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Sidrak MMA, De Feo MS, Gorica J, Corica F, Conte M, Filippi L, De Vincentis G, Frantellizzi V. Medication and ECG Patterns That May Hinder SPECT Myocardial Perfusion Scans. Pharmaceuticals (Basel) 2023; 16:854. [PMID: 37375801 DOI: 10.3390/ph16060854] [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: 04/28/2023] [Revised: 05/24/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023] Open
Abstract
Coronary artery disease (CAD) is the leading cause of death followed by cancer, in men and women. With risk factors being endemic and the increasing costs of healthcare for management and treatment, myocardial perfusion imaging (MPI) finds a central role in risk stratification and prognosis for CAD patients, but it comes with its limitations in that the referring clinician and managing team must be aware of and use at their advantage. This narrative review examines the utility of myocardial perfusion scans in the diagnosis and management of patients with ECG alterations such as atrioventricular block (AVB), and medications including calcium channel blockers (CCB), beta blockers (BB), and nitroglycerin which may impact the interpretation of the exam. The review analyzes the current evidence and provides insights into the limitations, delving into the reasons behind some of the contraindications to MPI.
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Affiliation(s)
- Marko Magdi Abdou Sidrak
- Department of Radiological Sciences, Oncology and Anatomo-Pathology, Sapienza, University of Rome, 00161 Rome, Italy
| | - Maria Silvia De Feo
- Department of Radiological Sciences, Oncology and Anatomo-Pathology, Sapienza, University of Rome, 00161 Rome, Italy
| | - Joana Gorica
- Department of Radiological Sciences, Oncology and Anatomo-Pathology, Sapienza, University of Rome, 00161 Rome, Italy
| | - Ferdinando Corica
- Department of Radiological Sciences, Oncology and Anatomo-Pathology, Sapienza, University of Rome, 00161 Rome, Italy
| | - Miriam Conte
- Department of Radiological Sciences, Oncology and Anatomo-Pathology, Sapienza, University of Rome, 00161 Rome, Italy
| | - Luca Filippi
- Department of Nuclear Medicine, Santa Maria Goretti Hospital, 04100 Latina, Italy
| | - Giuseppe De Vincentis
- Department of Radiological Sciences, Oncology and Anatomo-Pathology, Sapienza, University of Rome, 00161 Rome, Italy
| | - Viviana Frantellizzi
- Department of Radiological Sciences, Oncology and Anatomo-Pathology, Sapienza, University of Rome, 00161 Rome, Italy
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Eshraghi A, Talasaz AH, Salamzadeh J, Bahremand M, Salarifar M, Nozari Y, Jenab Y, Boroumand MA, Vaseghi G, Eshraghi N. Study of the possible medical and medication explanatory factors of angiographic outcomes in patients with acute ST elevation myocardial infarction undergoing primary percutaneous intervention. Adv Biomed Res 2014; 3:186. [PMID: 25250300 PMCID: PMC4166209 DOI: 10.4103/2277-9175.140096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 09/08/2013] [Indexed: 11/04/2022] Open
Abstract
Background: Myocardial blush grade (MBG), thrombolysis in myocardial infarction (TIMI) and corrected TIMI frame count (cTFC) are indices of successful angiographic reperfusion. This study sought to determine the predictors of angiographically successful reperfusion including demographic, clinical and angiographic factors in patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). Materials and Methods: A cross-sectional study of patients with a confirmed diagnosis of STEMI undergoing pPCI was designed. Eligible patients referring to a university heart center were enrolled in the study from March 2012 to December 2012. Successful epicardial reperfusion was defned as TIMI flow grade 3 or cTFC<= 28 frames and successful myocardial reperfusion as MBG 2 or 3. Results: The study population consisted of 100 patients, including 74 males and 26 females, with mean ± standard deviation age of 58.27 ± 11.60 years. Achieving open microvasculature (MBG 2/3) was positively associated with a history of nitrate intake (P = 0.03) and history of calcium channel blocker (CCB) intake (P = 0.005). Hyperglycemia was inversely associated with achieving a final cTFC ≤ 28 frames (r = −0.32, P = 0.001). Conclusions: Our findings suggest that patients with a history of nitrate and CCB intake had a higher likelihood of successful PCI. In addition, patients with a higher blood glucose level on admission may have a reduced rate of reperfusion success. Future studies with a larger sample size are recommended to investigate the significant relationships observed in this study.
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Affiliation(s)
- Azadeh Eshraghi
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti, University of Medical Sciences, Tehran, Iran ; Students Research Committee, Shahid Beheshti, University of Medical Sciences, Tehran, Iran
| | - Azita Hajhossein Talasaz
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran ; Department of cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jamshid Salamzadeh
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti, University of Medical Sciences, Tehran, Iran
| | | | - Mojtaba Salarifar
- Department of cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Yones Nozari
- Department of cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Yaser Jenab
- Department of cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Boroumand
- Department of cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Golnaz Vaseghi
- Department of pharmacology, Applid Physiology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nazanin Eshraghi
- Department of Radiology, Tabriz University of Medical Science, Tabriz, Iran
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Heaps CL, Parker JL. Effects of exercise training on coronary collateralization and control of collateral resistance. J Appl Physiol (1985) 2011; 111:587-98. [PMID: 21565987 DOI: 10.1152/japplphysiol.00338.2011] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Coronary collateral vessels serve as a natural protective mechanism to provide coronary flow to ischemic myocardium secondary to critical coronary artery stenosis. The innate collateral circulation of the normal human heart is typically minimal and considerable variability occurs in extent of collateralization in coronary artery disease patients. A well-developed collateral circulation has been documented to exert protective effects upon myocardial perfusion, contractile function, infarct size, and electrocardiographic abnormalities. Thus therapeutic augmentation of collateral vessel development and/or functional adaptations in collateral and collateral-dependent arteries to reduce resistance into the ischemic myocardium represent a desirable goal in the management of coronary artery disease. Tremendous evidence has provided documentation for the therapeutic benefits of exercise training programs in patients with coronary artery disease (and collateralization); mechanisms that underlie these benefits are numerous and multifaceted, and currently under investigation in multiple laboratories worldwide. The role of enhanced collateralization as a major beneficial contributor has not been fully resolved. This topical review highlights literature that examines the effects of exercise training on collateralization in the diseased heart, as well as effects of exercise training on vascular endothelial and smooth muscle control of regional coronary tone in the collateralized heart. Future directions for research in this area involve further delineation of cellular/molecular mechanisms involved in effects of exercise training on collateralized myocardium, as well as development of novel therapies based on emerging concepts regarding exercise training and coronary artery disease.
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Affiliation(s)
- Cristine L Heaps
- Michael E. DeBakey Institute for Comparative Cardiovascular Science and Biomedical Devices, Department of Veterinary Physiology and Pharmacology, Texas A&M University, College Station, Texas 77843, USA.
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Anti-ischemic medication during myocardial perfusion: with or without? Nucl Med Commun 2010; 31:94-6. [DOI: 10.1097/mnm.0b013e328333d2de] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ozdemir AO, Gulec S, Uslu N, Kaya CT, Ozdol C, Turhan S, Atmaca Y, Altin T, Erol C. The relation between endothelial dependent flow mediated dilation of the brachial artery and coronary collateral development - a cross sectional study. Cardiovasc Ultrasound 2009; 7:25. [PMID: 19527494 PMCID: PMC2702291 DOI: 10.1186/1476-7120-7-25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Accepted: 06/15/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endothelial dysfunction is thought to be a potential mechanism for the decreased presence of coronary collaterals. The aim of the study was to investigate the association between systemic endothelial function and the extent of coronary collaterals. METHODS We investigated the association between endothelial function assessed via flow mediated dilation (FMD) of the brachial artery following reactive hyperemia and the extent of coronary collaterals graded from 0 to 3 according to Rentrop classification in a cohort of 171 consecutive patients who had high grade coronary stenosis or occlusion on their angiograms. RESULTS Mean age was 61 years and 75% were males. Of the 171 patients 88 (51%) had well developed collaterals (grades of 2 or 3) whereas 83 (49%) had impaired collateral development (grades of 0 or 1). Patients with poor collaterals were significantly more likely to have diabetes (p = 0.001), but less likely to have used statins (p = 0.083). FMD measurements were not significantly different among good and poor collateral groups (11.5 +/- 5.6 vs. 10.4 +/- 6.2% respectively, p = 0.214). Nitroglycerin mediated dilation was also similar (13.4 +/- 5.9 vs. 12.8 +/- 6.5%, p = 0.521). CONCLUSION No significant association was found between the extent of angiographically visible coronary collaterals and systemic endothelial function assessed by FMD of the brachial artery.
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Affiliation(s)
- Aydan Ongun Ozdemir
- Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey.
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Mahmarian JJ. Myocardial perfusion imaging to evaluate the efficacy of medical therapy in patients with coronary artery disease. CURRENT CARDIOVASCULAR IMAGING REPORTS 2009. [DOI: 10.1007/s12410-009-0023-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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The Effects of Medications on Myocardial Perfusion. J Am Coll Cardiol 2008; 52:401-16. [PMID: 18672159 DOI: 10.1016/j.jacc.2008.04.035] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Revised: 04/14/2008] [Accepted: 04/21/2008] [Indexed: 11/23/2022]
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Silent Ischemia. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Eriksen UH, Nielsen TT, Egeblad H, Bagger JP. Coronary collaterals during single-vessel coronary angioplasty: effects of nitroglycerin. Clin Cardiol 2006; 25:340-4. [PMID: 12109868 PMCID: PMC6654386 DOI: 10.1002/clc.4950250707] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Although the protective role of collaterals in coronary artery disease (CAD) is well known, the influence of drugs on collateral function remains controversial. HYPOTHESIS We aimed to investigate prospectively the prevalence of spontaneously visible and recruitable coronary collaterals in consecutive patients with single-vessel CAD and the effect of systemic administration of nitroglycerin on these types of collaterals during percutaneous transluminal coronary angioplasty (PTCA). METHODS Ipsi- and contralateral coronary artery contrast injections were performed before and during PTCA. Simultaneously with balloon occlusion, we measured coronary artery occlusion pressure via the balloon catheter. All measurements were repeated after administration of 0.5 mg of nitroglycerin intravenously. RESULTS Of 101 consecutive patients, 24% had spontaneously visible and 30% had recruitable collaterals. Contralateral collaterals were five times more frequent than ipsilateral collaterals. Presence of collaterals was highly associated with the degree of coronary stenosis. Coronary occlusion pressure was higher in patients with than in those without collaterals. Collaterals prevented pain and ischemia during PTCA, and in this respect spontaneously visible collaterals were more effective than recruitable collaterals. There was no effect of systemic administration of nitroglycerin on appearance or occlusion pressure of coronary collaterals. CONCLUSION Coronary collaterals were found in more than half of patients with single-vessel CAD, as the prevalence of recruitable collaterals was slightly higher than that of spontaneously visible collaterals. Nitroglycerin did neither recruit nor augment coronary collaterals.
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Mahmarian JJ, Dakik HA, Filipchuk NG, Shaw LJ, Iskander SS, Ruddy TD, Keng F, Henzlova MJ, Allam A, Moyé LA, Pratt CM. An Initial Strategy of Intensive Medical Therapy Is Comparable to That of Coronary Revascularization for Suppression of Scintigraphic Ischemia in High-Risk But Stable Survivors of Acute Myocardial Infarction. J Am Coll Cardiol 2006; 48:2458-67. [PMID: 17174182 DOI: 10.1016/j.jacc.2006.07.068] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2006] [Revised: 07/05/2006] [Accepted: 07/06/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the relative benefit of intensive medical therapy compared with coronary revascularization for suppressing scintigraphic ischemia. BACKGROUND Although medical therapies can reduce myocardial ischemia and improve patient survival after acute myocardial infarction, the relative benefit of medical therapy versus coronary revascularization for reducing ischemia is unknown. METHODS A prospective randomized trial in 205 stable survivors of acute myocardial infarction was made to define the relative efficacy of an intensive medical therapy strategy versus coronary revascularization for suppressing scintigraphic ischemia as assessed by serial gated adenosine Tc-99m sestamibi myocardial perfusion tomography. All patients at baseline had large total (> or =20%) and ischemic (> or =10%) adenosine-induced left ventricular perfusion defects and an ejection fraction > or =35%. Imaging was performed during 1 to 10 days of hospital admission and repeated in an identical fashion after optimization of therapy. Patients randomized to either strategy had similar baseline demographic and scintigraphic characteristics. RESULTS Both intensive medical therapy and coronary revascularization induced significant but comparable reductions in total (-16.2 +/- 10% vs. -17.8 +/- 12%; p = NS) and ischemic (-15 +/- 9% vs. -16.2 +/- 9%; p = NS) perfusion defect sizes. Likewise, a similar percentage of patients randomized to medical therapy versus coronary revascularization had suppression of adenosine-induced ischemia (80% vs. 81%; p = NS). CONCLUSIONS Sequential adenosine sestamibi myocardial perfusion tomography can effectively monitor changes in scintigraphic ischemia after anti-ischemic medical or coronary revascularization therapy. A strategy of intensive medical therapy is comparable to coronary revascularization for suppressing ischemia in stable patients after acute infarction who have preserved LV function.
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Affiliation(s)
- John J Mahmarian
- Methodist DeBakey Heart Center, Department of Cardiology, The Methodist Hospital, Houston, Texas 77030, USA.
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Fukumoto Y, Ito A, Uwatoku T, Matoba T, Kishi T, Tanaka H, Takeshita A, Sunagawa K, Shimokawa H. Extracorporeal cardiac shock wave therapy ameliorates myocardial ischemia in patients with severe coronary artery disease. Coron Artery Dis 2006; 17:63-70. [PMID: 16374144 DOI: 10.1097/00019501-200602000-00011] [Citation(s) in RCA: 148] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Prognosis of severe coronary artery disease with no indication of percutaneous coronary intervention or coronary artery bypass grafting remains poor. We have recently demonstrated that shock wave therapy effectively induces neovascularization and improves myocardial ischemia in a porcine model in vivo. METHODS With permission from the Ethical Committee of our Institute, we treated nine patients with end-stage coronary artery disease with no indication of percutaneous coronary intervention or coronary artery bypass grafting (55-82 years old, five men and four women) with our cardiac shock wave therapy (200 shots/spot at 0.09 mJ/mm for 20-40 spots, 3 times a week/series). We followed-up the patients at 1, 3, 6, and 12 months after the therapy to examine the amelioration of myocardial ischemia. When needed, shock wave therapy was performed up to three series at 0, and 1, 3 or 6 months. RESULTS The cardiac shock wave therapy improved symptoms (Canadian Cardiovascular Society functional class score, from 2.7+/-0.2 to 1.8+/-0.2, P<0.01) and reduced nitroglycerin use (from 5.4+/-2.5 to 0.3+/-0.3/week, P<0.05). The treatment also improved myocardial perfusion as assessed by dipyridamole stress thallium scintigraphy (severity score, 25.2+/-7.2% improvement, P<0.05; extent score, 23.3+/-9.0% improvement, P=0.10; washout rate, 20+/-3 to 34+/-3, P<0.05). Myocardial perfusion was improved only in the ischemic area treated with the therapy. These beneficial effects persisted for 12 months. No procedural complications or adverse effects were noted. CONCLUSION These results indicate that our extracorporeal cardiac shock wave therapy is an effective and non-invasive treatment for end-stage coronary artery disease, although further careful evaluation is needed.
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Affiliation(s)
- Yoshihiro Fukumoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Entok E, Cavusoglu Y, Kaya E, Vardareli E, Timuralp B. Detection of hibernate myocardium by 99mTc sestamibi gated SPECT during low-dose dobutamine infusion plus nitrate in patients with first acute myocardial infarction. Nucl Med Commun 2005; 26:765-72. [PMID: 16096579 DOI: 10.1097/01.mnm.0000172739.90746.f3] [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: 11/26/2022]
Abstract
AIM To investigate the role of Tc-MIBI gated SPECT imaging following the administration of low-dose dobutamine plus nitrate (LDD+nitrate) in the assessment of left ventricular function and the perfusion of hibernate myocardial tissue. METHODS The study group comprised 29 patients diagnosed as having acute myocardial infarction. In the first month post-infarction, Tc-MIBI gated SPECT imaging was performed in all patients at rest-dobutamine stress and LDD+nitrate. Ejection fraction, end diastolic volume (EDV), end systolic volume (ESV), stroke volume, volume, extent score, and reversibility score values were calculated. RESULTS The findings of Tc-MIBI gated SPECT imaging following the administration of LDD+nitrate and the rest Tc-MIBI gated SPECT findings revealed that while the levels of ejection fraction (P=0.004) and reversibility score (P=0.000) increased significantly, there was a significant decrease in EDV (P=0.001), ESV (P=0.001), volume (P=0.017), stroke volume (P=0.257) and extent score (P=0.039) values. CONCLUSION The use of Tc-MIBI gated SPECT concomitantly with the administration of LDD+nitrate is useful in the determination of myocardial hibernation in patients with left ventricular failure following acute myocardial infarction.
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Affiliation(s)
- Emre Entok
- Department of Nuclear Medicine, Osmangazi University Medical Faculty, 26480 Eskişehir, Turkey.
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Gulati M, McBride PE. Functional capacity and cardiovascular assessment: submaximal exercise testing and hidden candidates for pharmacologic stress. Am J Cardiol 2005; 96:11J-19J. [PMID: 16246649 DOI: 10.1016/j.amjcard.2005.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Submaximal exercise testing is often used to estimate functional capacity in non-athletes, to assess cardiovascular disease in elderly or frail patients, to demonstrate exercise equipment, or to risk-stratify patients after myocardial infarction. However, submaximal exercise testing is not sufficiently sensitive, specific, or predictive to have widespread clinical utility, except in post-myocardial infarction protocols. Many patients for whom submaximal exercise testing is not useful are unable to exercise sufficiently for maximal testing and are referred for imaging with pharmacologic stress. Although some patients who are unable to exercise adequately are easily recognized, many are not. The identification of such patients before they fail a maximal exercise test attempt is beneficial to both the patient and the imaging laboratory.
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Affiliation(s)
- Martha Gulati
- Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA.
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Abstract
The utility of stress myocardial perfusion imaging (MPI) for the diagnosis and prognosis of coronary artery disease (CAD) has been firmly established in numerous clinical studies and has become an essential component of clinical practice. Stress MPI is now used regularly to guide initial risk stratification and management of patients with CAD. Because stress MPI provides an assessment of the physiologic significance of CAD, it is a particularly attractive procedure for assessing follow-up risk. Today, sequential stress MPI is being used increasingly to track disease progression, assess follow-up risk, detect restenosis following revascularization, and evaluate the efficacy of aggressive medical therapy and risk-factor modification. By providing serial snapshots of the disease and its impact on perfusion, sequential stress MPI may alter treatment decisions and ultimately improve long-term patient management and outcomes. Use of sequential stress MPI to detect changes in perfusion following surgical or medical therapies is being tested currently in the Clinical Outcomes Using Revascularization and Aggressive Drug Evaluation (COURAGE) and Adenosine Sestamibi Single-Photon Emission Computed Tomography Postinfarction Evaluation (INSPIRE) trials.
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Affiliation(s)
- Leslee J Shaw
- Department of Medicine and Imaging, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.
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Cuocolo A. FDG imaging should be considered the preferred technique for accurate assessment of myocardial viability: against. Eur J Nucl Med Mol Imaging 2005; 32:832-5. [PMID: 15895227 DOI: 10.1007/s00259-005-1827-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Alberto Cuocolo
- Department of Biomorphological and Functional Sciences, University Federico II, Via Pansini 5, 80131, Napoli, Italy.
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Abstract
The prevalence of left ventricular (LV) dysfunction and resultant congestive heart failure is increasing. Patients with this condition are at high risk for cardiac death and usually have significant limitations in their lifestyles. Although there have been advances in medical therapy resulting in improved survival and well being, the best and most definitive therapy, when appropriate, is revascularization. In the setting of coronary artery disease, accounting for approximately two thirds of cases of congestive heart failure, LV dysfunction often is not the result of irreversible scar but rather caused by impairment in function and energy use of still viable-myocytes, with the opportunity for improved function if coronary blood flow is restored. Patients with LV dysfunction who have viable myocardium are the patients at highest risk because of the potential for ischemia but at the same time benefit most from revascularization. It is important to identify viable myocardium in these patients, and radionuclide myocardial scintigraphy is an excellent tool for this. Single-photon emission computed tomography perfusion scintigraphy, whether using thallium-201, Tc-99m sestamibi, or Tc-99m tetrofosmin, in stress and/or rest protocols, has consistently been shown to be an effective modality for identifying myocardial viability and guiding appropriate management. Metabolic imaging with positron emission tomography radiotracers frequently adds additional information and is a powerful tool for predicting which patients will have an improved outcome from revascularization, including some patients referred instead for cardiac transplantation. Other noninvasive modalities, such as stress echocardiography, also facilitate the assessment of myocardial viability, but there are advantages and disadvantages compared with the nuclear techniques. Nuclear imaging appears to require fewer viable cells for detection, resulting in a higher sensitivity but a lower specificity than stress echocardiography for predicting post-revascularization improvement of ventricular function. Nevertheless, it appears that LV functional improvement may not always be necessary for clinical improvement. Future directions include use of magnetic resonance imaging, as well as larger, multicenter trials of radionuclide techniques. The increasing population of patients with LV dysfunction, and the increased benefit afforded by newer therapies, will make assessment of myocardial viability even more essential for proper patient management.
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Affiliation(s)
- Mark I Travin
- Department of Nuclear Medicine, Montefiore Medical Center, Bronx, NY 10467-2490, USA.
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Affiliation(s)
- Leslee J Shaw
- Atlanta Cardiovascular Research Institute, Atlanta, GA 30342, USA.
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Grines CL, Watkins MW, Mahmarian JJ, Iskandrian AE, Rade JJ, Marrott P, Pratt C, Kleiman N. A randomized, double-blind, placebo-controlled trial of Ad5FGF-4 gene therapy and its effect on myocardial perfusion in patients with stable angina. J Am Coll Cardiol 2003; 42:1339-47. [PMID: 14563572 DOI: 10.1016/s0735-1097(03)00988-4] [Citation(s) in RCA: 179] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The primary objective of this study was to determine whether intracoronary administration of the adenoviral gene for fibroblast growth factor (Ad5FGF-4) can improve myocardial perfusion compared with placebo. BACKGROUND Animal studies and observational clinical studies have shown improvement in perfusion of the ischemic myocardium using genes encoding angiogenic growth factors; however, randomized, double-blind data in humans are lacking. METHODS We performed a randomized, double-blind, placebo-controlled trial of intracoronary injection of 10(10) adenoviral particles containing a gene encoding fibroblast growth factor (Ad5FGF-4) to determine the effect on myocardial perfusion. Fifty-two patients with stable angina and reversible ischemia comprising >9% of the left ventricle on adenosine single-photon emission computed tomography (SPECT) imaging were randomized to gene therapy (n = 35) or placebo (n = 17). Clinical follow-up was performed, and 51 (98%) patients underwent a second adenosine SPECT scan after 8 weeks. RESULTS Overall (n = 52), the mean total perfusion defect size at baseline was 32.4% of the left ventricle, with 20% reversible ischemia and 12.5% scar. At eight weeks, Ad5FGF-4 injection resulted in a significant reduction of ischemic defect size (4.2% absolute, 21% relative; p < 0.001) and placebo-treated patients had no improvement (p = 0.32). Although the change in reversible perfusion defect size between Ad5FGF-4 and placebo was not significant (4.2% vs. 1.6%, p = 0.14), when a single outlier was excluded a significant difference was observed (4.2% vs. 0.8%, p < 0.05). Ad5FGF-4 was well tolerated and did not result in any permanent adverse sequelae. CONCLUSIONS Intracoronary injection of Ad5FGF-4 showed an encouraging trend for improved myocardial perfusion; however, further studies of therapeutic angiogenesis with Ad5FGF-4 will be necessary.
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Affiliation(s)
- Cindy L Grines
- Department of Medicine, William Beaumont Hospital, Royal Oak, Michigan, 48073-6967 USA.
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Kula M, Tutuş A, Unal S, Topsakal R, Ergin A. Technetium-99m-tetrofosmin imaging with incremental nitroglycerin infusion to detect severely ischaemic but viable myocardium: a comparative study with thallium-201. Nucl Med Commun 2003; 24:987-94. [PMID: 12960598 DOI: 10.1097/00006231-200309000-00007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to assess the influence of incremental nitroglycerin infusion (NTG+Inf) on the myocardial uptake of 99mTc-tetrofosmin (TF) in order to determine whether nitrates enhance the detection of viable myocardium with TF in patients with coronary artery disease (CAD) and left ventricular dysfunction. Fifty patients (39 males, 11 females; 54 +/- 11 years) with previous myocardial infarction and left ventricular dysfunction, who had been referred for coronary revascularization procedures, were studied. Myocardial single-photon emission tomography (SPET) images were obtained 1 h after injection of 750 MBq TF at baseline and after NTG+Inf, using a 2 day protocol. NTG+Inf was performed starting at 0.4 microg x kg(-1) x min(-1), with equal increments every 5 min up to 2 microg x kg(-1) x min(-1). Within 1 week of the TF study, rest-redistribution (R-RD) 201Tl SPET was performed after the injection of 111 MBq 201Tl. For each study, quantitative analysis was performed in 17 segments. Viability was defined as the presence of tracer uptake of > 50% of the peak activity on baseline studies or reversibility. There was significant correlation between quantitative regional RD 201Tl activity and TF activity after NTG+Inf (r = 0.90, P < 0.001). Of the 131 segments with severely reduced tracer uptake on resting TF images, 34 (26%) were reversible, showing increased tracer uptake after NTG+Inf (from 41%+/-7% to 57%+/-12% of peak activity; P < 0.001). All reversible segments after NTG+Inf had viability criteria on 201Tl studies. There was 95% concordance between TF with NTG+Inf and RD 201Tl imaging with regard to the presence of myocardial viability. We conclude that TF imaging with incremental NTG+Inf improves the detection of ischaemic but viable myocardium, correlating with the viability criteria observed on 201Tl studies. When the advantages of TF imaging are considered, rest TF imaging with NTG+Inf may be a practical diagnostic protocol in patients with CAD and left ventricular dysfunction who are being considered for revascularization.
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Affiliation(s)
- M Kula
- Department of Nuclear Medicine, Erciyes University, School of Medicine, Kayseri, Turkey.
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21
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Galasko GIW, Lahiri A. The non-invasive assessment of hibernating myocardium in ischaemic cardiomyopathy--a myriad of techniques. Eur J Heart Fail 2003; 5:217-27. [PMID: 12798818 DOI: 10.1016/s1388-9842(03)00008-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Heart failure is placing an ever-increasing burden on society. Many subjects with heart failure and underlying coronary artery disease have a significant amount of akinetic but viable myocardium that is able to contract should myocardial perfusion improve (hibernating myocardium). Non-randomised studies have shown prognostic benefit in subjects with hibernating myocardium undergoing revascularisation. Several non-invasive techniques have been developed to assess the presence or absence of hibernating myocardium. This review will examine the epidemiology and underlying pathogenesis of hibernating myocardium; evaluate the non-invasive techniques for diagnosing hibernating myocardium, and look at therapeutic intervention in subjects with hibernating myocardium.
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Affiliation(s)
- Gavin I W Galasko
- Department of Cardiovascular Medicine, Northwick Park Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK
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22
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Bøttcher M, Madsen MM, Randsbaek F, Refsgaard J, Dørup I, Sørensen K, Nielsen TT. Effect of oral nitroglycerin and cold stress on myocardial perfusion in areas subtended by stenosed and nonstenosed coronary arteries. Am J Cardiol 2002; 89:1019-24. [PMID: 11988188 DOI: 10.1016/s0002-9149(02)02268-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Physical obstruction and coronary vasoconstriction mediated by adrenergic stress are believed to be responsible for episodes of myocardial hypoperfusion and angina. Nitroglycerin relieves symptoms by reducing preload and dilating epicardial vessels. The net perfusion change and relation to stenosis severity of nitroglycerin and adrenergic stress have been debated. This study aimed to evaluate whether oral nitroglycerin and adrenergic stress alters perfusion in myocardial segments subtended by stenosed and nonstenosed coronary arteries. Myocardial perfusion was quantified (using N-13-ammonia positron emission tomography [PET]) at rest, after oral nitroglycerin 400 microg, and after cold stress in 25 patients with coronary artery disease (62 +/- 9 years, 21 men) and in 30 controls (34 +/- 9 years, 22 men). Myocardial perfusion was quantified in areas supplied by stenosed (>70%) and nonstenosed (<30%) coronary arteries. The cold pressor test did not significantly alter myocardial perfusion in any of the groups. However, when normalized for rate-pressure product, the response in stenosed areas showed a significantly more pronounced reduction compared with nonstenosed areas (0.78 +/- 0.18 vs 0.64 +/- 0.19 ml/g/min, p <0.005 and 0.86 +/- 0.19 vs 0.73 +/- 0.24 ml/g/min, p <0.05, p <0.05) for intergroup comparison. In both stenosed areas and nonstenosed areas nitroglycerin increased perfusion (0.51 +/- 0.14 vs 0.60 +/- 0.17 ml/g/min, p <0.05 and 0.56 +/- 0.14 vs 0.61 +/- 0.17 ml/g/min, p <0.05). Nitroglycerin did not alter myocardial perfusion in the control group. There was a negative correlation between the cold pressor test response and stenosis severity (r(2) = 0.17, p <0.046), whereas this was not the case for nitroglycerin. In patients with coronary artery disease, myocardial segments supplied by stenosed coronary arteries showed an altered perfusion response to adrenergic stress. Oral nitroglycerin increased myocardial perfusion irrespective of the presence of a stenosis.
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Affiliation(s)
- Morten Bøttcher
- Department of Cardiology B, Aarhus University Hospital, Aarhus, Denmark.
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23
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Toyama T, Hoshizaki H, Isobe N, Adachi H, Naito S, Oshima S, Taniguchi K. Detecting viable hibernating myocardium in chronic coronary artery disease--a comparison of resting 201Tl single photon emission computed tomography (SPECT), 99mTc-methoxy-isobutyl isonitrile SPECT after nitrate administration, and 201Tl SPECT after 201Tl-glucose-insulin infusion. JAPANESE CIRCULATION JOURNAL 2000; 64:937-42. [PMID: 11194287 DOI: 10.1253/jcj.64.937] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
To identify and quantify the amount of viable hibernating myocardium in patients with chronic coronary artery disease, resting 201Tl single photon emission computed tomography (SPECT) was compared with 99mTc-methoxy-isobutyl isonitrile (MIBI) SPECT after nitrate infusion (nitrate-99mTc-MIBI) and 201Tl SPECT after 201Tl with glucose-insulin-potassium infusion (201Tl-GIK) in 25 patients. Twenty-one patients also underwent completely left ventriculography beforehand and 5+/-4 months afterwards. SPECT images were divided into 9 segments and scored visually from 0 (normal uptake) to 3 (absent). The defect score was calculated as the summation of the total scores (TDS) in each patient. The TDS of nitrate-99mTc-MIBI images (6.3+/-4.3) and 201Tl-GIK images (5.8+/-4.2) were significantly lower than the 7.4+/-4.3 of resting 201Tl images (p<0.01). Based on the improvement of wall motion after coronary revascularization, the sensitivity of 201Tl-GIK imaging (85%) was significantly higher (p<0.05), and that of nitrate-99mTc-MIBI imaging (79%) also tended to be higher (p=0.08), than that of 201Tl imaging (62%) in detecting viable myocardium. The specificity of the 3 methods was almost the same. The nitrate-99mTc-MIBI and 201Tl-GIK methods were more useful than the resting 201Tl method for evaluating viable hibernating myocardium. Furthermore, the 201Tl-GIK method may provide a more accurate estimate of the amount of viable myocardium than the nitrate-99mTc-MIBI method.
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Affiliation(s)
- T Toyama
- Gunma Prefectural Cardiovascular Center, Maebashi, Japan.
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24
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Klassen CL, Traverse JH, Bache RJ. Nitroglycerin dilates coronary collateral vessels during exercise after blockade of endogenous NO production. THE AMERICAN JOURNAL OF PHYSIOLOGY 1999; 277:H918-23. [PMID: 10484411 DOI: 10.1152/ajpheart.1999.277.3.h918] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In a previous study nitroglycerin failed to dilate coronary collateral vessels during exercise. This study tested the hypothesis that failure of nitroglycerin to increase collateral flow occurred because endogenous nitric oxide (NO) had activated the guanylate cyclase vasodilator pathway so that additional NO from nitroglycerin could have no additional effect. Six dogs were collateralized using intermittent 2-min occlusions of the left anterior descending coronary artery followed by permanent occlusion. One week after permanent coronary occlusion, dogs were exercised on a treadmill (heart rate 202 +/- 5 beats/min), while blood flow was measured with radioactive microspheres. Blood flow to the collateral zone during control exercise was 1.90 +/- 0.11 ml. min(-1). g(-1) compared with 2.28 +/- 0.15 ml. min(-1). g(-1) in the normal zone (P < 0.05); systolic wall thickening was 23 +/- 3% in the collateral zone compared with 27 +/- 2% in the normal zone. When N(G)-nitro-L-arginine (L-NNA; 20 mg/kg iv) was administered to block NO production, collateral zone flow during exercise decreased to 1. 43 +/- 0.20 ml. min(-1). g(-1) (P < 0.05), and systolic wall thickening decreased to 12 +/- 4% (P < 0.05). A subsequent infusion of nitroglycerin (2 microg. kg(-1). min(-1) iv) increased collateral zone blood flow to 1.65 +/- 0.16 ml. min(-1). g(-1) (P < 0.05) and increased systolic wall thickening to 22 +/- 5% (P < 0.05). These findings demonstrate that endogenous NO contributes to collateral zone blood flow during exercise. If endogenous NO synthesis is blocked, then nitroglycerin is effective in improving collateral zone blood flow and contractile function during exercise.
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Affiliation(s)
- C L Klassen
- Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota 55455, USA
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25
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Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM, Grunwald MA, Levy D, Lytle BW, O'Rourke RA, Schafer WP, Williams SV, Ritchie JL, Cheitlin MD, Eagle KA, Gardner TJ, Garson A, Russell RO, Ryan TJ, Smith SC. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). J Am Coll Cardiol 1999; 33:2092-197. [PMID: 10362225 DOI: 10.1016/s0735-1097(99)00150-3] [Citation(s) in RCA: 367] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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26
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van Liebergen RA, Piek JJ, Koch KT, de Winter RJ, Schotborgh CE, Lie KI. Quantification of collateral flow in humans: a comparison of angiographic, electrocardiographic and hemodynamic variables. J Am Coll Cardiol 1999; 33:670-7. [PMID: 10080467 DOI: 10.1016/s0735-1097(98)00640-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Evaluation of collateral vascular circulation according to hemodynamic variables and its relation to myocardial ischemia. BACKGROUND There is limited information regarding the hemodynamic quantification of recruitable collateral vessels. METHODS Angiography of the donor coronary artery was performed before and during balloon coronary occlusion in 63 patients with one vessel disease. Patients were divided into groups of those with an absence of collateral vessels (group 1, n = 10), those with recruitable collateral vessels (group 2, n = 23) and those with spontaneously visible collateral vessels (group 3, n = 30). During balloon inflation the coronary wedge/aortic pressure ratio (Pw/Pao) was determined as were collateral blood flow velocity variables, using a 0.014" Doppler guide wire. Myocardial ischemia was defined as > or =0.1 mV ST-shift on a 12 lead electrocardiogram at 1 min coronary occlusion. RESULTS Myocardial ischemia was present in all patients of group 1, in 14 patients of group 2 and in 3 patients of group 3. Recruitable collateral flow without ischemia showed similar hemodynamic values as in group 3 while these values were similar to group 1 in regard to the presence of recruitable collateral vessels showing ischemia. Logistic regression analysis revealed both Pw/Pao and Vi(col) as independent predictors for the function of collateral vessels. CONCLUSIONS Hemodynamic variables of collateral vascular circulation are better markers of the functional significance of collateral vessels than is coronary angiography. The total collateral blood flow velocity integral and coronary wedge/aortic pressure ratio are good and independent predictors of the function of collateral vessels producing complementary information.
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Affiliation(s)
- R A van Liebergen
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
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27
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Dakik HA, Kleiman NS, Farmer JA, He ZX, Wendt JA, Pratt CM, Verani MS, Mahmarian JJ. Intensive medical therapy versus coronary angioplasty for suppression of myocardial ischemia in survivors of acute myocardial infarction: a prospective, randomized pilot study. Circulation 1998; 98:2017-23. [PMID: 9808599 DOI: 10.1161/01.cir.98.19.2017] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients who have inducible ischemia after acute myocardial infarction (AMI) generally undergo coronary angiography with the intent to revascularize. Whether this approach is superior to intensive treatment with anti-ischemic medications is unknown. METHODS AND RESULTS We performed a prospective, randomized pilot study comparing intensive medical therapy with coronary angioplasty (PTCA) for suppression of myocardial ischemia in 44 stable survivors of AMI. Myocardial ischemia was quantified with adenosine 201Tl tomography (SPECT) performed 4.5+/-2.9 days after AMI. All patients at baseline had a large total (>/=20%) and ischemic (>/=10%) left ventricular perfusion defect size (PDS). SPECT was repeated at 43+/-26 days after therapy was optimized. The total stress-induced PDS was comparably reduced with medical therapy (from 38+/-13% to 26+/-16%; P<0.0001) and PTCA (from 35+/-12% to 20+/-16%; P<0.0001). The reduction in ischemic PDS was also similar (P=NS) in both groups. Cardiac events occurred in 7 of 44 patients over 12+/-5 months. Patients who remained clinically stable had a greater reduction in ischemic PDS (-13+/-9%) than those who had a recurrent cardiac event (-5+/-7%; P<0.02). Event-free survival was superior in the 24 patients who had a significant (>/=9%) reduction in PDS (96%) compared with those who did not (65%; P=0.009). CONCLUSIONS In this small pilot study, intensive medical therapy and PTCA were comparable at suppressing ischemia in stable patients after AMI. Sequential imaging with adenosine SPECT can track changes in PDS after anti-ischemic therapies and thereby predict subsequent outcome. Corroboration of these preliminary findings in a larger cardiac-event trial is warranted.
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Affiliation(s)
- H A Dakik
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
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28
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Peix A, López A, Ponce F, Morales J, de la Vega AR, Chesa CS, Maltas AM, García-Barreto D. Enhanced detection of reversible myocardial hypoperfusion by technetium 99m-tetrofosmin imaging and first-pass radionuclide angiography after nitroglycerin administration. J Nucl Cardiol 1998; 5:469-76. [PMID: 9796893 DOI: 10.1016/s1071-3581(98)90177-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Reversal of ischemia after myocardial infarction by revascularization is worthwhile only if viability exists in a sufficiently large portion of the left ventricle. METHODS AND RESULTS To determine myocardial hypoperfusion reversibility and its influence on segmental and global function, we studied 50 patients after myocardial infarction. Three technetium 99m-tetrofosmin scintigraphies were performed: 1 at rest, 1 after 0.6 mg sublingual nitroglycerin (NTG), and 1 after injection at peak stress. First-pass multigated radionuclide angiography was obtained at rest and after NTG. Each patient also underwent a stress redistribution-reinjection thallium-201 scintigraphy. During stress 99mTc-tetrofosmin, 104 segments had normal uptake, 51 showed moderately reduced uptake, and 186 had severely reduced uptake. Of these 186 segments, 33 (18%) improved at rest, and 41 (22%) improved only after NTG. Fifty-nine (79%) of these segments with improved uptake were also found to have reversible defects on 201TI imaging. In the 26 patients with ventricular dysfunction, a 73% agreement was found between the functional and 99mTc-tetrofosmin uptake post-NTG improvement, whereas a 69% agreement was found with thallium reinjection. No significant differences were seen between 99mTc-tetrofosmin and 201T1 imaging. CONCLUSION Nitroglycerin administration during 99mTc-tetrofosmin scintigraphy improves the detection of myocardium with reversible hypoperfusion in patients with a previous myocardial infarction.
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Affiliation(s)
- A Peix
- Institute of Cardiology, Havana, Cuba
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29
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Abstract
This study was performed to determine whether nitroglycerin can increase blood flow to collateral-dependent myocardium during exercise. Intermittent repetitive occlusions of the left circumflex coronary artery (LCX) were used to stimulate growth of coronary collateral vessels in seven adult mongrel dogs. Coronary pressure distal to the occluder was measured with a long-term implanted microcatheter. When sufficient collateral growth had occurred to increase distal coronary pressure to >40 mm Hg during occlusion, the artery was permanently occluded. Dogs were returned to the laboratory 1 week later for study. Measurements were obtained at rest and during treadmill exercise during control conditions and after a 300-microg bolus of nitroglycerin (i.v.). Aortic and coronary pressures were measured with fluid-filled catheters, whereas myocardial blood flow was measured with radioactive microspheres. During control conditions, exercise caused significant increases of blood flow in the normal and collateral zones with significant decreases in vascular resistance. However, nitroglycerin failed to cause a further increase in blood flow to either the normal or the collateral-dependent myocardial regions during exercise. Furthermore, neither calculated transcollateral resistance (TCR) nor small-vessel resistance (SVR) changed significantly in response to nitroglycerin (TCR, 27 +/- 9 mm Hg/ml/min/g before nitroglycerin and 27 +/- 6 mm Hg/ml/min/g after; SVR, 43 +/- 5 mm Hg/ml/min/g before nitroglycerin and 49 +/- 7 mm Hg/ml/min/g after). The finding that the collateral vessels failed to dilate in response to nitroglycerin suggests that the nitric oxide system is already maximally recruited during exercise.
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Affiliation(s)
- B B Quebbemann
- Department of Medicine, University of Minnesota Medical School, Minneapolis 55455, USA
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30
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Koike A, Yajima T, Koyama Y, Shimizu N, Kano H, Kobayashi K, Taniguchi K, Marumo F, Hiroe M. Effects of isosorbide dinitrate on oxygen uptake kinetics in cardiac patients. Med Sci Sports Exerc 1998; 30:190-4. [PMID: 9502344 DOI: 10.1097/00005768-199802000-00003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Although nitrates are known to improve indices of exercise capacity in patients with coronary artery disease, their effects on oxygen uptake kinetics during the onset of exercise have not been clarified. We evaluated the acute effects of isosorbide dinitrate on the kinetics of oxygen uptake during the onset of exercise at a constant work rate in patients with coronary artery disease. METHODS We studied 14 patients with coronary artery disease who performed 6 min of low-intensity exercise at a constant work rate on a cycle ergometer 30 min after oral administration of 10 mg of isosorbide dinitrate or placebo in a double-blind, crossover manner. Oxygen uptake was calculated from breath-by-breath analysis of respired gases. The time constant of oxygen uptake kinetics during the onset of exercise was determined by fitting a single exponential function to the oxygen uptake response. RESULTS Heart rate was significantly increased at rest, and systolic blood pressure was significantly decreased both at rest and during exercise after administration of isosorbide dinitrate. The time constant of oxygen uptake was significantly shorter (the kinetics were faster) after administration of isosorbide dinitrate (39.4+/-10.1 vs 44.5+/-10.5 s, P = 0.038). CONCLUSIONS Isosorbide dinitrate was found to speed the kinetics of the increase in oxygen uptake during constant work-rate exercise. The time constant of oxygen uptake, which reflects the rapidity of cardiovascular adaptation at the onset of exercise, seems to be a useful parameter of the effectiveness of therapy in patients with coronary artery disease.
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Affiliation(s)
- A Koike
- The Kasumigaura Branch Hospital, Tokyo Medical and Dental University, Ibaraki, Japan
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31
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Basu S, Senior R, Raval U, Lahiri A. Superiority of nitrate-enhanced 201Tl over conventional redistribution 201Tl imaging for prognostic evaluation after myocardial infarction and thrombolysis. Circulation 1997; 96:2932-7. [PMID: 9386159 DOI: 10.1161/01.cir.96.9.2932] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND 201Tl imaging has been widely used for postinfarction risk stratification. However, thrombolytic therapy and aspirin have significantly changed outcome, and there are few nuclear imaging studies that assess prognosis in such patients. Furthermore, newer techniques of 201Tl imaging, such as reinjection and nitrate-enhanced rest 201Tl imaging, have been shown to improve the detection of viable but jeopardized myocardium. METHODS AND RESULTS We studied 100 consecutive patients, who remained event free 6 weeks after myocardial infarction and thrombolysis. Patients underwent conventional exercise and 4-hour redistribution imaging, followed on a separate day by nitrate-enhanced rest 201Tl study. Planar images were reported semiquantitatively by two experienced observers blinded to clinical data. Redistribution and rest injection images were classified as demonstrating reversible ischemia if they showed improvement in uptake by at least two grades in at least two segments in comparison with the initial exercise scintigram. Patients were followed up for 8 to 32 months (mean, 21 months); during this period, 37 patients had first cardiac events. Reversible ischemia was present in 29 patients on redistribution, of whom 14 (48%) had events; of 71 without reversible defects, 23 (32%) had events (hazard ratio, 1.5; 95% CI, 0.8 to 3.0; P=NS). Nitrate-enhanced rest 201Tl imaging detected reversible defects in 68 patients, of whom 33 (49%) had events, whereas of 32 without reversible defects, only 4 (13%) had subsequent cardiac events (hazard ratio, 8.1; 95% CI, 2.7 to 23.8; P<.001). CONCLUSIONS Thus, after myocardial infarction and thrombolysis, even "stable" patients have a high (68%) incidence of viable but jeopardized myocardium, causing a high event rate. Those identified to be at high risk by perfusion imaging may benefit from early intervention.
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Affiliation(s)
- S Basu
- Department of Cardiac Research, Northwick Park Hospital, and Institute for Medical Research, Harrow, Middlesex, UK
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Piek JJ, van Liebergen RA, Koch KT, de Winter RJ, Peters RJ, David GK. Pharmacological modulation of the human collateral vascular resistance in acute and chronic coronary occlusion assessed by intracoronary blood flow velocity analysis in an angioplasty model. Circulation 1997; 96:106-15. [PMID: 9236424 DOI: 10.1161/01.cir.96.1.106] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The pharmacological responsiveness of the coronary collateral circulation in humans has been studied only by indirect means. METHODS AND RESULTS Patients with one-vessel disease and recruitable (n = 14) or spontaneously visible (n = 24) collateral vessels were studied during coronary angioplasty. Collateral flow in the recipient coronary artery was determined with a 0.014-in Doppler guide wire during balloon coronary occlusion and expressed as the diastolic blood flow velocity integral (dVi). Collateral blood flow velocity, mean aortic pressure (Pao), and coronary wedge pressure (Pw) were used to calculate the collateral vascular resistance index: Rcoll = (Pao-Pw)/ dVi (mm Hg/cm) and the peripheral vascular resistance index of the recipient coronary artery: R4 = Pw/dVi (mm Hg/cm). Adenosine (12 to 18 micrograms) and nitroglycerin (0.2 mg) were injected as a bolus in the donor coronary artery during subsequent balloon inflations to assess their effect on these hemodynamic variables. The administration of adenosine or nitroglycerin in patients with recruitable collateral vessels did not induce a change in dVi and Pw/Pao ratio. In patients with spontaneously visible collateral vessels, dVi increased from 8.0 +/- 4.5 to 10.8 +/- 8.0 cm (P = .01) after adenosine and from 7.4 +/- 4.5 to 10.3 +/- 6.9 cm (P = .003) after nitroglycerin. The Pw/Pao ratio remained unchanged after adenosine and nitroglycerin. Rcoll decreased from 10.3 +/- 9.5 to 8.6 +/- 8.5 mm Hg/cm (P = .01) after adenosine and from 11.6 +/- 10.4 to 8.3 +/- 8.9 mm Hg/cm (P < .001) after nitroglycerin. R4 decreased from 7.7 +/- 5.5 to 5.9 +/- 5.1 mm Hg/cm (P < .001) after adenosine and from 8.4 +/- 6.6 to 7.1 +/- 7.2 mm Hg/cm (P = .01) after nitroglycerin. CONCLUSIONS Coronary collateral blood flow can be increased with adenosine and nitroglycerin in patients with one-vessel disease and spontaneously visible collateral vessels, which is in contrast to patients with recruitable collateral vessels. This effect is the result of a reduction in the collateral vascular resistance and peripheral vascular resistance of the recipient coronary artery.
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Affiliation(s)
- J J Piek
- Department of Cardiology, Academic Medical Center, Amsterdam, Netherlands
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33
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Abstract
The efficacy of antianginal agents in the treatment of patients with chronic stable angina has traditionally been evaluated by performance measures, such as the exercise treadmill test (ETT). Although reliable and reproducible, ETT is not a sensitive measure of changes in myocardial ischemia. The effects of antianginal agents on coronary blood flow and myocardial perfusion have been less frequently studied. Angiographic studies have demonstrated that nitrates may operate by preferentially directing blood flow to ischemic regions of the myocardium. These investigations have been limited, however, by the invasive nature of the evaluation. Measurements of regional myocardial perfusion may also be made with noninvasive tests. Both quantitative single-photon emission computed tomography (SPECT) and positron emission tomography (PET) have been employed, but few studies have used these techniques to assess the effects of antianginal drugs (in general) and nitrates (in particular) on changes in reversible myocardial perfusion defects. Studies that have evaluated the direct effects of nitrate treatment on coronary blood flow and myocardial perfusion defects in patients with chronic stable angina are reviewed, and preliminary data from a study of the effects of long-term nitrate treatment on myocardial perfusion are discussed.
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Affiliation(s)
- H C Lewin
- Division of Nuclear Medicine and Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California 90048-1865, USA
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34
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He ZX, Medrano R, Hays JT, Mahmarian JJ, Verani MS. Nitroglycerin-augmented 201T1 reinjection enhances detection of reversible myocardial hypoperfusion. A randomized, double-blind, parallel, placebo-controlled trial. Circulation 1997; 95:1799-805. [PMID: 9107166 DOI: 10.1161/01.cir.95.7.1799] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recent observations suggest that administration of nitrates before 201Tl reinjection enhances the detection of reversible myocardial hypoperfusion. METHODS AND RESULTS Ninety-six patients who underwent exercise-redistribution 201Tl single photon emission computed tomography (SPECT) and had persistent defects at 4-hour redistribution imaging were prospectively randomized into a double-blind protocol in which they received a reinjection of 201Tl (1.0 mCi) 5 minutes after either placebo or 0.8 mg sublingual nitroglycerin administration, followed by repeat SPECT imaging. Of the 69 patients who had coronary angiography, all except one had significant coronary stenoses. The overall extent of perfusion defect and the reversible component assessed by polar maps of the stress-redistribution images were similar in patients who received nitroglycerin or placebo. Among the 66 patients with persistent defects in the redistribution images, 58% of those receiving nitroglycerin showed improved reversibility after reinjection, compared with 33% of patients receiving placebo (P < .05). Among 68 patients with significant coronary stenoses, those who received nitroglycerin and had coronary collateral circulation were more likely to exhibit improved reversibility after reinjection than the remaining patients (50% versus 21%, P < .05). Moreover, the ratio of reversible to total defect in the vascular territories supplied by collaterals was > or = 0.50 after reinjection in 80% of patients who received nitroglycerin (n = 20) compared with 40% of the patients who received placebo (n = 15) (P < .05). CONCLUSIONS Nitrate-augmented 201Tl reinjection significantly, albeit modestly, improves detection of defect reversibility, especially in patients with coronary collateral circulation.
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Affiliation(s)
- Z X He
- Section of Cardiology, Baylor College of Medicine, Houston, Tex 77030, USA
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Afridi I, Main ML, Grayburn PA. Accuracy of dobutamine echocardiography for detection of myocardial viability in patients with an occluded left anterior descending coronary artery. J Am Coll Cardiol 1996; 28:455-9. [PMID: 8800125 DOI: 10.1016/0735-1097(96)00141-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We studied the accuracy of dobutamine echocardiography for the detection of myocardial viability in patients with an occluded left anterior descending coronary artery and regional ventricular dysfunction. BACKGROUND Contractile reserve during dobutamine echocardiography is an accurate marker of myocardial viability in patients with coronary stenoses and ventricular dysfunction. However, its accuracy in patients with an occluded vessel has not been evaluated. METHODS We studied 41 patients with > 50% stenosis of the left anterior descending coronary artery and regional ventricular dysfunction who underwent dobutamine echocardiography for detection of viable myocardium. Contractile reserve was defined as improvement in wall motion score of two or more contiguous septal or anterior segments during doubutamine echocardiography. Recovery of function was defined as improvement in rest wall motion score of two or more contiguous segments after revascularization. RESULTS Patients were classified into two groups according to the presence (n = 20) or absence (n = 21) of left anterior descending coronary artery occlusion. Contractile reserve was detected in 40% of patients with an occluded and 43% with a nonoccluded artery (p = 0.8). Of 41 patients, 27 underwent revascularization, 12 with and 15 without an occluded vessel. Recovery of function occurred in 6 (50%) of 12 patients in the occluded artery group and in 5 (33%) of 15 in the nonoccluded artery group (p = 0.4). Among patients with an occluded artery, the positive and negative predictive values of dobutamine echocardiography for recovery of function were 100% (95% confidence interval [CI] 48% to 100%) and 86% (95% CI 42% to 100%), respectively. CONCLUSIONS Our results indicate that contractile reserve during dobutamine echocardiography can be detected in patients with an occluded vessel and may be useful for predicting recovery of function after revascularization.
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Affiliation(s)
- I Afridi
- Department of Medicine, University of Texas Southwestern and Veterans Affairs Medical Centers, Dallas, USA
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He ZX, Verani MS, Liu XJ. Nitrate-augmented myocardial imaging for assessment of myocardial viability. J Nucl Cardiol 1995; 2:352-7. [PMID: 9420811 DOI: 10.1016/s1071-3581(05)80081-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
201Tl myocardial perfusion imaging is presently done by several possible strategies. Stress/delayed redistribution, stress/redistribution/reinjection, and rest/redistribution imaging can be useful in the clinical assessment of myocardial viability. Unfortunately, the extent of myocardial viability may still be underestimated even by 201Tl reinjection imaging, compared with 18F-fluorodeoxyglucose positron emission tomography. 99mTc-labeled sestamibi imaging provides results similar to those of 201Tl imaging in the detection of coronary artery disease, but several previous studies suggest that stress/rest 99mTc-labeled sestamibi imaging significantly underestimates myocardial viability. Recently it has been reported that the administration of nitrates, before 201Tl reinjection, improves detection of defect reversibility. Several studies also suggested that administration of nitrates before the injection of 99mTc-labeled sestamibi significantly improved detection of reversibility with this agent, whereas additional studies showed further that this combination improves the predictive accuracy for recovery of left ventricular function and perfusion after coronary revascularization, compared with a standard rest 99mTc-labeled sestamibi study. Nitrate administration before the injection of 201Tl and 99mTc-labeled sestamibi may thus be a potentially attractive alternative for the evaluation of myocardial viability. Although the available results are encouraging, further studies are needed to evaluate the clinical value of 201Tl and 99mTc-labeled sestamibi imaging, in combination with nitrates, for predicting recovery of left ventricular dysfunction.
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Kern MJ, Piek JJ, Aguirre FV, Bach RG, Caracciolo EA, Donohue TJ. Collateral flow velocity alterations in the supply and receiving coronary arteries during angioplasty for total coronary occlusion. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1995; 34:167-74. [PMID: 7788698 DOI: 10.1002/ccd.1810340420] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The unique observations of contralateral and ipsilateral coronary artery collateral supply before and after angioplasty suggest highly responsive conduits to hemodynamic conditions. The study of collateral supply system is not only significant for our current understanding of the dynamic behavior of the collateral circulation, but may also have important clinical implications for the treatment of patients with a chronic coronary occlusion.
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Affiliation(s)
- M J Kern
- Department of Internal Medicine, St. Louis University, Missouri, USA
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Ritchie JL, Bateman TM, Bonow RO, Crawford MH, Gibbons RJ, Hall RJ, O'Rourke RA, Parisi AF, Verani MS. Guidelines for clinical use of cardiac radionuclide imaging. Report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Radionuclide Imaging), developed in collaboration with the American Society of Nuclear Cardiology. J Am Coll Cardiol 1995; 25:521-47. [PMID: 7829809 DOI: 10.1016/0735-1097(95)90027-6] [Citation(s) in RCA: 123] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Newhouse HK, Wexler JP. Myocardial perfusion imaging for evaluating interventions in coronary artery disease. Semin Nucl Med 1995; 25:15-27. [PMID: 7716554 DOI: 10.1016/s0001-2998(05)80003-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Myocardial perfusion imaging provides a means for evaluating the effects of interventional therapy in several groups of patients with coronary artery disease. In patients with unstable angina, imaging during or after chest pain can be used to identify areas of jeopardized myocardium and to predict the risk of subsequent cardiac events including myocardial infarction. In patients with acute myocardial infarction, the effect of thrombolytic therapy can be monitored, and in patients with chronic ischemia and left ventricular dysfunction, thallium imaging can be used to predict whether revascularization will improve myocardial function. In patients with stable coronary artery disease, perfusion imaging has been used to evaluate efficacy of anti-anginal medications. This article reviews the use of myocardial perfusion imaging in determining the need for, and success of, various medical and surgical therapeutic interventions in patients with ischemic heart disease.
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Affiliation(s)
- H K Newhouse
- Montefiore Medical Center, Albert Einstein College of Medicine, Department of Nuclear Medicine, Bronx, NY 10467, USA
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Bisi G, Sciagrà R, Santoro GM, Fazzini PF. Rest technetium-99m sestmibi temography in combination with short-term administration of nitrates: Feasibility and reliability for prediction of postrevascularization outcome of asynergic territories. J Am Coll Cardiol 1994; 24:1282-9. [PMID: 7930251 DOI: 10.1016/0735-1097(94)90110-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study investigated the role of nitrate technetium-99m sestamibi imaging in predicting the postrevascularization outcome of chronically hypoperfused asynergic territories. BACKGROUND Rest technetium-99m sestamibi myocardial scintigraphy underestimates the presence of viable myocardium in asynergic territories. Stimulation that improves coronary blood flow could increase tracer uptake in hibernating territories. METHODS Nineteen patients with a previous myocardial infarction and left ventricular dysfunction scheduled for revascularization underwent quantitative technetium-99m sestamibi tomography under baseline conditions and during isosorbide dinitrate infusion. Global and regional function were assessed, respectively, before and after revascularization by radionuclide angiocardiography and two-dimensional echocardiography. RESULTS Seven patients (group A) showed postrevascularization regional function recovery, and 12 (group B) showed no significant changes. In group A, nitrate infusion induced a decrease in the extent of the global uptake defect ([mean +/- SD] -37.4 +/- 21.6% of baseline value); in group B, no change or a slight increase was observed (+5.8 +/- 8.4%, p < 0.0005 vs. group A). The nitrate-induced changes in the extent of uptake defect correlated with postrevascularization changes in ejection fraction (r = -0.94, SEE 7.6). After revascularization, 11 asynergic vascular territories showed improvement (hibernating), and 34 remained unchanged (fibrotic). With administration of nitrates, 10 hibernating territories had a decrease in the extent of uptake defect, whereas only 4 of 34 of the fibrotic territories showed a nitrate-induced uptake improvement. CONCLUSIONS Short-term administration of isosorbide dinitrate immediately before injection of technetium-99m sestamibi increases tracer uptake in some chronically hypoperfused asynergic territories. This finding correlates with the observation of post-revascularization functional recovery. Nitrate technetium-99m sestamibi myocardial scintigraphy could be a promising method for the noninvasive detection of viable hibernating myocardium.
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Affiliation(s)
- G Bisi
- Department of Clinical Pathophysiology, University of Florence, Italy
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Fujita M, Yamanishi K, Inoko M, Miwa K. Preferential dilation of recipient coronary arteries of the collateral circulation by intracoronary administration of nitroglycerin. J Am Coll Cardiol 1994; 24:631-5. [PMID: 8077531 DOI: 10.1016/0735-1097(94)90007-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The purpose of this study was to test the hypothesis that the sensitivity to nitroglycerin of collateral vessels and recipient arteries is greater than that of donor arteries of the collateral circulation. BACKGROUND The collateral circulation responds vigorously to nitroglycerin. However, the mechanisms of the efficacy of nitroglycerin for improving collateral circulation are not fully elucidated. METHODS The diameter of donor and recipient arteries of the collateral circulation was measured with a computer-assisted analysis system in eight patients with well developed collateral vessels. Coronary angiography was repeated before and after the intracoronary injection of 50 micrograms of nitroglycerin. RESULTS After nitroglycerin, the mean diameter +/- SD of donor arteries increased to 1.61 +/- 0.53 from 1.29 +/- 0.39 mm (p < 0.01), whereas the diameter of recipient arteries increased to 1.59 +/- 0.50 from 1.10 +/- 0.49 mm (p < 0.01). The change in the diameter of recipient arteries was significantly greater than that of donor arteries (52.3 +/- 24.6% vs. 24.7 +/- 11.5%, p < 0.05). These changes induced by the intracoronary injection of nitroglycerin were accompanied by a decrease in pacing-induced ST segment depression (0.16 +/- 0.06 to 0.06 +/- 0.04 mV, p < 0.01), suggesting increased flow reserve through collateral channels. CONCLUSIONS These findings indicate that the sensitivity to nitroglycerin of recipient arteries of the collateral circulation is significantly greater than that of donor arteries. This observation may explain the strong response of the collateral circulation to nitroglycerin in patients with functionally significant collateral channels.
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Affiliation(s)
- M Fujita
- Second Department of Internal Medicine, Toyama Medical and Pharmaceutical University, Japan
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Mahmarian JJ, Fenimore NL, Marks GF, Francis MJ, Morales-Ballejo H, Verani MS, Pratt CM. Transdermal nitroglycerin patch therapy reduces the extent of exercise-induced myocardial ischemia: results of a double-blind, placebo-controlled trial using quantitative thallium-201 tomography. J Am Coll Cardiol 1994; 24:25-32. [PMID: 8006274 DOI: 10.1016/0735-1097(94)90537-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES This study prospectively evaluated whether transdermal nitroglycerin patches could limit the extent of exercise-induced left ventricular ischemia as assessed by quantitative thallium-201 tomography. BACKGROUND Although antianginal medications are effective at reducing chest pain symptoms in patients with coronary artery disease, there is limited evidence that these agents can also reduce myocardial ischemia. METHODS This was a randomized, double-blind, parallel, placebo-controlled trial evaluating nitroglycerin patch therapy in patients in stable condition with angiographic coronary artery disease and no previous myocardial infarction. All patients were weaned from antianginal agents and had a baseline symptom-limited treadmill test followed by thallium-201 tomography. Forty patients with perfusion defects involving > or = 5% of the left ventricle were randomized to receive either intermittent (12 h on/off) active nitroglycerin patch therapy (0.4 mg/h) or placebo. Exercise tomography was repeated a mean (+/- SD) of 6.1 +/- 1.8 days after randomization. RESULTS Patients randomized to receive active patch therapy had a significant reduction in their total perfusion defect size (-8.9 +/- 11.1%) compared with placebo-treated patients (-1.8 +/- 6.1%, p = 0.04), which was most apparent in those with the largest (> or = 20%) baseline perfusion defects (-11.4 +/- 13.4% vs. 1.0 +/- 3.6%, respectively, p < 0.02). Furthermore, 7 (33%) of 21 patients receiving active therapy had a > or = 10% decrease in their perfusion defects compared with only 1 (5%) of 19 patients randomized to receive placebo (p = 0.002). Nitrate therapy did not significantly reduce heart rate, blood pressure or double product, indicating benefit through enhancement of coronary blood flow. CONCLUSIONS Short-term, intermittent nitroglycerin patch therapy significantly reduces myocardial ischemia, particularly in patients with large ischemic perfusion defects. Thallium-201 tomography can be used to assess sequential changes in the extent of exercise-induced left ventricular ischemia.
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Affiliation(s)
- J J Mahmarian
- Department of Medicine, Baylor College of Medicine, Houston, Texas
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Pupita G, Mazzara D, Centanni M, Rimatori C, Ferretti GF, Dessì-Fulgheri P, Russo P, Rappelli A. Ischemia in collateral-dependent myocardium: effects of nifedipine and diltiazem in man. Am Heart J 1993; 126:86-94. [PMID: 8322695 DOI: 10.1016/s0002-8703(07)80013-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
It has recently been shown that ischemia in collateral-dependent myocardium may develop at a very variable threshold in anginal patients; accordingly, the aim of this study was to assess whether nifedipine and diltiazem can increase blood flow to collateralized myocardium in man. Nine patients with complete coronary occlusion filled by collaterals, with no other coronary stenosis, normal left ventricular function, and reproducibly positive exercise tests were studied. They underwent exercise tests off therapy and after acute randomized administration of nifedipine (10 mg sublingually), diltiazem (120 mg orally), and nitroglycerin (0.5 mg sublingually), the latter a drug known to increase blood flow to collateralized myocardium. Following nifedipine, time to 1 mm ST segment depression increased significantly (from 430 +/- 176 to 576 +/- 205 seconds, p < 0.01), while heart rate and rate-pressure product remained unchanged (115 +/- 16 vs 121 +/- 17 beats/min and 199 +/- 29 vs 204 +/- 44 beats/min.mm Hg.10(2), respectively, p = NS for both). Similarly, diltiazem significantly increased time to ischemic threshold from baseline to 638 +/- 125 seconds (p < 0.01), but did not change heart rate and rate-pressure product at 1 mm ST segment depression. Submaximal rate-pressure products were significantly lowered by both nifedipine and diltiazem. Nitroglycerin not only significantly improved time to ischemic threshold (from baseline to 666 +/- 76 seconds, p < 0.01), but also increased heart rate (from baseline to 137 +/- 16 beats/min, p < 0.01) and rate-pressure product (from baseline to 242 +/- 48 beats/min.mm Hg.10(2), p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- G Pupita
- Institute of Patologia Medica, University of Ancona, Italy
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Hellstrom HR. Evidence in support of the spasm of resistance vessel concept of ischemic heart disease: an update in 1993. Med Hypotheses 1993; 41:11-22. [PMID: 8231973 DOI: 10.1016/0306-9877(93)90026-m] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The goal of this communication is to provide more evidence for the ischemic heart disease (IHD) component of the spasm of resistance vessel (S-RV) concept of IHD and other ischemic diseases. The S-RV concept of IHD is considered to be an alternate paradigm which challenges the accepted understanding of this disorder. The theory asserts that primary S-RV directly induces symptoms in IHD, and this position is in opposition to the accepted view that symptoms are induced directly by primary occlusions of epicardial arteries by coronary artery disease, spasm, and thromboses. The theory, if valid, should be useful in reducing the impact of IHD, as it generally is accepted that the correct appreciation of basic pathophysiological mechanisms helps ensure the most appropriate prevention and treatment of disease.
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Affiliation(s)
- H R Hellstrom
- Veterans Affairs Medical Center, Laboratory Service, Syracuse, NY 13210
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