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Wong JJJ, Yew MS. Implications of transient ischemic dilatation and impaired left ventricular ejection fraction reserve in patients with normal stress myocardial perfusion imaging and elevated coronary artery calcium. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:1651-1658. [PMID: 38819545 DOI: 10.1007/s10554-022-02549-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/01/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Guidelines recommend stress only (SO) myocardial perfusion imaging (MPI) without follow-up rest imaging if perfusion and left ventricular ejection fraction (LVEF) are normal. However additional rest imaging may show transient ischaemic dilation (TID) and/or impaired LVEF reserve (iLVEFr) suggestive of 'balanced ischemia'. Concurrent coronary artery calcium (CAC) scoring helps to identify subclinical atherosclerosis. The safety of SO MPI when CAC is elevated is unclear. We aim to assess the incidence and outcomes of TID and iLVEFr amongst stress/rest MPIs with normal SO images and elevated CAC. METHODS Retrospective analysis of normal stress/rest MPIs performed between 1 March 2016 to 31 January 2017 with concurrently measured CAC >300. Cases were stratified by presence of TID and/or iLVEFr. Major adverse cardiac events (MACE, defined as cardiac death, non-fatal myocardial infarction and revascularization) within 24 months were compared. RESULTS There were 230 cases included of which 43 (18.7%) had TID and/or iLVEFr. Presence of TID and/or iLVEFr was associated with higher 24-month MACE (23.3 vs. 8.6%, p = 0.013), driven by more elective revascularizations (18.6 vs. 4.3%, p = 0.001). Cardiac death and non-fatal myocardial infarction rates were similar. TID and/or iLVEFr significantly predicted overall MACE after multivariate analysis (OR 2.933 [1.214 - 7.087], p = 0.017). CONCLUSIONS TID and/or iLVEFr is seen in the minority of normal stress MPI with elevated CAC, and is associated with higher 24-month MACE, driven by higher elective revascularizations. Overall cardiac death and non-fatal myocardial infarction rates were low and not significantly different between both groups.
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Affiliation(s)
| | - Min Sen Yew
- Department of Cardiology, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, 308433, Singapore, Singapore.
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Obeidat OS, Alhouri A, Baniissa B, Alqaisi O, Akkawi M, Zyad H, Alrimawi O, Al Jabi M, Jaradat S, Jawabreh H, Al-Batsh O, Alaraj O, Juweid ME. Prognostic significance of post-stress reduction in left ventricular ejection fraction with adenosine stress in Jordanian patients with normal myocardial perfusion. J Nucl Cardiol 2020; 27:1596-1606. [PMID: 31044401 DOI: 10.1007/s12350-019-01725-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 04/01/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The significance of post-stress reduction in left ventricular ejection fraction (LVEF) in patients with normal perfusion on adenosine stress/rest imaging remains controversial. METHODS Consecutive patients who underwent 2-day adenosine gated stress/rest 99mTc-sestamibi imaging and had normal perfusion were analyzed. LVEF was quantified at rest and 1 hour post-adenosine. Patients were followed up for hard (cardiac death or nonfatal MI) and soft (coronary revascularization or congestive heart failure) cardiac events for 24.1 ± 11.0 months. RESULTS Of 560 patients included in the study, 135 (24.1%) had a post-stress reduction in LVEF of ≥ 5%. Rest LVEF (P < 0.001), known history of CAD (P = 0.01) and transient ischemic dilatation ratio (P = 0.02) were independent predictors of LVEF reduction. Event-free survivals were similar in patients with and without ≥ 5% LVEF reduction (P = 0.8). The unadjusted hazard ratio (95% CI) for cardiac events for ≥ 5% LVEF reduction was 1.09 (0.55-2.15), P = 0.81, while the hazard ratio adjusted for known history of CAD, smoking, post-stress LVEF and peak heart rate was 0.87 (0.44-1.75), P = 0.71. CONCLUSIONS Significant post-adenosine reduction in LVEF occurs in about one-fourth of patients with normal perfusion but does not confer adverse prognosis compared with patients without such reduction.
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Affiliation(s)
- Omar S Obeidat
- Division of Cardiology/Department of Medicine, University of Jordan, Amman, Jordan
| | - Abdullah Alhouri
- Division of Cardiology/Department of Medicine, University of Jordan, Amman, Jordan
| | - Bayan Baniissa
- Division of Cardiology/Department of Medicine, University of Jordan, Amman, Jordan
| | - Omar Alqaisi
- Division of Cardiology/Department of Medicine, University of Jordan, Amman, Jordan
| | - Mohammad Akkawi
- Division of Cardiology/Department of Medicine, University of Jordan, Amman, Jordan
| | - Heba Zyad
- Division of Cardiology/Department of Medicine, University of Jordan, Amman, Jordan
| | - Omar Alrimawi
- Division of Cardiology/Department of Medicine, University of Jordan, Amman, Jordan
| | - Mira Al Jabi
- Division of Nuclear Medicine/Department of Radiology and Nuclear Medicine, University of Jordan, Queen Rania Street, Al Jubeiha, Amman, 11942, Jordan
| | - Saba Jaradat
- Division of Nuclear Medicine/Department of Radiology and Nuclear Medicine, University of Jordan, Queen Rania Street, Al Jubeiha, Amman, 11942, Jordan
| | - Hamza Jawabreh
- Division of Cardiology/Department of Medicine, University of Jordan, Amman, Jordan
| | - Odai Al-Batsh
- Division of Cardiology/Department of Medicine, University of Jordan, Amman, Jordan
| | - Othman Alaraj
- Division of Cardiology/Department of Medicine, University of Jordan, Amman, Jordan
| | - Malik E Juweid
- Division of Nuclear Medicine/Department of Radiology and Nuclear Medicine, University of Jordan, Queen Rania Street, Al Jubeiha, Amman, 11942, Jordan.
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Bestetti A, Cuko B, Gasparini M, De Servi S. Better characterization of dipyridamole-induced myocardial stunning by systolic wall thickening. A gated perfusion SPECT study. J Nucl Cardiol 2020; 27:137-146. [PMID: 29951894 DOI: 10.1007/s12350-018-1340-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/04/2018] [Indexed: 11/30/2022]
Abstract
AIM AND PATIENTS The aim of the present study was to assess the additional value of systolic wall thickening to myocardial perfusion in diagnosing myocardial stunning induced by dipyridamole infusion. We selected 52 ischemic patients (43 males; mean age 65.5 ± 7.64), with CAD documented by angiography. Ischemia was defined as a summed difference score ≥ 5. All patients underwent a 2-day gated perfusion SPECT protocol. The patients received a dose of 740 MBq of 99mTc-tetrofosmin after stress and at rest. RESULTS The post-stress LVEF was significantly lower than rest LVEF (48.3% ± 14.5% vs. 50.7% ± 15%; P = 0.0001). The wall thickening summed difference score was 3.97 ± 3.84 (P = 0.0001). At a multivariate regression analysis, only WT-SDS as independent variable was significantly correlated with myocardial ischemia (SDS) (P = 0.001). We divided patients according to SDS in those with mild (SDS < 8) and severe (SDS ≥ 8) ischemia. WT-SDS, but not ∆LVEF, was significantly different between groups. CONCLUSIONS WT-SDS showed a better correlation with the degree of ischemia than the depression in the global function of the left ventricle. It allowed to better identify the stunning phenomenon in patients submitted to pharmacological stress.
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Affiliation(s)
- Alberto Bestetti
- Department of Clinical and Biomedical Sciences, University of Milan, Milan, Italy.
- Department of Nuclear Medicine, IRCCS MultiMedica Sesto San Giovanni, Milan, Italy.
| | - Besart Cuko
- School of Specialty in Cardiac Surgery, University of Brescia, Brescia, Italy
| | - Massimo Gasparini
- Department of Nuclear Medicine, IRCCS MultiMedica Sesto San Giovanni, Milan, Italy
| | - Stefano De Servi
- Cardiovascular Department, IRCCS MultiMedica Sesto San Giovanni, Milan, Italy
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Marcassa C, Giubbini R, Acampa W, Cittanti C, Djepaxhija O, Gimelli A, Kokomani A, Medolago G, Milan E, Sciagrà R. Impact of imaging protocol on left ventricular ejection fraction using gated-SPECT myocardial perfusion imaging. J Nucl Cardiol 2017; 24:1292-1301. [PMID: 27052809 DOI: 10.1007/s12350-016-0483-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND There are limited data on the impact of the imaging protocol (single-day stress-rest, SD, vs. dual-day, DD) on the change in left ventricular (LV) ejection fraction (EF) (post-stress-rest) in relation to ischemia and on outcome. METHODS Using propensity score matching procedure, 490 of 1121 patients with known CAD, undergoing a SD or a DD in a multicenter study, were evaluated. Stress and rest gated-SPECT myocardial perfusion imaging was used to quantify LV perfusion, EF, and volumes. Outcome was assessed at an average follow-up time of 3.2 years. RESULTS Post-stress LVEF in SD and DD were comparable across all degrees of ischemia. The change in LVEF in patients with severe ischemia was, however, higher in the DD protocol, independent of the extent of CAD. At follow-up, 240 patients (49.0%) required coronary revascularization (CR) and 52 patients (10.6%) had hard events. The ischemic burden was independently associated with CR and hard-events; the post-stress LVEF was associated with CR but the change in EF was not predictive of either CR or hard events. CONCLUSIONS In patients with severe ischemia, underestimation of post-stress myocardial stunning could be observed with the SD protocol. Post-stress LVEF and the extent ischemia, but not the change in EF, are predictive of CR and hard events.
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Affiliation(s)
- C Marcassa
- Cardiology Department, S. Maugeri Fnd, IRCCS, Scientific Institute of Veruno, Veruno, Italy.
| | - R Giubbini
- Department of Medical Imaging, University and Spedali Civili, Brescia, Italy
| | - W Acampa
- Department of Advanced Biomedical Sciences, University "Federico II", Naples, Italy
| | - C Cittanti
- Nuclear Medicine Unit, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - O Djepaxhija
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - A Gimelli
- Fondazione Toscana G. Monasterio, Pisa, Italy
| | - A Kokomani
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | | | - E Milan
- Nuclear Medicine Unit, San Giacomo Apostolo Hospital, Castelfranco Veneto, Italy
| | - R Sciagrà
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
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Folate therapy improves the stress-to-rest mean LV volume ratio in myocardial perfusion imaging in patients with diabetes. Ann Nucl Med 2015; 29:740-4. [PMID: 26184841 DOI: 10.1007/s12149-015-0996-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Accepted: 06/24/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Patients with diabetes have higher stress-to-rest mean left ventricular volume (SRLVV) ratio in myocardial perfusion imaging (MPI) and hyperhomocysteinemia. We studied the effect of folate therapy on SRLVV ratio and plasma homocysteine levels in patients with diabetes. METHODS Forty patients were enrolled and thirty-two completed the study. The patients underwent a 2-day pharmacological stress test and rest MPI before and 2 months after treatment with either 5 mg folic acid or placebo. SRLVV ratios were calculated, and plasma homocysteine levels were measured, before and after treatment. RESULTS Among the 32 patients who completed the study, 15 received folic acid and 17 received placebo. The age of subjects (folate 51.5 ± 6.1 years; placebo 50.6 ± 8.1 years), male/female ratio (folate 6/11; placebo 9/6),or MPI findings (proportion of normal results: folate 80.0 %; placebo 94.1 %) were similar between the two groups. The baseline SRLVV ratio was similar between groups (folate: 1.00 ± 0.09 vs. placebo: 0.97 ± 0.13); however, the post-treatment SRLVV ratio was significantly lower (P < 0.001) in the folate group than in the placebo group (folate: 0.93 ± 0.10 vs. placebo: 1.04 ± 0.17). A general linear repeated-measures model showed a significant difference in the change in SRLVV ratio between participants receiving folate and those receiving placebo. Post-treatment homocysteine level was lower after folate treatment (from 14.5 ± 4.6 to 11.5 ± 5.3 µmol/L), as compared to placebo (from 13.7 ± 5.0 to 17.9 ± 4.5 µmol/L) (P = 0.01). The changes in SRLVV ratio and homocysteine level were correlated (r = 0.45; P = 0.016). CONCLUSIONS Short-term folate therapy reduced SRLVV ratio and plasma homocysteine level.
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Modolo R, de Faria AP, Paganelli MO, Sabbatini AR, Barbaro NR, Nascimento BB, Ramos CD, Fontana V, Calhoun DA, Moreno H. Predictors of silent myocardial ischemia in resistant hypertensive patients. Am J Hypertens 2015; 28:200-7. [PMID: 25063735 DOI: 10.1093/ajh/hpu140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Hypertension is the most prevalent and significant modifiable risk factor for coronary heart disease. A portion of patients with uncontrolled hypertension are considered to have resistant hypertension (RHTN). Myocardial ischemia incidence increases along with blood pressure (BP) levels. However, the prevalence of myocardial ischemia in patients with RHTN, as well as the factors associated with it, is unknown. METHODS We enrolled 129 patients with true RHTN regularly followed in our specialty hypertension clinic and evaluated then by resting and dipyridamole pharmacological stress myocardial perfusion scintigraphy. Patients were then divided into 2 groups: those with (I-RHTN; n = 36) and those without (NI-RHTN; n = 93) myocardial ischemia. Echocardiography, 24-hour ambulatory BP monitoring (ABPM), and flow mediated dilation (FMD) were also evaluated. RESULTS Thirty six (28%) patients had myocardial ischemia. There was no difference between groups regarding age, sex, biochemical parameters, office, and 24-hour ABPM levels. Patients in the I-RHTN group were more likely diabetic (31% vs. 11%; P < 0.05) and obese (75% vs. 40%; P < 0.001). Adjusting for age and body mass index, multiple logistic regression showed that diabetes (odds ratio (OR) = 6.5; 95% confidence interval (CI) = 1.06-40.14; P = 0.04), FMD (OR = 0.18; 95% CI = 0.07-0.41; P < 0.001), heart rate (OR = 1.23; 95% CI = 1.11-1.36; P < 0.001), left ventricular mass index (OR = 1.02; 95% CI = 1.01-1.04; P = 0.04), and microalbuminuria (OR = 1.02; 95% CI = 1.01-1.04; P = 0.002) were independent predictors of ischemia. CONCLUSIONS In conclusion, there is a high prevalence of myocardial ischemia in patients with RHTN. Increased microalbuminuria, heart rate, endothelial dysfunction, and left ventricular mass can be useful to guide the investigation for myocardial ischemia in these high risk patients.
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Affiliation(s)
- Rodrigo Modolo
- Department of Pharmacology, Faculty of Medical Sciences University of Campinas-UNICAMP, Campinas, SP, Brazil;
| | - Ana Paula de Faria
- Department of Pharmacology, Faculty of Medical Sciences University of Campinas-UNICAMP, Campinas, SP, Brazil
| | - Maria O Paganelli
- Department of Pharmacology, Faculty of Medical Sciences University of Campinas-UNICAMP, Campinas, SP, Brazil
| | - Andréa R Sabbatini
- Department of Pharmacology, Faculty of Medical Sciences University of Campinas-UNICAMP, Campinas, SP, Brazil
| | - Natália R Barbaro
- Department of Pharmacology, Faculty of Medical Sciences University of Campinas-UNICAMP, Campinas, SP, Brazil
| | - Beatriz B Nascimento
- Department of Radiology, Faculty of Medical Sciences, University of Campinas-UNICAMP, Campinas, SP, Brazil
| | - Celso D Ramos
- Department of Radiology, Faculty of Medical Sciences, University of Campinas-UNICAMP, Campinas, SP, Brazil
| | - Vanessa Fontana
- Department of Pharmacology, Faculty of Medical Sciences University of Campinas-UNICAMP, Campinas, SP, Brazil
| | - David A Calhoun
- Vascular Biology and Hypertension Program, University of Alabama at Birmingham, Birmingham, Alabama
| | - Heitor Moreno
- Department of Pharmacology, Faculty of Medical Sciences University of Campinas-UNICAMP, Campinas, SP, Brazil
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Impaired renal function is a major determinant of left ventricular diastolic dysfunction: assessment by stress myocardial perfusion imaging. Ann Nucl Med 2013; 27:729-36. [PMID: 23712332 PMCID: PMC3824632 DOI: 10.1007/s12149-013-0739-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 05/14/2013] [Indexed: 11/15/2022]
Abstract
Objective Relationships between myocardial scintigraphic parameters and renal function have not been fully determined. We investigated correlations between estimated glomerular filtration rate (eGFR) and left ventricular (LV) diastolic function using stress electrocardiographic (ECG)-gated myocardial single photon emission computed tomography (SPECT). Methods We enrolled 136 consecutive patients with suspected coronary artery disease (CAD) who were assessed using technetium-99m stress ECG-gated myocardial SPECT. We evaluated SPECT images using 17-segment defect scores graded on a 5-point scale, summed stress score, summed rest score and summed difference score (SDS). The parameters for assessing LV diastolic function were peak filling rate (PFR), 1/3 mean filling rate and time to peak filling. The CAD was defined as SDS ≥2. Chronic kidney disease (CKD) was defined as eGFR <60 mL/min/1.73 m2. Patients were assigned to the following four groups (no CAD/no CKD: control group, n = 68; CAD/no CKD: CAD group, n = 24; no CAD/CKD: CKD group, n = 34; CAD/CKD: CAD + CKD group, n = 10). Results The PFR was significantly impaired after stress in the CKD and CAD + CKD groups compared with controls (p < 0.001 for both). Furthermore, PFR at rest positively correlated with eGFR (r = 0.29, p < 0.001) and inversely correlated with SDS (r = −0.18, p < 0.05). Multivariate stepwise regression analysis independently associated eGFR with PFR (β coefficient = 0.260, p = 0.002). Conclusions Our data suggest that impaired renal function is a significant determinant of LV diastolic dysfunction in patients with suspected CAD.
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Assessment of left ventricular dyssynchrony in patients with coronary artery disease during adenosine stress using ECG-gated myocardial perfusion single-photon emission computed tomography. Nucl Med Commun 2010; 31:864-73. [PMID: 20683366 DOI: 10.1097/mnm.0b013e32833cf4be] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Some investigators have reported that left ventricular (LV) mechanical systolic and diastolic dyssynchrony occurs in coronary artery disease (CAD) patients without earlier myocardial infarction and narrow QRS complex duration. However, earlier studies evaluated LV dyssynchrony only at rest. The purpose of this study was to investigate LV dyssynchrony in CAD patients with preserved ejection fraction during adenosine stress using electrocardiogram-gated myocardial perfusion single-photon emission computed tomography (SPECT). METHODS The study population included 18 CAD patients and 18 control subjects. CAD patients had significant stenosis in their coronary arteries by coronary angiogram without earlier myocardial infarction. SPECT images were acquired at rest and during stress with adenosine. The regional time to end systole (TES), time to peak ejection, the time from 0 to peak filling during the whole diastolic period (TPF1), and the time from end systole to peak filling during the whole diastolic period (TPF2) were obtained by using the Quantitative Gated SPECT software. The maximal difference (MD), which is the difference between the earliest and latest temporal parameter among 17 segments, was considered to represent LV dyssynchrony. RESULTS MD-TES and MD-TPF1 during stress were significantly greater than those of rest in CAD patients (MD-TES: stress=242+/-107 ms, rest=164+/-79 ms; P=0.005, MD-TPF1: stress=249+/-121 ms, rest=164+/-88 ms; P=0.015) but there were no significant differences in control patients. CONCLUSION LV dyssynchrony was shown in CAD with preserved ejection fraction during adenosine stress.
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