moderate-, and high-risk groups. This score is derived from ST segment depression, angina, and exercise duration. To determine the coronary arteriographic and exercise thallium perfusion correlates of the score, we examined the extent of coronary artery disease and exercise single photon emission computed thallium-201 results in 834 patients for whom cardiac catheterization data were available. Of those, 174 had no coronary artery disease, 195 had one-vessel, 246 had two-vessel, and 219 had three-vessel disease. Based on the treadmill exercise score, 369 were in the low-risk, 384 in the moderate-risk, and 81 in the high-risk group. The extent of coronary artery disease was 2.1 +/- 1 diseased vessels in the high-risk, 1.7 +/- 1 in the moderate, and 1.4 +/- 1.1 in the low-risk group (p < 0.01). The extent of the thallium abnormality (maximum number of abnormal segments 120/patient) was 10 +/- 6 in the high-risk, 7 +/- 6 in the moderate, and 6 +/- 5 in the low-risk group (p < 0.05). Based on the extent of coronary artery disease and results of thallium imaging, patients were reclassified into three groups: group 1 had three-vessel disease and/or > or = 10 abnormal segments (n = 387), group 3 had no coronary artery disease or one-vessel disease and less than five abnormal segments (n = 212), and the remaining patients were in group 2 (n = 235).(ABSTRACT TRUNCATED AT 250 WORDS)