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Jang K, Kim HL, Park M, Oh S, Oh SW, Lim WH, Seo JB, Kim SH, Zo JH, Kim MA. Additional Value of Brachial-Ankle Pulse Wave Velocity to Single-Photon Emission Computed Tomography in the Diagnosis of Coronary Artery Disease. J Atheroscler Thromb 2017; 24:1249-1257. [PMID: 28835579 PMCID: PMC5742370 DOI: 10.5551/jat.40071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Aim: The aim of this study was to investigate whether information on arterial stiffness can improve the value of single-photon emission computed tomography (SPECT) in the detection of obstructive coronary artery disease (CAD). Methods: A total of 233 patients (age: 62.2 ± 10.8 years, 60.3% males) with detected ischemia on SPECT undergoing invasive coronary angiography (ICA) and brachial-ankle pulse wave velocity (baPWV) measurement within a month was retrospectively reviewed. Results: Of the 233 patients, 190 (81.5%) had obstructive CAD (≥ 50% luminal stenosis). The difference in baPWV according to the presence of obstructive CAD was significant in patients in the mild ischemia group [summed stress score (SSS): 4–8] (1,770 ± 364 cm versus 1,490 ± 328 cm, p < 0.001) but not in the moderate (SSS: 9–13) or severe (SSS: ≥14) ischemia groups (p > 0.05 for each). Receiver operating characteristic curve analyses showed that the diagnostic value of baPWV for obstructive CAD was significant only in patients in the mild ischemia group (area under curve: 0.714; p = 0.001) but not in the moderate or severe ischemia groups (p > 0.05 for each). Adding information on baPWV to SPECT results and clinical parameters significantly increased diagnostic accuracy in the detection of obstructive CAD in patients with mild ischemia (integrated discrimination improvement p = 0.006) but not in those with moderate or severe ischemia on SPECT (p > 0.05 for each). Conclusions: The results of this study suggest that baPWV may have additional value to SPECT for the detection of obstructive CAD, especially in patients with mild ischemia on SPECT.
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Affiliation(s)
| | - Hack-Lyoung Kim
- Division of Cardiology, Boramae Medical Center, Seoul National University College of Medicine
| | - Miri Park
- Department of Nursing, Boramae Medical Center
| | - Sohee Oh
- Department of Biostatistics, Boramae Medical Center
| | - So Won Oh
- Department of Nuclear Medicine, Boramae Medical Center, Seoul National University College of Medicine
| | - Woo-Hyun Lim
- Division of Cardiology, Boramae Medical Center, Seoul National University College of Medicine
| | - Jae-Bin Seo
- Division of Cardiology, Boramae Medical Center, Seoul National University College of Medicine
| | - Sang-Hyun Kim
- Division of Cardiology, Boramae Medical Center, Seoul National University College of Medicine
| | - Joo-Hee Zo
- Division of Cardiology, Boramae Medical Center, Seoul National University College of Medicine
| | - Myung-A Kim
- Division of Cardiology, Boramae Medical Center, Seoul National University College of Medicine
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Nabi F, Chang SM, Xu J, Gigliotti E, Mahmarian JJ. Assessing risk in acute chest pain: The value of stress myocardial perfusion imaging in patients admitted through the emergency department. J Nucl Cardiol 2012; 19:233-43. [PMID: 22147618 DOI: 10.1007/s12350-011-9484-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 11/05/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND To prospectively assess the clinical value of stress-gated myocardial single photon emission computed tomography (SPECT) for triaging patients admitted through the emergency department (ED) with acute chest pain (ACP). METHODS Prospective, observational cohort study in 1,576 consecutive patients who were evaluated for ACP over a 29-month period. Stress SPECT was performed within 24 hours of admission from the ED. Analysis included quantification of total and ischemic left ventricular perfusion defect size (PDS). Cardiac events were defined as an acute coronary syndrome during the index hospitalization or in follow-up over 7.3 ± 2.8 months. RESULTS Eighty-five cardiac events occurred in 77 patients (4.9%). SPECT was abnormal in 135 patients (8.6%) of whom 83 (61.5%) had a reversible defect. Event rates were significantly higher in patients with an abnormal (40%) versus a normal (1.6%) SPECT (P < .0001); and in those with a (1) large (>15%) versus small (≤15%) PDS (50.0% vs 33.7%, P = .05) and (2) large (>10%) versus small (≤10%) ischemic PDS (87.5% vs 42.4%, P < .0001, respectively). SPECT best predicted cardiac events by multivariate analysis. The addition of SPECT to clinical variables significantly improved overall risk prediction (global χ(2) 103.6 vs 207.1, P < .001). CONCLUSIONS Stress SPECT can accurately assess risk in a heterogeneous group of patients with ACP of unclear cardiac etiology, and beyond that provided by a clinical risk assessment alone. Our results support the use of stress SPECT for identifying very low-risk ACP patients with normal study results who can be safely discharged home.
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Affiliation(s)
- Faisal Nabi
- Methodist DeBakey Heart and Vascular Center and The Methodist Hospital Research Institute, The Methodist Hospital, Houston, TX 77030, USA
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Symptom-limited exercise combined with dipyridamole stress: prognostic value in assessment of known or suspected coronary artery disease by use of gated SPECT imaging. J Nucl Cardiol 2008; 15:42-56. [PMID: 18242479 DOI: 10.1016/j.nuclcard.2007.09.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Accepted: 09/10/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND Combining vasodilator and exercise stress reduces noncardiac side effects, improves image quality, and enhances the detection of ischemia, compared with suboptimal exercise or vasodilator stress alone. However, prognostic data with combined protocols are limited. METHODS AND RESULTS Consecutive patients (n = 2064) who underwent symptom-limited exercise and dipyridamole stress with gated single-photon emission computed tomography (SPECT) imaging, without early revascularization, were studied. Subsequent cardiac death or nonfatal myocardial infarction was related to exercise and gated SPECT variables. Cox proportional hazards regression modeling was performed to identify predictors of adverse outcome. Annualized event rates in patients with normal and abnormal images were 0.96% and 2.71%, respectively (P < .001). With abnormal imaging, annualized event rates were 0.86% and 3.13% in patients with average to high and fair or poor functional capacity, respectively (P = .019). Abnormal imaging, a severely reduced post-stress ejection fraction, transient ischemic dilation, and fair or poor functional capacity emerged as predictors of adverse outcome. Accordingly, patients were stratified into low-risk, intermediate-risk, and high-risk cohorts with annualized event rates of 0.94%, 2.24%, and 8.19%, respectively (P < .001 in any two-way comparison). CONCLUSIONS A protocol that combines symptom-limited exercise and dipyridamole stress with gated SPECT imaging provides highly effective risk stratification for adverse outcomes.
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99mTc-MIBI brain SPECT as an indicator of the chemotherapy response of recurrent, primary brain tumors. Nucl Med Commun 2008; 28:888-94. [PMID: 18090213 DOI: 10.1097/mnm.0b013e3282f1646c] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Malignant brain tumors carry a pejorative prognosis and necessitate aggressive therapy. Chemotherapy can be used in cases of tumor recurrence. With limited response rate and potential toxicity to chemotherapeutic treatment in patients with recurrent glioma, reliable response assessment is essential. AIM To define the place of 99mTc hexakis 2-methoxyisobutylisonitrile (99mTc-MIBI) Single Positron Emission Computed Tomography (SPECT) in monitoring chemotherapy response in recurrent primary brain tumors. METHODS In a retrospective analysis, thirty patients were investigated with MIBI SPECT. Imaging was performed 1h after the intravenous injection of 555 MBq of 99mTc-MIBI using a dedicated SPECT system. A MIBI uptake index (UI) was computed as the ratio of counts in the lesion to those in contralateral region. For all patients, we compared changes over time in UI with MRI and clinical data. RESULTS The changes in UI agreed well with the clinical and MRI-based assessments in 97% of cases. In 44% of these cases, the scintigraphic response appeared before the MRI response. In instances of treatment failure or rebound, the concordance between scintigraphy and MRI was 52%, and the scintigraphic response appeared before the MRI response in 48% of cases. CONCLUSION This study confirms our previous results obtained on a short series of patients with recurrent glioma, concerning the usefulness of MIBI SPECT in prediction of chemotherapy response. Moreover, in cases of tumor progression, we show that MIBI SPECT is an earlier indicator of escape from chemotherapy, an average 4 months before MRI changes.
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Affiliation(s)
- John J Mahmarian
- Department of Cardiology, Methodist DeBakey Heart Center, The Methodist Hospital, Houston, TX 77030, USA.
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Antonopoulos A, Vijay Anand D, Lahiri A. Diabetes mellitus: evaluation of patients with known or suspected coronary artery disease and the role played by myocardial perfusion imaging. Nucl Med Commun 2005; 26:587-91. [PMID: 15942478 DOI: 10.1097/01.mnm.0000168406.18380.d1] [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: 12/13/2022]
Abstract
Type 2 diabetes markedly increases cardiovascular risk, and patients often present with advanced and asymptomatic disease. The fact that diabetes is associated with an increased risk of acute coronary events and poor long-term survival makes a strong case for detecting coronary artery disease early, perhaps before clinical manifestation in this patient population. This article examines the role of myocardial perfusion scintigraphy in the diagnostic and prognostic evaluation of diabetic patients with suspected coronary artery disease and in screening high-risk asymptomatic diabetic patients.
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Brown KA. Evaluation of the unstable angina patient in 2005: is there still a role for noninvasive risk stratification? J Nucl Cardiol 2005; 12:9-11. [PMID: 15682360 DOI: 10.1016/j.nuclcard.2004.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Klocke FJ, Baird MG, Lorell BH, Bateman TM, Messer JV, Berman DS, O'Gara PT, Carabello BA, Russell RO, Cerqueira MD, St John Sutton MG, DeMaria AN, Udelson JE, Kennedy JW, Verani MS, Williams KA, Antman EM, Smith SC, Alpert JS, Gregoratos G, Anderson JL, Hiratzka LF, Faxon DP, Hunt SA, Fuster V, Jacobs AK, Gibbons RJ, Russell RO. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). J Am Coll Cardiol 2003; 42:1318-33. [PMID: 14522503 DOI: 10.1016/j.jacc.2003.08.011] [Citation(s) in RCA: 483] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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9
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Klocke FJ, Baird MG, Lorell BH, Bateman TM, Messer JV, Berman DS, O'Gara PT, Carabello BA, Russell RO, Cerqueira MD, St John Sutton MG, DeMaria AN, Udelson JE, Kennedy JW, Verani MS, Williams KA, Antman EM, Smith SC, Alpert JS, Gregoratos G, Anderson JL, Hiratzka LF, Faxon DP, Hunt SA, Fuster V, Jacobs AK, Gibbons RJ, Russell RO. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). Circulation 2003; 108:1404-18. [PMID: 12975245 DOI: 10.1161/01.cir.0000080946.42225.4d] [Citation(s) in RCA: 498] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Giri S, Shaw LJ, Murthy DR, Travin MI, Miller DD, Hachamovitch R, Borges-Neto S, Berman DS, Waters DD, Heller GV. Impact of diabetes on the risk stratification using stress single-photon emission computed tomography myocardial perfusion imaging in patients with symptoms suggestive of coronary artery disease. Circulation 2002; 105:32-40. [PMID: 11772873 DOI: 10.1161/hc5001.100528] [Citation(s) in RCA: 229] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary artery disease can develop prematurely and is the leading cause of death among diabetics, making noninvasive risk stratification desirable. METHODS AND RESULTS Patients with symptoms of coronary artery disease who were undergoing stress myocardial perfusion imaging (MPI) from 5 centers were prospectively followed (2.5+/-1.5 years) for the subsequent occurrence of cardiac death, myocardial infarction (MI), and revascularization. Stress MPI results were categorized as normal or abnormal (fixed or ischemic defects and 1, 2, or 3 vessel distribution). Of 4755 patients, 929 (19.5%) were diabetic. Patients with diabetes, despite an increased revascularization rate, had 80 cardiac events (8.6%; 39 deaths and 41 MIs) compared with 172 cardiac events (4.5%; 69 deaths and 103 MIs) in the nondiabetic cohort (P<0.0001). Abnormal stress MPI was an independent predictor of cardiac death and MI in both populations. Diabetics with ischemic defects had an increased number of cardiac events (P<0.001), with the highest MI rates (17.1%) observed with 3-vessel ischemia. Similarly, a multivessel fixed defect was associated with the highest rate of cardiac death (13.6%) among diabetics. The unadjusted cardiac survival rate was lower for diabetic patients (91% versus 97%, P<0.001), but it became comparable once adjusted for the pretest clinical risk and stress MPI results. In multivariable Cox analysis, both ischemic and fixed MPI defects independently predicted cardiac death alone or cardiac death/MI. Diabetic women had the worst outcome for any given extent of myocardial ischemia. CONCLUSIONS In this large cohort of diabetics undergoing stress MPI, the presence and the extent of abnormal stress MPI independently predicted subsequent cardiac events. Using stress MPI in conjunction with clinical information can provide risk stratification of diabetic patients.
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Affiliation(s)
- Satyendra Giri
- Nuclear Cardiology Laboratory, Division of Cardiology, Hartford Hospital, and the Department of Medicine and Nuclear Medicine, University of Connecticut School of Medicine, Farmington, Ct 06102-5037, USA
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Borm JJJ, Bouwsma H, van der Wall EE, Pauwels EKJ. The prognostic value of myocardial perfusion scintigraphy: investigators, are you (mis)leading us? Eur J Nucl Med Mol Imaging 2001; 28:1439-46. [DOI: 10.1007/s002590100606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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12
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Borm JJ, Bouwsma H, van der Wall EE, Pauwels EK. The prognostic value of myocardial perfusion scintigraphy: investigators, are you (mis)leading us? EUROPEAN JOURNAL OF NUCLEAR MEDICINE 2001; 28:1299-305. [PMID: 11585287 DOI: 10.1007/s002590100557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Hendel RC. Diagnostic and prognostic applications for vasodilator stress myocardial perfusion imaging and the importance of radiopharmaceutical selection. J Nucl Cardiol 2001; 8:523-7. [PMID: 11481575 DOI: 10.1067/mnc.2001.117116] [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: 01/26/2023]
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14
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Guideline for the management of patients with acute coronary syndromes without persistent ECG ST segment elevation. British Cardiac Society Guidelines and Medical Practice Committee and Royal College of Physicians Clinical Effectiveness and Evaluation Unit. Heart 2001; 85:133-42. [PMID: 11156660 PMCID: PMC1729608 DOI: 10.1136/heart.85.2.133] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Iskander S, Iskandrian AE. Risk assessment using single-photon emission computed tomographic technetium-99m sestamibi imaging. J Am Coll Cardiol 1998; 32:57-62. [PMID: 9669249 DOI: 10.1016/s0735-1097(98)00177-6] [Citation(s) in RCA: 282] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES This review summarizes the results of single-photon emission computed tomographic (SPECT) technetium-99m (Tc-99m) tracer imaging in patients with stable symptoms, patients with acute coronary syndromes, patients undergoing major non-cardiac surgery and patients with chest pain in the emergency department. BACKGROUND Previous studies have examined the prognostic value of stress thallium imaging in several subsets of patients with ischemic heart disease. At present, >50% of myocardial perfusion studies are performed with technetium-labeled tracers in the United States. Furthermore, there is a shift from diagnostic to the prognostic utility of stress testing. There are important differences between technetium-labeled tracers and thallium-201. It is therefore important to review the prognostic value of technetium-labeled tracers. METHODS We analyzed published reports in English on risk assessment using Tc-99m perfusion tracers. Results. The largest experience is in patients with stable symptoms, comprising >12,000 patients in 14 studies. In these patients, normal stress SPECT sestamibi images were associated with an average annual hard event rate of 0.6% (death or nonfatal myocardial infarction [MI]). In contrast, patients with abnormal images had a 12-fold higher event rate (7.4% annually). Both fixed and reversible defects are prognostically important, and quantitative analysis shows increased risk in relation to the severity of the abnormality. These results are similar to those obtained with thallium-201. CONCLUSIONS Patients with stable chest pain syndromes and normal stress SPECT sestamibi images have a very low risk of death or nonfatal MI. It is highly unlikely that coronary revascularization can improve survival in such patients. Patients with abnormal images have an intermediate to high risk for future cardiac events, depending on the degree of the abnormality. Further prospective studies comparing aggressive medical therapy with coronary revascularization in these patients are warranted.
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Affiliation(s)
- S Iskander
- Department of Medicine, MCP-Hahnemann School of Medicine, Allegheny University of the Health Sciences, Philadelphia, Pennsylvania 19102, USA
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Claeys MJ, Blockx PP, Rademakers FE, Vrints CJ, Snoeck JP. Adenosine technetium-99m sestamibi single-photon emission tomography for the assessment of jeopardized myocardium early after acute myocardial infarction. Paradoxical scintigraphic underestimation of jeopardized myocardium in patients with a severe infarct-related stenosis. EUROPEAN JOURNAL OF NUCLEAR MEDICINE 1997; 24:1121-7. [PMID: 9283104 DOI: 10.1007/bf01254243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This study investigated the value of technetium-99m sestamibi scintigraphy in identifying patients at risk for post-infarct ischaemia (=jeopardized myocardium), especially within the reperfused infarct region. In 51 patients with a recent (<1 month) myocardial infarction, adenosine 99mTc-sestamibi single-photon emission tomography (SPET) and dobutamine stress echocardiography (DSE) were performed and correlated with the presence of significant coronary artery stenosis [% diameter stenosis (DS) >50%] on quantitative coronary angiography. Regional perfusion activity was analysed semi-quantitatively (score 0-4) on a 13-segment left ventricular model. DSE was used for the estimation of the infarct size (low-dose DSE) and for concomitant evaluation of ischaemia (high-dose DSE). A reversible perfusion defect within the infarct region was observed in 20 of the 37 patients with a significant infarct-related lesion (sensitivity of 54%) and only in one patient without a significant infarct-related lesion (specificity of 93%). Further analysis revealed that the scintigraphic assessment of jeopardized myocardium was fairly good in patients with a moderate (DS 51%-64%) infarct-related stenosis but was inadequate in patients with a severe (DS>/=65%) infarct-related stenosis (sensitivity of 80% vs 36%, P<0.01), while the echocardiographic detection of ischaemia was not influenced by stenosis severity (sensitivity of 73% in both subgroups). This scintigraphic underestimation of jeopardized myocardium was mainly related to a severely impaired myocardial perfusion under baseline conditions, as was evidenced by a significantly more severe rest perfusion score in the infarct region in patients with a severe stenosis as compared to those with a moderate stenosis (average score: 1.5+/-0.7 vs 2.1+/-0.6, P<0.01), while infarct size on echocardiography was similar for both subgroups. It may be concluded that early after an acute myocardial infarction, adenosine 99mTc-sestamibi SPET may underestimate reperfused but still jeopardized myocardium, particularly in patients with a severe infarct-related stenosis. In these patients the evaluation of the ischaemic burden on rest-stress scintigraphy is hampered by the presence of a severely impaired myocardial perfusion in resting conditions.
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Affiliation(s)
- M J Claeys
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
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17
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Radensky PW, Hilton TC, Fulmer H, McLaughlin BA, Stowers SA. Potential cost effectiveness of initial myocardial perfusion imaging for assessment of emergency department patients with chest pain. Am J Cardiol 1997; 79:595-9. [PMID: 9068515 DOI: 10.1016/s0002-9149(96)00822-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Previous investigations have confirmed the diagnostic and predictive usefulness of initial single-photon emission computed tomography (SPECT) myocardial perfusion imaging using technetium-99m sestamibi in the evaluation of emergency department patients with chest pain. Patients with a normal SPECT perfusion scan performed during chest pain have an excellent short-term prognosis, and may be candidates for expeditious cardiac evaluation or outpatient management. However, there are limited data regarding the cost effectiveness of this technique. This analysis models the potential cost effectiveness of this procedure. In the current investigation we compared 2 model strategies for management of emergency department patients with typical chest pain and a normal or nondiagnostic electrocardiogram (ECG). In 1 model strategy, (the technetium-99m sestamibi SPECT myocardial perfusion imaging [SCAN] strategy), the decision whether to admit or discharge a patient from the emergency department is based on results of initial technetium-99m sestamibi SPECT myocardial imaging. Patients with normal scans are discharged; others are admitted. In the second model strategy, (the NO SCAN strategy), the decision whether or not to admit a patient is based on a combination of clinical and electrocardiographic variables. Patients with > or = 3 cardiac risk factors or an abnormal ECG are admitted; others are discharged. Adverse cardiac events were prospectively defined as cardiac death, nonfatal myocardial infarction, or the need for acute coronary intervention. Costs were assigned using data derived from 102 patients who underwent SPECT myocardial perfusion imaging and an additional 107 emergency department patients with ongoing chest pain who either underwent or were eligible for initial SPECT myocardial perfusion imaging. Mean (+/- SE) costs were highest among hospital admitted patients who experienced an adverse cardiac event ($21,375 +/- $2,733) and lowest in patients discharged from the emergency department ($715 +/- 71). Mean costs per patient of the SCAN strategy and NO SCAN strategy were $5,019 versus $6,051, respectively. These results were stable in a sensitivity analysis across a range of costs and predictive values. Thus, the SCAN model strategy for initial management of emergency department patients with typical ongoing angina and a normal or nondiagnostic ECG using initial myocardial perfusion imaging with technetium-99m sestamibi appears to be safe, accurate, and potentially cost effective. Validation of these preliminary retrospective observations will require further prospective investigation.
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Affiliation(s)
- P W Radensky
- Health Law Department, McDermott, Will and Emery, Miami, Florida 33131, USA
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Zanco P, Zampiero A, Favero A, Borsato N, Chierichetti F, Rubello D, Ferlin G. Prognostic evaluation of patients after myocardial infarction: incremental value of sestamibi single-photon emission computed tomography and echocardiography. J Nucl Cardiol 1997; 4:117-24. [PMID: 9115063 DOI: 10.1016/s1071-3581(97)90060-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study compares the prognostic value of 99mTc-labeled methoxyisobutyl isonitrile (MIBI) single-photon emission computed tomographic (SPECT) imaging, echocardiography, and other clinical and laboratory prognostic factors in the long-term risk stratification of patients with stable uncomplicated infarcts. METHODS AND RESULTS Ninety-one consecutive patients affected by a first myocardial infarction without serious complications were enrolled. After at least 3 months from the infarction, they were submitted to stress-rest MIBI SPECT and rest echocardiography. Eighty-six patients completed a follow-up of at least 4 years (range 48 to 72 months; mean 55 months). By univariate (log-rank test) and multivariate analysis (Cox proportional hazards model), the main clinical, electrocardiographic, scintigraphic, and echocardiographic findings were evaluated and correlated statistically with the incidence of ensuing cardiac events. Twenty-five patients had cardiac events during the follow-up (four cardiac deaths, four myocardial infarctions, and 17 cases of unstable angina). At the multivariate analysis, the presence of reversible defects on MIBI SPECT (p = 0.008 and relative risk [RR] = 7.09), the wall motion score index, and the ejection fraction at echocardiography (respectively, p = 0.010, RR = 3.67, p = 0.036, and RR = 3.12), and stress angina (p = 0.007 and RR = 3.40) were significant and independent prognostic factors. CONCLUSIONS In our long-term follow-up, MIBI SPECT and echocardiography appeared to be significant and independent prognostic tools in the risk stratification of patients with stable, uncomplicated infarcts, furnishing complementary information. The reversibility of MIBI defects appeared the best indicator for a bad prognosis.
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Affiliation(s)
- P Zanco
- Nuclear Medicine Department, Castelfranco Veneto, Italy
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Heller GV, Herman SD, Travin MI, Baron JI, Santos-Ocampo C, McClellan JR. Independent prognostic value of intravenous dipyridamole with technetium-99m sestamibi tomographic imaging in predicting cardiac events and cardiac-related hospital admissions. J Am Coll Cardiol 1995; 26:1202-8. [PMID: 7594033 DOI: 10.1016/0735-1097(95)00329-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES This study sought to establish the prognostic value of intravenous dipyridamole technetium-99m (Tc-99m) sestamibi single-photon emission computed tomographic (SPECT) myocardial perfusion imaging. BACKGROUND Optimal management of patients with coronary artery disease involves strategies designed to reduce the risk of myocardial infarction and cardiac death. The role of myocardial perfusion imaging using newer clinical techniques to determine risk and possible benefit from therapy has not been evaluated. METHODS Myocardial imaging results were classified as normal or abnormal (fixed or reversible defects; small, moderate or large). Follow-up evaluation of all patients included the occurrence of cardiac death or nonfatal myocardial infarction and other cardiac-related hospital admissions. RESULTS During a mean (+/- SD) follow-up period of 12.8 +/- 6.8 months in 512 patients, 25 had a cardiac event. Patients with abnormal perfusion had significantly more cardiac events than those with normal perfusion (22 vs. 3, p < 0.01). Patients with reversible defects had the highest event rates (8.6%), and those with normal study results had a very low event rate (1.4%). Large defects were strongly associated with more cardiac events and hospital admissions than either normal scan results or abnormal results showing small defects. CONCLUSIONS Patients with normal study results or a small defect after intravenous dipyridamole Tc-99m sestamibi SPECT imaging had an excellent short-term prognosis. Those with abnormal results (reversible or large defect) had an increased risk of subsequent cardiac death, nonfatal myocardial infarction and other cardiac-related hospital admissions.
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Affiliation(s)
- G V Heller
- Nuclear Cardiology Laboratory, Hartford Hospital, Connecticut 06102, USA
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Zanco P, Zampiero A, Favero A, Borsato N, Chierichetti F, Rubello D, Saitta B, Ferlin G. Myocardial technetium-99m sestamibi single-photon emission tomography as a prognostic tool in coronary artery disease: multivariate analysis in a long-term prospective study. EUROPEAN JOURNAL OF NUCLEAR MEDICINE 1995; 22:1023-8. [PMID: 7588939 DOI: 10.1007/bf00808414] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
To date several studies have evaluated the accuracy of thallium-201 myocardial scan in risk stratification of coronary artery disease (CAD), while reports using technetium-99m methoxyisobutylisonitrile (MIBI), a tracer particularly suited to single-photon emission tomographic (SPET) imaging, are lacking. To rectify this omission, a prospective study was started in 1988 and at present 176 consecutive, and thus unselected, patients have been enrolled. All of them have been submitted to stress-rest MIBI SPET for the diagnosis or evaluation of CAD; 147 patients (121 males and 26 females, aged 53 +/- 9 years) have completed a surveillance period of at least 36 months following the scintigraphic study (range 36-60 months, mean 43). Sixty-one patients had a documented previous myocardial infarction. The mean pre-test likelihood of CAD was 44% in the patients without prior infarction. The main anamnestic, clinical, EKG and scintigraphic findings were evaluated and statistically correlated with the incidence of ensuing cardiac events using both univariate (chi-square test) and multivariate analysis (logistic regression model). Twenty-nine patients suffered from a cardiac event during the follow-up period (i.e. three cardiac deaths, six myocardial infarctions and 20 cases of unstable angina). Statistical multivariate analysis identified MIBI scan as the only highly significant and independent prognostic predictor [P = 0.006, relative risk (RR) = 17.62]. In detail, the most important scintigraphic parameters were the presence of a reversible defect (P = 0.0089, RR = 5.11) and the extension of the stress perfusion defect (P = 0.0255, RR = 3.27). The presence of typical angina proved to be a slightly significant predictor (P = 0.051, RR = 2.45), while no other examined parameter showed a significant correlation with a bad prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P Zanco
- Department of Nuclear Medicine, Ospedale S. Giacomo Apostolo, Castelfranco Veneto, Italy
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Travin MI, Dessouki A, Cameron T, Heller GV. Use of exercise technetium-99m sestamibi SPECT imaging to detect residual ischemia and for risk stratification after acute myocardial infarction. Am J Cardiol 1995; 75:665-9. [PMID: 7900657 DOI: 10.1016/s0002-9149(99)80650-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The clinical presentation, electrocardiographic findings, and technetium-99m sestamibi single-photon emission computed tomography (SPECT) imaging results of 134 consecutive patients who underwent nuclear exercise testing within 14 days of an acute myocardial infarction (AMI) were correlated with cardiac events over a 15 +/- 10-month follow-up. Whereas only 23 patients (17%) had chest pain and 31 (23%) had ischemic ST-segment depression during exercise, 94 (70%) had ischemia on SPECT (p < 0.001). On follow-up, 13 patients experienced a cardiac event: 7 were rehospitalized for unstable angina, 3 had recurrent AMI, and 3 died of cardiac causes. Ischemia on the sestamibi images identified 11 of these patients (85%), whereas chest pain identified only 3 (23%, p = 0.006), and electrocardiographic ischemia identified only 4 (31%, p = 0.017). The presence of either ischemia as seen on SPECT or defects in multiple vascular territories identified 12 patients (92%) with an event, including all who had cardiac death. By Cox regression analysis of clinical, stress, and image parameters, the number of ischemic defects on SPECT was the only significant correlate of a future event (chi-square = 4.62, p = 0.03), and patients with > or = 3 reversible sestamibi defects had an event rate of 38%. The extent of ischemia as seen on nuclear imaging remained a strong correlate (p = 0.008) of an event in the 54 patients (40%) who had received thrombolytic therapy. Thus, exercise technetium-99m sestamibi SPECT after AMI frequently reveals residual ischemia, and is better than clinical data, symptoms, and stress electrocardiographic data in identifying patients who will have a subsequent cardiac event.
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Affiliation(s)
- M I Travin
- Division of Cardiology, Roger Williams Medical Center, Providence, Rhode Island 02908, USA
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