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Chow BJ, Galiwango P, Poulin A, Raggi P, Small G, Juneau D, Kazmi M, Ayach B, Beanlands RS, Sanfilippo AJ, Chow CM, Paterson DI, Chetrit M, Jassal DS, Connelly K, Larose E, Bishop H, Kass M, Anderson TJ, Haddad H, Mancini J, Doucet K, Daigle JS, Ahmadi A, Leipsic J, Lim SP, McRae A, Chou AY. Chest Pain Evaluation: Diagnostic Testing. CJC Open 2023; 5:891-903. [PMID: 38204849 PMCID: PMC10774086 DOI: 10.1016/j.cjco.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/01/2023] [Indexed: 01/12/2024] Open
Abstract
Chest pain/discomfort (CP) is a common symptom and can be a diagnostic dilemma for many clinicians. The misdiagnosis of an acute or progressive chronic cardiac etiology may carry a significant risk of morbidity and mortality. This review summarizes the different options and modalities for establishing the diagnosis and severity of coronary artery disease. An effective test selection algorithm should be individually tailored to each patient to maximize diagnostic accuracy in a timely fashion, determine short- and long-term prognosis, and permit implementation of evidence-based treatments in a cost-effective manner. Through collaboration, a decision algorithm was developed (www.chowmd.ca/cadtesting) that could be adopted widely into clinical practice.
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Affiliation(s)
- Benjamin J.W. Chow
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Paul Galiwango
- Department of Medicine, Scarborough Health Network and Lakeridge Health, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Poulin
- Department of Medicine, Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Paolo Raggi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Gary Small
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Daniel Juneau
- Department of Radiology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Mustapha Kazmi
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Bilal Ayach
- Department of Medicine, Lakeridge Health, Queen’s University, Kingston, Ontario, Canada
| | - Rob S. Beanlands
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Anthony J. Sanfilippo
- Department of Medicine, Lakeridge Health, Queen’s University, Kingston, Ontario, Canada
| | - Chi-Ming Chow
- Division of Cardiology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D. Ian Paterson
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael Chetrit
- Department of Cardiovascular Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Davinder S. Jassal
- Department of Physiology and Pathophysiology, Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kim Connelly
- Division of Cardiology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Eric Larose
- Department of Medicine, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Quebec, Canada
| | - Helen Bishop
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Malek Kass
- Department of Internal Medicine, Rady Faculty of Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Todd J. Anderson
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Haissam Haddad
- Division of Cardiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - John Mancini
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Katie Doucet
- Peterborough Regional Health Centre, Kawartha Cardiology Clinic, Peterborough, Ontario, Canada
| | - Jean-Sebastien Daigle
- Department of Internal Medicine, Dr Everett Chalmers Hospital, Fredericton, New Brunswick, Canada
| | - Amir Ahmadi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan Leipsic
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Siok Ping Lim
- Mayfair Diagnostics, Saskatoon, Saskatchewan, Canada
| | - Andrew McRae
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Annie Y. Chou
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Radiology, St. Paul’s Hospital, Vancouver, British Columbia, Canada
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Significance of indeterminate and abnormal stress electrocardiography despite normal imaging in patients with suspected coronary artery disease – An analysis of the PROMISE trial. J Electrocardiol 2022; 73:79-86. [DOI: 10.1016/j.jelectrocard.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/02/2022] [Accepted: 05/22/2022] [Indexed: 11/22/2022]
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Martineau P, Slomka P, Goertzen A, Leslie WD. CRAX: A simple cardiovascular risk assessment tool to predict risk of acute myocardial infarction or death. J Nucl Cardiol 2020; 27:2365-2374. [PMID: 30535920 PMCID: PMC6565497 DOI: 10.1007/s12350-018-01556-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/21/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Determining the risk of cardiovascular events is essential to optimize patient management. METHODS AND RESULTS 5842 individuals underwent SPECT myocardial perfusion imaging (MPI) with 4.4 ± 1.2 years of follow-up. Models (the CRAX tool) were derived to predict the cumulative risk of death and acute myocardial infarction (AMI) at 1, 3, and 5 years using clinical and MPI variables. Predictors of AMI and death included age, number of hospitalizations in the 3 years preceding MPI, and left ventricular ejection fraction (LVEF). Additional predictors of death were the use of pharmacological stress, and global stress total perfusion deficit (sTPD), while transient ischemic dilation (TID), and ischemic total perfusion deficit (iTPD) change were predictive of AMI. CRAX predictions were significantly (P < .001) more accurate than clinical variables or MPI results alone, resulting in a significant net reclassification improvement (NRI, 7.5% for AMI, 14.5% death) compared to clinical variables alone. Accuracy for predicting major adverse cardiac events (MACE, comprising all-cause death, AMI, unstable angina, late revascularization) was comparable to that of AMI or death. CONCLUSIONS CRAX is a risk assessment tool that predicts the risk of AMI, death, or MACE, and improves prediction compared to clinical variables or MPI results alone.
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Affiliation(s)
- Patrick Martineau
- Department of Nuclear Medicine, University of Manitoba, 820 Sherbrook Street GC321, Winnipeg, MB, R3A 1R9, Canada
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Piotr Slomka
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew Goertzen
- Department of Nuclear Medicine, University of Manitoba, 820 Sherbrook Street GC321, Winnipeg, MB, R3A 1R9, Canada
| | - William D Leslie
- Department of Nuclear Medicine, University of Manitoba, 820 Sherbrook Street GC321, Winnipeg, MB, R3A 1R9, Canada.
- Department of Internal Medicine, University of Manitoba, C5121-409 Tache Ave, Winnipeg, MB, R2H 2A6, Canada.
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Humbert O, Noirot E, Leclerc T, Mouhat B, Pommier T, Cochet A, Cottin Y. [Comparison of the prognostic value of different clinical, angiographic and scintigraphic scores in stable coronary patients after acute coronary syndrome]. Ann Cardiol Angeiol (Paris) 2020; 69:12-23. [PMID: 31522776 DOI: 10.1016/j.ancard.2019.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 07/22/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION To date, there is no consensus regarding the follow-up of asymptomatic coronary patients with an intermediate risk of events. Indeed, most of cardiovascular events (CVE) occur in asymptomatic patients, hence the clinician's interest in establishing risk stratification scores. In asymptomatic patient, the risk assessment after acute coronary syndrome (ACS) can currently be based on 3 types of score: clinical with, for example, the REACH score; angiographic with the residual SYNTAX score; imaging with different scintigraphic scores. These scores differ widely in terms of evaluation criteria and period of analysis. The aim of our study was therefore, in stable and asymptomatic coronary patients after ACS, to compare these different predictive scores; to establish that the combination of these scores makes it possible to optimize the risk assessment during the follow-up. METHODS Our retrospective study included 236 revascularized patients after ACS. Three different risk scores were collected: 1) the residual SYNTAX score, calculated at the time of revascularization; 2) the scintigraphic risk score described by Sharir et al., performed 3 to 12 months after the event and taking into account the extent of ischemia (SDS) and the poststress left ventricular ejection fraction (LVEF). Patients with LVEF <50% and/or moderate to severe ischemic disease (SDS≥2) were considered with an intermediate or high scintigraphic risk; 3) the REACH clinical score calculated on the day of the scintigraphic examination. After the myocardial scintigraphic exam, patients had a 1-year follow-up and CVE were recorded. Continuous data were analyzed either by Student's t-test or non-parametric Mann-Whitney test. The dichotomous data were compared either by the χ2 test or by Fisher's exact test. RESULTS Forty-eight patients (20.1%) had a CVE during the 1-year follow-up. Thirty patients (13.8%) had a high residual SYNTAX score (≥8) without any correlation observed between the residual SYNTAX score and CVE (P=0.359). 148 patients (57.7%) had a high REACH clinical score (≥11) with no significant correlation observed with CVE (P=0.079). Lastly, 34 patients (14.4%) had an intermediate or high scintigraphic score, this imaging score being strongly correlated with a greater number of CVE (P<0.001). Multivariate analysis revealed 3 independent factors associated with CVE: a scintigraphic score> 2 (OR [(95% CI): 5.530 [2.426-12.605] P<0.001); Peripheral Arterial Obstructive Disease (PAOD) (OR [95% CI]: 8.531 [2.540-28.660] P<0.001); diabetes (OR [95% CI]: 2.86 [1.262-6.517] P=0,012). CONCLUSION The combination of the scintigraphic score with two clinical factors, such as PAOD and diabetes, provides optimal prognostic value in the evaluation of asymptomatic and stable patients after ACS. Our study therefore highlights the importance of optimizing evaluation strategies in the follow-up of these patients who remain at risk of post-revascularization CVE.
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Affiliation(s)
- O Humbert
- Département de médecine nucléaire, centre Georges-François-Leclerc, 21000 Dijon, France; Département de médecine nucléaire, centre Antoine-Lacassagne, université Côte d'Azur (UCA), 33, avenue de Valombrose, 06189 Nice, France.
| | - E Noirot
- Département de cardiologie, CHU de Dijon, France
| | - T Leclerc
- Département d'imagerie, CHU de Dijon, 21000 Dijon, France; Département de cardiologie, CHU de Dijon, France
| | - B Mouhat
- Département de cardiologie, CHU de Dijon, France
| | - T Pommier
- Département de cardiologie, CHU de Dijon, France
| | - A Cochet
- Département de médecine nucléaire, centre Georges-François-Leclerc, 21000 Dijon, France; Département d'imagerie, CHU de Dijon, 21000 Dijon, France
| | - Y Cottin
- Département de cardiologie, CHU de Dijon, France
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van Assen M, De Cecco CN, Eid M, von Knebel Doeberitz P, Scarabello M, Lavra F, Bauer MJ, Mastrodicasa D, Duguay TM, Zaki B, Lo GG, Choe YH, Wang Y, Sahbaee P, Tesche C, Oudkerk M, Vliegenthart R, Schoepf UJ. Prognostic value of CT myocardial perfusion imaging and CT-derived fractional flow reserve for major adverse cardiac events in patients with coronary artery disease. J Cardiovasc Comput Tomogr 2019; 13:26-33. [PMID: 30796003 DOI: 10.1016/j.jcct.2019.02.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/11/2019] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The purpose of this study was to analyze the prognostic value of dynamic CT perfusion imaging (CTP) and CT derived fractional flow reserve (CT-FFR) for major adverse cardiac events (MACE). METHODS 81 patients from 4 institutions underwent coronary computed tomography angiography (CCTA) with dynamic CTP imaging and CT-FFR analysis. Patients were followed-up at 6, 12, and 18 months after imaging. MACE were defined as cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization, or revascularization. CT-FFR was computed for each major coronary artery using an artificial intelligence-based application. CTP studies were analyzed per vessel territory using an index myocardial blood flow, the ratio between territory and global MBF. The prognostic value of CCTA, CT-FFR, and CTP was investigated with a univariate and multivariate Cox proportional hazards regression model. RESULTS 243 vessels in 81 patients were interrogated by CCTA with CT-FFR and 243 vessel territories (1296 segments) were evaluated with dynamic CTP imaging. Of the 81 patients, 25 (31%) experienced MACE during follow-up. In univariate analysis, a positive index-MBF resulted in the largest risk for MACE (HR 11.4) compared to CCTA (HR 2.6) and CT-FFR (HR 4.6). In multivariate analysis, including clinical factors, CCTA, CT-FFR, and index-MBF, only index-MBF significantly contributed to the risk of MACE (HR 10.1), unlike CCTA (HR 1.2) and CT-FFR (HR 2.2). CONCLUSION Our study provides initial evidence that dynamic CTP alone has the highest prognostic value for MACE compared to CCTA and CT-FFR individually or a combination of the three, independent of clinical risk factors.
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Affiliation(s)
- M van Assen
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; University of Groningen, University Medical Center Groningen, Center for Medical Imaging - North East Netherlands, Groningen, the Netherlands.
| | - C N De Cecco
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; Department of Radiology, Emory University, Atlanta, Georgia, USA.
| | - M Eid
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - P von Knebel Doeberitz
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - M Scarabello
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - F Lavra
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - M J Bauer
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - D Mastrodicasa
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - T M Duguay
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - B Zaki
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - G G Lo
- Department of Diagnostic and Interventional Radiology, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, China.
| | - Y H Choe
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Y Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
| | | | - Christian Tesche
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany.
| | - M Oudkerk
- University of Groningen, University Medical Center Groningen, Center for Medical Imaging - North East Netherlands, Groningen, the Netherlands.
| | - R Vliegenthart
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; University of Groningen, University Medical Center Groningen, Center for Medical Imaging - North East Netherlands, Groningen, the Netherlands; University of Groningen, University Medical Center Groningen, Departments of Radiology, Groningen, the Netherlands.
| | - U J Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
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Tamarappoo BK, Fong Ling L, Cerqueira M, Hachamovitch R. Independent prognostic value of left ventricular contractile reserve and chronotropic response in patients with reduced left ventricular ejection fraction undergoing vasodilator stress myocardial perfusion imaging with Rb-82 positron emission tomography. Eur Heart J Cardiovasc Imaging 2018; 19:442-449. [PMID: 28673042 DOI: 10.1093/ehjci/jex157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 06/14/2017] [Indexed: 11/13/2022] Open
Abstract
Objectives We evaluated the prognostic value of heart rate reserve (ΔHR) and left ventricular ejection fraction reserve (ΔLVEF) among patients with systolic dysfunction. Background Inadequate ΔHR (maximal stress HR - resting HR) and ΔLVEF (LVEF at stress - LVEF at rest) in response to stress are associated with adverse cardiac events. However, the significance of an abnormal ΔHR and ΔLVEF in patients with systolic dysfunction has not been described. Methods and results We performed a retrospective analysis of patients with rest LVEF < 45% who underwent dipyridamole stress-rest gated Rb-82 PET myocardial perfusion imaging (PET-MPI) at the Cleveland Clinic between 2006 and 2009. Stress LVEF and volumes were calculated using commercially available software (4DM). A Cox proportional hazards model (CPH) was used to examine the association between ΔLVEF, ΔHR, and all-cause death (ACD). Among 461 patients (mean age 65.7 ± 11.3 years, 82% men) 167 experienced ACD (median follow-up 1045 days). Survival was reduced among patients with ΔHR < 0 (1090 vs. 1300 days, P = 0.04) and ΔLVEF < 0 (1002 vs. 1057 days, P = 0.03). In a CPH after adjusting for confounding variables, ΔHR ≤ 0 and ΔLVEF ≤ 0 were associated with reduced survival (hazard ratio 0.93, P < 0.01 and 0.84, P = 0.01, respectively) with an interaction between age and ΔHR (χ2 = 8.1, P < 0.01). Our model predicts that the magnitude of ΔHR is associated with improved survival among younger patients. For any given ΔLVEF the magnitude of ΔHR has a greater positive effect on survival among younger patients. Conclusion Both ΔHR and ΔLVEF during pharmacologic stress PET-MPI provide incremental value in predicting ACD among patients with systolic dysfunction.
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Affiliation(s)
- Balaji K Tamarappoo
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Lee Fong Ling
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Manuel Cerqueira
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Rory Hachamovitch
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Abstract
Coronary artery disease (CAD) continues to be a leading cause of morbidity and mortality worldwide. Although invasive coronary angiography has previously been the gold standard in establishing the diagnosis of CAD, there is a growing shift to more appropriately use the cardiac catheterization laboratory to perform interventional procedures once a diagnosis of CAD has been established by noninvasive imaging modalities rather than using it primarily as a diagnostic facility to confirm or refute CAD. With ongoing technological advancements, noninvasive imaging plays a pre-eminent role in not only diagnosing CAD but also informing the choice of appropriate therapies, establishing prognosis, all while containing costs and providing value-based care. Multiple imaging modalities are available to evaluate patients suspected of having coronary ischemia, such as stress electrocardiography, stress echocardiography, single-photon emission computed tomography myocardial perfusion imaging, positron emission tomography, coronary computed tomography (CT) angiography, and magnetic resonance imaging. These imaging modalities can variably provide functional and anatomical delineation of coronary stenoses and help guide appropriate therapy. This review will discuss their advantages and limitations and their usage in the diagnostic pathway for patients with CAD. We also discuss newer technologies such as CT fractional flow reserve, CT angiography with perfusion, whole-heart coronary magnetic resonance angiography with perfusion, which can provide both anatomical as well as functional information in the same test, thus obviating the need for multiple diagnostic tests to obtain a comprehensive assessment of both, plaque burden and downstream ischemia. Recognizing that clinicians have a multitude of tests to choose from, we provide an underpinning of the principles of ischemia detection by these various modalities, focusing on anatomy vs physiology, the database justifying their use, their prognostic capabilities and lastly, their appropriate and judicious use in this era of patient-centered, cost-effective imaging.
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Kondo C, Watanabe E, Momose M, Fukushima K, Abe K, Hagiwara N, Sakai S. In vivo validation of gated myocardial SPECT imaging for quantification of small hearts: comparison with cardiac MRI. EJNMMI Res 2016; 6:9. [PMID: 26857778 PMCID: PMC4746205 DOI: 10.1186/s13550-015-0156-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 12/15/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In patients with small hearts, the Quantitative Gated single-photon emission computed tomography (SPECT) (QGS) program frequently underestimates the left ventricular (LV) end-systolic volume (ESV) and overestimates the ejection fraction (EF). A newly developed cardiac software program, cardioREPO/EXINI heart (cREPO), has been proposed to more accurately quantify small hearts using active shape modeling and a volume-dependent edge correction algorithm for LV delineation. The aim of this study was to validate cREPO in vivo for measuring the LV volumes and EF of both small and non-small hearts, in comparison with values obtained via cardiac MRI (CMR). METHODS We performed stress (99m)Tc-MIBI SPECT and CMR within a 30-day interval for 44 patients (mean age, 66 years; 27 men). Resting EF, end-diastolic volume (EDV), and ESV with QGS and cREPO were compared with values obtained via CMR. RESULTS The subjects consisted of 17 small and 27 non-small hearts. CMR yielded EDV, ESV, and EF values of 135 ± 31 ml (mean ± SD, range 85-217 ml), 57 ± 21 ml (27-105 ml), and 60 ± 6 % (45-70 %), respectively. Compared with CMR, both QGS and cREPO systematically underestimated both EDV and ESV and overestimated EF. The magnitude of the overestimation of EF by QGS, compared with CMR, correlated strongly with the given EF values (r = 0.71, P < 0.0001). In contrast, no significant correlation was seen with cREPO (r = 0.18, P = 0.24). In addition, no significant correlation was found between the magnitude of the underestimation of ESV and heart size with cREPO (r = 0.03, P = 0.83). Thus, cREPO provided a relatively constant 9 % overestimation of EF values relative to CMR, for the studied EF range for both small and non-small hearts. CONCLUSIONS The use of the new algorithm of cREPO ameliorated exaggerated EF in small hearts but not resolved completely. The program provided a constant 9 % overestimation for both small and non-small hearts, which should be carefully taken into account for clinical assessment of LV function.
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Affiliation(s)
- Chisato Kondo
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjyuku-ku, Tokyo, 162-8666, Japan.
| | - Eri Watanabe
- Department of Cardiology, Aoyama Hospital, Tokyo Women's Medical University, Tokyo, Japan
| | - Mitsuru Momose
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjyuku-ku, Tokyo, 162-8666, Japan
| | - Kenji Fukushima
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjyuku-ku, Tokyo, 162-8666, Japan
| | - Koichiro Abe
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjyuku-ku, Tokyo, 162-8666, Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shuji Sakai
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjyuku-ku, Tokyo, 162-8666, Japan
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Bajaj NS, Singh S, Farag A, El-Hajj S, Heo J, Iskandrian AE, Hage FG. The prognostic value of non-perfusion variables obtained during vasodilator stress myocardial perfusion imaging. J Nucl Cardiol 2016; 23:390-413. [PMID: 26940574 DOI: 10.1007/s12350-016-0441-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 01/21/2016] [Indexed: 11/25/2022]
Abstract
Myocardial perfusion imaging (MPI) is an established diagnostic test that provides useful prognostic data in patients with known or suspected coronary artery disease. In more than half of the patients referred for stress testing, vasodilator stress is used in lieu of exercise. Unlike exercise, vasodilator stress does not provide information on exercise and functional capacity, heart rate recovery, and chronotropy, and ECG changes are less frequent. These non-perfusion data provide important prognostic and patient management information. Further, event rates in patients undergoing vasodilator MPI are higher than in those undergoing exercise MPI and even in those with normal images probably due to higher pretest risk. However, there are a number of non-perfusion variables that are obtained during vasodilator stress testing, which have prognostic relevance but their use has not been well emphasized. The purpose of this review is to summarize the prognostic values of these non-perfusion data obtained during vasodilator MPI.
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Affiliation(s)
- Navkaranbir S Bajaj
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA
| | - Siddharth Singh
- Division of Cardiovascular Disease, Cedars Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Ayman Farag
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA
| | - Stephanie El-Hajj
- Division of Cardiovascular Disease, Medical University of South Carolina, Charleston, SC, USA
| | - Jack Heo
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA
| | - Ami E Iskandrian
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA
| | - Fadi G Hage
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA.
- Section of Cardiology, Birmingham Veteran's Administration Medical Center, Birmingham, AL, USA.
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Narihiro H, Masahisa O, Osamu H, Hiroyuki K, Masakazu M, Noriko M. Development of a 2-Layer Double-Pump Dynamic Cardiac Phantom. J Nucl Med Technol 2016; 44:31-5. [PMID: 26769601 DOI: 10.2967/jnmt.115.168252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 12/28/2015] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED The conventional dynamic cardiac phantom used in the field of nuclear medicine has a structure for which the size of the external side of the heart (the outer membrane substituting the myocardial layer) is fixed and only the inner side (the inner membrane substituting the ventricle part) moves anteroposteriorly. Therefore, its usefulness in technical evaluation is limited. Hence, we developed a new dynamic cardiac phantom in which the outer and inner membranes freely move. METHODS Using a SPECT/CT system, we performed validation by filling the myocardial layer of the dynamic cardiac phantom with solution and the ventricle part with contrast medium. We evaluated myocardial wall motions of 3 segments (basal, mid, and apical) by setting the stroke ratios at 20:20 and 10:10 (ventricle-to-myocardial layer ratio). RESULTS The myocardial wall motions (mean ± SD) at the stroke ratio of 20:20 were 7.50 ± 0.44, 11.15 ± 0.56, and 9.90 ± 0.24 mm in the basal, mid, and apical segments, respectively. The wall motions (mean ± SD) at the stroke ratio of 10:10 were 3.82 ± 0.43, 5.63 ± 0.39, and 4.53 ± 0.10 mm, respectively. CONCLUSION In our dynamic cardiac phantom, different movements could be induced in the myocardial wall by freely changing the stroke ratio. These results suggest that the use of this phantom can realize technical evaluation that presumes various clinical conditions.
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Affiliation(s)
- Hara Narihiro
- Sumitomo Hospital, Radiological Technology, Nakanoshima, Kita-ku, Osaka, Japan; and Kanazawa University, Graduate School of Medical Sciences, Kodatsuno, Kanazawa, Japan
| | - Onoguchi Masahisa
- Kanazawa University, Graduate School of Medical Sciences, Kodatsuno, Kanazawa, Japan
| | - Hojyo Osamu
- Sumitomo Hospital, Radiological Technology, Nakanoshima, Kita-ku, Osaka, Japan; and
| | - Kawaguchi Hiroyuki
- Sumitomo Hospital, Radiological Technology, Nakanoshima, Kita-ku, Osaka, Japan; and
| | - Murai Masakazu
- Sumitomo Hospital, Radiological Technology, Nakanoshima, Kita-ku, Osaka, Japan; and
| | - Matsushima Noriko
- Sumitomo Hospital, Radiological Technology, Nakanoshima, Kita-ku, Osaka, Japan; and
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Kortelainen MJ, Koivumäki TM, Vauhkonen MJ, Hakulinen MA. Dependence of left ventricular functional parameters on image acquisition time in cardiac-gated myocardial perfusion SPECT. J Nucl Cardiol 2015; 22:643-51. [PMID: 26048265 DOI: 10.1007/s12350-015-0178-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/05/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Reduction of image acquisition time in single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) examinations has been considered. However, association between left ventricular (LV) functional parameters and acquisition time is unclear. METHODS Twenty-four patients referred to one-day stress/rest SPECT MPI examinations were imaged at rest with dual-headed gamma camera. List-mode emission data were processed into sets of cardiac-gated images corresponding to different acquisition times: 20%, 30%, 40%, 50%, 60%, 80%, and 100% of total acquisition time (30 seconds per projection). Image quality was quantitatively evaluated by computing contrast-to-noise ratio. LV volumes, wall motion, wall thickening, and mechanical dyssynchrony were quantified with automatic clinical software (QGS; Cedars-Sinai Medical Center). RESULTS A significant negative dependence was found between phase analysis parameter values and image acquisition time. Differences in LV volume parameters were small but statistically significant at relative acquisition times of less than 50%. LV wall motion and wall thickening were found to be robust to the increase of noise. CONCLUSIONS Image acquisition time of gated SPECT MPI examination can be reduced to 15 seconds per projection without significantly affecting LV volumes, wall motion, or wall thickening. However, reduction of acquisition time has a significant effect on phase analysis results.
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Affiliation(s)
- Matti J Kortelainen
- Diagnostic Imaging Centre, Kuopio University Hospital, POB 100, 70029 KYS, Kuopio, Finland,
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Lee TS, Tsui BMW. The development and initial evaluation of a realistic simulated SPECT dataset with simultaneous respiratory and cardiac motion for gated myocardial perfusion SPECT. Phys Med Biol 2015; 60:1399-413. [PMID: 25612263 DOI: 10.1088/0031-9155/60/4/1399] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We developed a realistic simulation dataset for simultaneous respiratory and cardiac (R&C) gated SPECT/CT using the 4D NURBS-based Cardiac-Torso (NCAT) Phantom and Monte Carlo simulation methods, and evaluated it for a sample application study. The 4D NCAT phantom included realistic respiratory motion and beating heart motion based on respiratory gated CT and cardiac tagged MRI data of normal human subjects. To model the respiratory motion, a set of 24 separate 3D NCAT phantoms excluding the heart was generated over a respiratory cycle. The beating heart motion was modeled separately with 48 frames per cardiac cycle for each of the 24 respiratory phases. The resultant set of 24 × 48 3D NCAT phantoms provides a realistic model of a normal human subject at different phases of combined R&C motions. An almost noise-free SPECT projection dataset for each of the 1152 3D NCAT phantoms was generated using Monte Carlo simulation techniques and the radioactivity uptake distribution of (99m)Tc sestamibi in different organs. By grouping and summing the separate projection datasets, separate or simultaneous R&C gated acquired data with different gating schemes could be simulated. In the initial evaluation, we combined the projection datasets into ungated, 6 respiratory-gates only, 8 cardiac-gates only, and combined 6 respiratory-gates & 8 cardiac-gates projection datasets. Each dataset was reconstructed using 3D OS-EM without and with attenuation correction using the averaged and respiratory-gated attenuation maps, and the resulting reconstructed images were compared. These results were used to demonstrate the effects of R&C motions and the reduction of image artifact due to R&C motions by gating and attenuation corrections. We concluded that the realistic 4D NCAT phantom and Monte Carlo simulated SPECT projection datasets with R&C motions are powerful tools in the study of the effects of R&C motions, as well as in the development of R&C gating schemes and motion correction methods for improved SPECT/CT imaging.
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Affiliation(s)
- Taek-Soo Lee
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD 21287, USA
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Mut F, Giubbini R, Vitola J, Lusa L, Sobic-Saranovic D, Peix A, Bertagna F, Hang Bui D, Cunha C, Obaldo J, Rodella C, Camoni L, Paez D, Dondi M. Detection of post-exercise stunning by early gated SPECT myocardial perfusion imaging: results from the IAEA multi-center study. J Nucl Cardiol 2014; 21:1168-76. [PMID: 25213203 DOI: 10.1007/s12350-014-9983-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 07/25/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Transient post-ischemic LV dysfunction due to myocardial stunning in patients with coronary artery disease can be missed by conventional gated SPECT (GSPECT) acquisitions. The aim of this IAEA-sponsored multi-center study was to determine whether early post-exercise imaging is more likely to detect stunning than conventional without adversely affecting image quality or perfusion information. METHODS AND RESULTS Patients undergoing exercise/rest GSPECT were enrolled in this international multicenter study. Post-exercise studies were acquired at 15 ± 5 minutes after radiotracer injection (Stress-1) and repeated at 60 ± 15 minutes (Stress-2). Rest studies (R) were acquired at 60 minutes post injection. A core laboratory quantitatively assessed perfusion pattern and LV blinded to the acquisition time. Ischemia was defined as summed stress score (SDS) ≥4, and stunning was defined as the difference between rest and post-stress LVEF (Δ-LVEF). In the 229 patients enrolled into the study, both image quality and perfusion information were similar between Stress-1 and Stress-2. Post-stress LVEF was associated with both ischemia and time of acquisition, with a significant correlation between SDS and Δ-LVEF, which was stronger at Stress-1 than Stress-2 in the ischemic compared to the non-ischemic population (r = 0.23 vs 0.08, P = 0.10). CONCLUSIONS Early post-exercise imaging is feasible, and can potentially improve the detection of post-ischemic stunning without compromising image quality and perfusion data.
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Affiliation(s)
- Fernando Mut
- Department of Nuclear Medicine, Spanish Association Hospital, Montevideo, Uruguay
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Is computed tomography attenuation correction more efficient than gated single photon emission computed tomography analysis in improving the diagnostic performance of myocardial perfusion imaging in patients with low prevalence of ischemic heart disease? Nucl Med Commun 2014; 36:69-77. [PMID: 25279709 DOI: 10.1097/mnm.0000000000000218] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this study was to compare computed tomography (CT)-based attenuation correction (AC) using a hybrid single photon emission computed tomography (SPECT)-CT system and quantitative analysis of wall thickening using gated SPECT with regard to the diagnostic accuracy of myocardial perfusion imaging. MATERIALS AND METHODS We prospectively included 70 patients with low prevalence of acute coronary artery disease who underwent a myocardial stress-rest SPECT study. Interpretation was based on supine nongated SPECT data with (AC) or without (NC) CT-based attenuation correction, and on gated SPECT data without attenuation correction (GNC). The scintigraphic diagnosis was obtained using standard automated quantitative analysis software and compared with a 23±14 months' clinical follow-up for 57 patients or with the results of a coronary angiography for 13 patients. RESULTS The sensitivity, specificity, and overall accuracy were, respectively, 77, 60, and 63% for NC SPECT, 67, 81, and 79% for AC SPECT, and 69, 98, and 93% for GNC SPECT. The initial diagnosis was modified in about one-third of the cases for both AC and GNC, this rate being independent of any clinical parameter (including BMI) except sex (two to four times more artifact correction in men). CONCLUSION Its widespread availability, cost effectiveness, safety in terms of radiation exposure, and ability to significantly improve myocardial perfusion imaging specificity and accuracy make gated SPECT a self-sufficient modality for coronary artery disease screening and follow-up, whereas CT-AC should be discussed on a case-by-case basis.
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Nakata T, Hashimoto A. Improved Prediction of Major Cardiac Events by Gated Myocardial Perfusion Imaging. CURRENT CARDIOVASCULAR IMAGING REPORTS 2014. [DOI: 10.1007/s12410-014-9264-2] [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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Abidov A, Germano G, Hachamovitch R, Slomka P, Berman DS. Gated SPECT in assessment of regional and global left ventricular function: an update. J Nucl Cardiol 2013; 20:1118-43; quiz 1144-6. [PMID: 24234974 DOI: 10.1007/s12350-013-9792-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 09/11/2013] [Indexed: 01/31/2023]
Abstract
Gated myocardial perfusion SPECT (GSPECT) is a major clinical tool, widely used for performing myocardial perfusion imaging procedures. In this review, we have presented the fundamentals of GSPECT and the ways in which the functional measurements it provides have contributed to the emergence of myocardial perfusion SPECT in its important role as a major tool of modern cardiac imaging. GSPECT imaging has shown unique capability to provide accurate, reproducible and operator-independent quantitative data regarding myocardial perfusion, global and regional systolic and diastolic function, stress-induced regional wall-motion abnormalities, ancillary markers of severe and extensive disease, left ventricular geometry and mass, as well as the presence and extent of myocardial scar and viability. Adding functional data to perfusion provides an effective means of increasing both diagnostic accuracy and reader's confidence in the interpretation of the results of perfusion scans. Assessment of global and regional LV function has improved the prognostic power of myocardial perfusion SPECT and has been shown in a large registry to add to the perfusion assessment in predicting benefit from revascularization.
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Nakajima K, Okuda K, Nyström K, Richter J, Minarik D, Wakabayashi H, Matsuo S, Kinuya S, Edenbrandt L. Improved quantification of small hearts for gated myocardial perfusion imaging. Eur J Nucl Med Mol Imaging 2013; 40:1163-70. [PMID: 23632963 PMCID: PMC3699706 DOI: 10.1007/s00259-013-2431-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 04/10/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE In patients with a small heart, defined as an end-systolic volume (ESV) of ≤20 mL calculated using the Quantitative Gated SPECT (QGS) program, underestimation of ESV and overestimation of ejection fraction (EF) using gated myocardial perfusion imaging are considered errors caused by inappropriate delineation of the left ventricle (LV). The aim of this study was to develop a new method for delineation of the LV and to evaluate it in studies using a digital phantom, normal subjects and patients. METHODS The active shape-based method for LV delineation, EXINI heart (ExH), was adjusted to more accurately process small hearts. In small hearts, due to the partial volume effect and the short distance to the opposite ventricular wall, the endocardial and the epicardial surfaces are shifted in the epicardial direction depending on the midventricular volume. The adjusted method was evaluated using digital XCAT phantoms with Monte Carlo simulation (8 virtual patients), a Japanese multicentre normal database (69 patients) and consecutive Japanese patients (116 patients). The LV volumes, EF and diastolic parameters derived from ExH and QGS were compared. RESULTS The digital phantom studies showed a mean ESV of 87% ± 9% of the true volume calculated using ExH and 22 % ± 18% calculated using QGS. In the normal database, QGS gave higher EFs in women than in men (71.4 ± 6.0 % vs. 67.2 ± 6.0%, p = 0.0058), but ExH gave comparable EFs (70.7 ± 4.9% and 71.4 ± 5 % in men and women, respectively, p = ns). QGS gave higher EFs in subjects with a small heart than in those with a normal-sized heart (74.5 ± 5.1% vs. 66.1 ± 4.9%), but ExH gave comparable values (70.0 ± 5.9% vs. 71.6 ± 4.2%, respectively, p = ns). In consecutive patients, the average EFs with QGS in patients with ESV >20 mL, 11-20 mL and ≤10 mL were 57.9%, 71.9% and 83.2%, but with ExH the differences among these groups were smaller (65.2%, 67.8% and 71.5%, respectively). CONCLUSION The volume-dependent edge correction algorithm was able to effectively reduce the effects on ESV and EF of a small heart. The uniform normal values might be applicable to both men and women and to both small and normal-sized hearts.
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Prognostic Implications of the Difference Between Left Ventricular Ejection Fractions After Stress and at Rest in Addition to the Quantification of Myocardial Perfusion Abnormalities Obtained With Gated SPECT. Clin Nucl Med 2012; 37:748-54. [DOI: 10.1097/rlu.0b013e31825ae755] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sood N, Kazi FA, Lundbye JB, Katten D, Heller GV. Risk stratification of CAD with SPECT-MPI in women with known estrogen status. J Nucl Cardiol 2012; 19:330-7. [PMID: 22259010 DOI: 10.1007/s12350-011-9511-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 12/26/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To compare exercise tolerance testing (ETT) with gated single photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) risk stratification in women with an intermediate to high CAD pretest risk and known estrogen status (ES). BACKGROUND SPECT-MPI is an effective test for risk stratifying patients with stable angina. However in women, the current guidelines recommend the exercise tolerance testing (ETT) as first line test. Further, the relationship of stress imaging to ES, an independent risk indicator for CAD, is unknown. METHODS 2,194 women with an intermediate to high CAD pre-test risk were referred for a clinically indicated ETT with gated SPECT-MPI. Duke treadmill scores (DTS) and summed stress score (SSS) were calculated. SSS were classified as normal (SSS < 3), mildly abnormal (SSS 4-8), or moderate-severely abnormal (SSS > 8). The ES was assessed as premenopausal, postmenopausal on hormone replacement therapy (HRT) as ES+ while postmenopausal not on HRT were ES-. An annualized cardiac event rate of a composite of cardiac death, unstable angina (UA) leading to hospitalization, non-fatal myocardial infarction, or late coronary revascularization was calculated for all the groups. RESULTS The annualized cardiac event rate was 1.3% PPY, 2.1% PPY, and 3.2% PPY for low, intermediate, and high risk DTS (P = .2). Patients with intermediate DTS and mildly abnormal or moderate-severely abnormal gated SPECT-MPI had a significantly higher cardiac event rates (5.3% PPY and 10.8% PPY, respectively) than those with a normal gated SPECT-MPI (1.2%, PPY, P = .01). This was also demonstrated on further Cox-regression analysis. Risk stratification of SPECT-MPI over DTS was independent of ES. CONCLUSION Gated SPECT-MPI provides risk stratification beyond standard exercise stress testing for women with suspected coronary artery disease, especially in patients with intermediate DTS and is independent of ES.
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Affiliation(s)
- Nitesh Sood
- Division of Cardiology, Nuclear Cardiology Laboratory, Henry Low Heart Center, Hartford Hospital, Hartford, CT, USA.
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Ischemic changes on rubidium-82 positron emission tomography imaging are associated with left ventricular functional and volumetric change independent of metabolic properties and echocardiographic functional variables in ischemic cardiomyopathy. Int J Cardiovasc Imaging 2011; 28:1395-405. [DOI: 10.1007/s10554-011-9973-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Accepted: 10/28/2011] [Indexed: 10/15/2022]
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van der Zee PM, Verberne HJ, Cornel JH, Kamp O, van der Zant FM, Bholasingh R, De Winter RJ. GRACE and TIMI risk scores but not stress imaging predict long-term cardiovascular follow-up in patients with chest pain after a rule-out protocol. Neth Heart J 2011; 19:324-30. [PMID: 21584800 PMCID: PMC3144333 DOI: 10.1007/s12471-011-0154-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective To determine the long-term prognostic value of stress imaging and clinical risk scoring for cardiovascular mortality in chest pain patients after ruling out acute coronary syndrome (ACS). Methods A standard rule-out protocol was performed in emergency room patients with a normal or non-diagnostic admission electrocardiogram (ECG) within 6 h of chest pain onset. ACS patients were identified by troponin T, recurrent angina and serial ECG. Dobutamine stress echocardiography (DSE) was performed after ACS was ruled out. Myocardial perfusion scintigraphy (MPS) was performed within 6 months in an outpatient setting according to the physician’s discretion. Results 524 patients were included. GRACE and TIMI risk scores were 75 (57–96) and 1 (0–2) in the rule-out ACS group, and 89 (74–107) and 2 (1–3) in the ACS group, respectively (median, interquartile range). Follow-up (median 9.4 (8.9–10.0) years) was complete in 96%. 350 of 379 rule-out ACS patients had an interpretable DSE and 52 patients underwent an MPS. 21 of the rule-out ACS patients (6%) died of a cardiovascular cause compared with 24 (17%) ACS patients (p < 0.001). For rule-out ACS patients, C-statistics were 0.829 and 0.803 for the GRACE and TIMI scores. In these patients, DSE and MPS outcome did not predict long-term cardiovascular mortality. In multivariate analysis, known chronic heart failure, ACE inhibitor use, and GRACE score were independent predictors of cardiovascular mortality. Conclusions TIMI and GRACE score but not DSE and MPS are accurate predictors of long-term cardiovascular mortality, even in chest pain patients with a normal or non-diagnostic electrocardiogram undergoing a rule-out protocol.
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Affiliation(s)
- P M van der Zee
- Department of Cardiology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands,
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Klem I, Shah DJ, White RD, Pennell DJ, van Rossum AC, Regenfus M, Sechtem U, Schvartzman PR, Hunold P, Croisille P, Parker M, Judd RM, Kim RJ. Prognostic value of routine cardiac magnetic resonance assessment of left ventricular ejection fraction and myocardial damage: an international, multicenter study. Circ Cardiovasc Imaging 2011; 4:610-9. [PMID: 21911738 DOI: 10.1161/circimaging.111.964965] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cardiac magnetic resonance (CMR) is considered the reference standard for assessment of left ventricular ejection fraction (LVEF) and myocardial damage. However, few studies have evaluated the relationship between CMR findings and patient outcome, and of these, most are small and none multicenter. We performed an international, multicenter study to assess the prognostic importance of routine CMR in patients with known or suspected heart disease. METHODS AND RESULTS From 10 centers in 6 countries, consecutive patients undergoing routine CMR assessment of LVEF and myocardial damage by cine and delayed-enhancement imaging (DE-CMR), respectively, were screened for enrollment. Clinical data, CMR protocol information, and findings were collected at all sites and submitted to the data coordinating center for verification of completeness and analysis. The primary end point was all-cause mortality. A total of 1560 patients (age, 59±14 years; 70% men) were enrolled. Mean LVEF was 45±18%, and 1049 (67%) patients had hyperenhanced tissue (HE) on DE-CMR indicative of damage. During a median follow-up time of 2.4 years (interquartile range, 1.2, 2.9 years), 176 (11.3%) patients died. Patients who died were more likely to be older (P<0.0001), have coronary disease (P=0.004), have lower LVEF (P<0.0001), and have more segments with HE (P<0.0001). In multivariable analysis, age, LVEF, and number of segments with HE were independent predictors of mortality. Among patients with near-normal LVEF (≥50%), those with above-median HE (>4 segments) had reduced survival compared to patients with below- or at-median HE (P=0.02). CONCLUSIONS Both LVEF and amount of myocardial damage as assessed by routine CMR are independent predictors of all-cause mortality. Even in patients with near-normal LVEF, significant damage identifies a cohort with a high risk for early mortality.
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Affiliation(s)
- Igor Klem
- Duke University Medical Center, Durham, NC, USA
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Abstract
Pharmacologic stress myocardial perfusion imaging is a noninvasive method for evaluating coronary artery disease in patients unable to exercise sufficiently to achieve a heart rate high enough to facilitate satisfactory imaging. The nuclear cardiology nurse is an invaluable member of the laboratory team that performs these tests. In this specialist role, the nurse must have a thorough knowledge of the different pharmacologic stress agents (dipyridamole, adenosine, regadenoson, and dobutamine) that can be used. This should comprise an understanding of their mechanisms of action, contraindications, drug-drug interactions, adverse effects, and administration protocols. By drawing on this knowledge, the nurse is able to verify that the right agent has been selected for each patient based on his/her medical history. The nurse also can help patients follow pretest instructions (such as withholding caffeine and certain medications) by explaining that the measures are necessary for a safe and successful procedure and that violation may result in test cancellation or postponement. On the day of the stress test, the nurse has an important role in safeguarding the patient as well as providing support and reassurance throughout the different stages of the examination. Responsibilities include explaining the entire procedure to the patients, notably, what they will be asked to do, the effect of the stress agent, the timing of each step, the adverse effects that they may experience, how any adverse events will be managed, and the importance of remaining still during imaging. This central role of the nuclear cardiology nurse in overseeing the practical aspects of the pharmacologic stress test has important implications in terms of optimizing the productivity and efficiency of their noninvasive cardiology laboratory and nuclear medicine department.
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Hovland A, Staub UH, Bjørnstad H, Prytz J, Sexton J, Støylen A, Vik-Mo H. Gated SPECT offers improved interobserver agreement compared with echocardiography. Clin Nucl Med 2011; 35:927-30. [PMID: 21206222 DOI: 10.1097/rlu.0b013e3181f9ddfb] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Left ventricular ejection fraction (EF) is a powerful predictor of prognosis in coronary artery disease. The purpose of the present study was to measure interobserver differences for gated SPECT (GSPECT) software and echocardiography, and to compare these modalities regarding left ventricular volumes and EF. MATERIALS AND METHODS Eighty-four patients scheduled for nuclear imaging underwent a 1-day GSPECT with Tc-99m-tetrofosmin. Images were processed by 2 raters who calculated volumes and EF using Cedar-Sinai quantitative gated-SPECT (QGS), Emory Cardiac Toolbox (ECT), and 4D-MSPECT of the University of Michigan. Echocardiographic volumes were measured by 2 raters. Interobserver reliability was assessed by intraclass correlation coefficient (ICC). Differences in volumes and EF between echocardiography and GSPECT were compared with t-tests. RESULTS ICC was 0.61 for echocardiography, 0.94 for QGS, 0.88 for ECT, and 0.91 for 4D-MSPECT (P < 0.0001 compared with echocardiography). For small ventricles (ESV ≤30 mL), ICC was 0.58 for echocardiography and 0.90 for QGS (P = 0.008 compared with echocardiography); 0.77 and 0.73 for ECT and 4D-MSPECT, respectively (P = ns). End-diastolic and end-systolic volumes were significantly larger with GSPECT than with echocardiography, also echocardiographic ejection fraction was significantly different from GSPECT. CONCLUSIONS There is better interobserver reliability in GSPECT as compared with echocardiography, and QGS seems more robust in this study especially when it comes to small ventricles.
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Affiliation(s)
- Anders Hovland
- Coronary Care Unit, Department of Internal Medicine, Nordland Hospital, Bodø, Norway.
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Mathur S, Shah AR, Ahlberg AW, Katten DM, Heller GV. Blunted heart rate response as a predictor of cardiac death in patients undergoing vasodilator stress technetium-99m sestamibi gated SPECT myocardial perfusion imaging. J Nucl Cardiol 2010; 17:617-24. [PMID: 20490960 DOI: 10.1007/s12350-010-9242-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Accepted: 04/30/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The prognostic value of a blunted heart rate response (BHR) during ECG-gated vasodilator stress SPECT MPI in relation to ventricular function on long-term cardiovascular events is not well established. We performed this study to evaluate the incremental prognostic value of BHR during pharmacological stress SPECT MPI. METHODS Consecutive patients who underwent dipyridamole stress Tc-99m sestamibi ECG-gated SPECT MPI (without exercise) were identified. The ratio of peak stress heart rate to baseline was noted. If the ratio was <1.20, it was considered blunted (BHR). The images were interpreted using the standard ASNC 17 segment model. Patients were followed up for a mean time period of 2.3 +/- 1.5 years. RESULTS Sixty-four percent (2,890/4,484) of patients demonstrated BHR during dipyridamole stress testing. Cardiac death, the primary end point, occurred in 6.8% of patients. Patients with BHR had a significantly lower cardiac death-free survival as compared to NO BHR group in total population (83% vs 94%; P < .001) as well as in subgroup with normal ejection fraction (89% vs 96%; P < .001). BHR was an independent predictor of cardiac death after adjusting for multiple clinical, perfusion, and function-related gated SPECT variables. CONCLUSION Blunted heart rate response during vasodilator stress SPECT MPI is an important prognostic marker for cardiac death.
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Affiliation(s)
- Shishir Mathur
- Nuclear Cardiology Laboratory, Henry Low Heart Center, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA.
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Mudrick DW, Velazquez E, Borges-Neto S. Does Myocardial Perfusion Imaging Provide Incremental Prognostic Information to Left Ventricular Ejection Fraction? Curr Cardiol Rep 2010; 12:155-61. [DOI: 10.1007/s11886-010-0093-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Harpaz D, Asman A, Kuperstein R, Boaz M, Chouraqui P. Left ventricular ejection fraction assessment by Tl-201 gated SPECT: a comparison with echocardiography. Clin Cardiol 2010; 33:E56-62. [PMID: 20127905 DOI: 10.1002/clc.20577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Few studies including only a limited number of patients have compared left ventricular ejection fraction (LVEF) assessed by 2-dimensional echocardiography (2-DE) and electrocardiography-gated Tl-201 single-photon emission computed tomography (SPECT). HYPOTHESIS LVEF assessment by Tl-201 gated spect is comparable with LVEF assessed by 2-DE in two different echocardiographic laboratories. MATERIAL AND METHODS Patients (n = 402) underwent Tl-201 gated SPECT in the same laboratory and 2-DE in 2 different laboratories. Patients were divided into 2 groups according to the study laboratory: group 1, at the tertiary hospital and group 2, at a community laboratory. RESULTS LVEF evaluations were similar (mean LVEF: 50.73% +/- 11.67% by 2-DE vs 50.11% +/- 11.41% by SPECT in group 1 and 57.27% +/- 7.44% by 2-DE vs 57.41% +/- 8.37% by SPECT in group 2). All LVEF measurements were highly correlated (r = 0.7, P<.001). Baseline characteristics differed between the groups, with a higher prevalence of past myocardial infarction in the in-hospital vs the community echo group (46.7% vs 22.2%, P<.01), resulting in a higher LVEF in the latter, both by 2-DE (mean 50.7% +/- 11.7% vs 57.3% +/- 7.4%, P<.01) and SPECT (50.1% +/- 11.4% vs 57.4% +/- 8.4%, P<.01). CONCLUSIONS The Tl-201 gated SPECT is a reliable clinical tool for LVEF assessment, with good correlation when compared to 2-DE. It may be routinely used as an alternative for patients with poor acoustic visualization and should be performed systematically in patients undergoing myocardial perfusion imaging with Tl-201.
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Affiliation(s)
- David Harpaz
- The Heart Institute, E. Wolfson Medical Center, Holon, Israel.
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Hachamovitch R, Kang X, Amanullah AM, Abidov A, Hayes SW, Friedman JD, Cohen I, Thomson LEJ, Germano G, Berman DS. Prognostic implications of myocardial perfusion single-photon emission computed tomography in the elderly. Circulation 2009; 120:2197-206. [PMID: 19917890 DOI: 10.1161/circulationaha.108.817387] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The goal of this study was to assess the clinical value of stress myocardial perfusion scintigraphy (MPS) in elderly patients (> or =75 years of age). METHODS AND RESULTS We followed up 5200 elderly patients (41% exercise) after dual-isotope MPS over 2.8+/-1.7 years (362 cardiac deaths [CDs], 7.0%, 2.6%/y) and a subset with extended follow-up (684 patients for 6.2+/-2.9 years; 320 all-cause deaths). Survival modeling of CD revealed that both MPS-measured ischemia and fixed defect added incrementally to pre-MPS data in both adenosine and exercise stress patients. Modeling a subset with gated MPS (n=2472) revealed that ejection fraction and perfusion data added incrementally to each other, further enhancing risk stratification. Unadjusted, annualized post-normal MPS CD rate was 1.3% but <1% in patients with normal rest ECG, exercise stress, or age of 75 to 84 years and was 2.3% to 3.7% in patients > or =85 years of age or undergoing pharmacological stress. However, compared with age-matched US population CD rates (75 to 84 years of age, 1.5%; > or =85 years, 4.8%), normal MPS CD rates were approximately one-third lower than the baseline risk of US individuals (both P<0.05). Modeling of all-cause death in 684 patients with extended follow-up revealed that after risk adjustment, an interaction between early treatment and ischemia was present; increasing ischemia was associated with increasing survival with early revascularization, whereas in the setting of little or no ischemia, medical therapy had improved outcomes. CONCLUSIONS Stress MPS effectively stratifies CD risk in elderly patients and may identify optimal post-MPS therapy. CD rates after normal MPS are low in all subsets in relative terms compared with the age-matched US population.
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Affiliation(s)
- Rory Hachamovitch
- Department of Imaging, Division of Nuclear Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Willerson JT. Myocardial perfusion scintigraphy and value in patients with non-ST segment elevation acute coronary syndromes. Am J Cardiol 2009; 104:738. [PMID: 19699355 DOI: 10.1016/j.amjcard.2009.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2009] [Revised: 04/15/2009] [Accepted: 04/15/2009] [Indexed: 11/26/2022]
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Gjertsson P, Ekberg S, Lomsky M, Gan LM, Edenbrandt L. Evaluation of new automated gated-SPECT and echocardiographic methods for calculating left ventricular volumes and ejection fraction. Int J Cardiol 2009; 136:171-7. [DOI: 10.1016/j.ijcard.2008.04.082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Revised: 03/20/2008] [Accepted: 04/23/2008] [Indexed: 10/21/2022]
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Peix A, González A, García EJ, Valiente J, Cabrera LO, Sixto S, Filgueiras CE, Cabalé B, Hechavarría S, González I, Carrillo R, García-Barreto D. Left ventricular dysfunction secondary to ischemia in women with angina and normal coronary angiograms. J Womens Health (Larchmt) 2009; 18:155-61. [PMID: 19183086 DOI: 10.1089/jwh.2008.0844] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Microvascular disease is proposed as a cause of segmental myocardial blood flow abnormalities and heterogeneous myocardial perfusion in cardiac syndrome X. OBJECTIVE To assess if myocardial ischemia can be evidenced through both perfusion abnormalities and poststress left ventricular ejection fraction (LVEF) reduction by gated single photon emission tomography (SPECT) myocardial scintigraphy in women with syndrome X in a similar way to those with epicardial coronary lesions. METHODS Three groups of postmenopausal women were studied: group I, 20 women with angina, perfusion defects, and normal coronary angiography; group II, 20 women with epicardial coronary lesions (> or =50% of coronary lumen reduction); group III, 15 volunteers without signs or symptoms of ischemia (control group). Each underwent technetium-99m ((99m)TC) methoxyisobutylisonitrile gated SPECT myocardial scintigraphy (protocol: exercise-stress-rest), brachial artery endothelial function measured by ultrasonography, and lipidogram. RESULTS Groups I and III patients had a higher body mass index (BMI). There were more smokers in groups I and II. Very low density lipoprotein cholesterol (VLDL-C) and triglycerides were higher in group II patients. The brachial artery vasodilator responsiveness after 5 minutes of ischemia was similarly lower in patients of groups I and II compared with those of group III (3% vs. 6.5%, respectively; p = 0.03 group III vs. group I and group II). Mean DeltaLVEF (LVEF poststress minus LVEF at rest) was -3.86%, -2.90%, and 4.18% in groups I, II, and III, respectively (p = NS between I and II, p = 0.005 between II and III, and p = 0.003 between I and III). In 43% of group I patients and in 10 of 18 group III patients with perfusion defects, there was a poststress LVEF reduction >5%. CONCLUSIONS Stress-induced ischemia is associated with poststress LVEF reduction as a probable manifestation of myocardial stunning in postmenopausal women with typical angina and normal coronary angiography.
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Baghdasarian SB, Noble GL, Ahlberg AW, Katten D, Heller GV. Risk stratification with attenuation corrected stress Tc-99m sestamibi SPECT myocardial perfusion imaging in the absence of ECG-gating due to arrhythmias. J Nucl Cardiol 2009; 16:533-9. [PMID: 19288163 DOI: 10.1007/s12350-009-9071-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Revised: 01/17/2009] [Accepted: 02/10/2009] [Indexed: 01/09/2023]
Abstract
BACKGROUND Despite growing recognition of attenuation correction (AC) utilizing an external radiation source, prognostic studies using AC are lacking. METHODS Consecutive patients (n = 419) who underwent stress Tc-99m sestamibi SPECT imaging with AC but without ECG-gating, due to arrhythmia, were followed for cardiac death or non-fatal myocardial infarction (MI). A 17-segment model and the summed stress score (SSS) were used to classify both the non-AC and AC images. RESULTS The 419 patients had a mean age of 71.5 +/- 11.7 years and most (70.6%) underwent pharmacologic stress. In follow-up, 35 (8.4%) patients suffered an adverse cardiac event. Patients with AC-SSS 1-3 and AC-SSS 4-8 had similar cardiac event rates (11.4% vs 10.5%, P = NS). Accordingly, AC-SSS cutoffs of 0, 1-8, and >8 were selected to classify perfusion as normal, mildly abnormal, and moderately to severely abnormal with annualized event rates of 2.1%, 10.8%, and 18.7%, respectively (P < .001). In multivariable analysis, AC-SSS >8 was the most powerful predictor of cardiac events followed by AC-SSS 1-8, history of CAD, age >75 and pharmacologic stress. CONCLUSIONS AC provides powerful risk stratification when added to clinical variables in patients undergoing stress Tc-99m sestamibi SPECT imaging without ECG-gating. Moreover, smaller/less severe defects on AC data are more significant than if the same defects were seen on non-AC data.
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Affiliation(s)
- Sarkis B Baghdasarian
- Division of Cardiology, Nuclear Cardiology Laboratory, Deborah Heart and Lung Center, 200 Trenton Road, Browns Mills, NJ 08015, USA.
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America YGCJ, Bax JJ, Boersma E, Stokkel M, van der Wall EE. The additive prognostic value of perfusion and functional data assessed by quantitative gated SPECT in women. J Nucl Cardiol 2009; 16:10-9. [PMID: 19152124 DOI: 10.1007/s12350-008-9012-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Revised: 07/15/2008] [Accepted: 07/31/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to assess the prognostic value of technetium-99m tetrofosmin gated SPECT imaging in women using quantitative gated single photon emission computed tomography (SPECT) imaging. METHODS We followed 453 consecutive female patients. Average follow-up was 1.33 years (max. 2.55). Hard endpoints were cardiac death, acute myocardial infarction, or documented ventricular fibrillation. Event-free survival curves were obtained. Optimal cutoff values for left ventricular (LV) volumes, LV ejection fraction (LVEF), and perfusion data to predict outcome were determined by ROC curve analysis. RESULTS A total of 236 patients had an abnormal study, of whom 27 patients experienced hard events (16 deaths) and 47 patients soft events. For hard events summed stress score (SSS) and LVEF, and for any cardiac event SSS showed independent incremental prognostic value. The survival curves were maximally separated when using cutoff values for SSS of > or = 22 and LVEF < 52% (P < 0.001, HR 4.61 and P < 0.001 HR 5.24 for SSS and LVEF resp.), and SSS > or = 14 (P < 0.001 HR 3.76) for any cardiac event. CONCLUSION In women, perfusion and functional parameters derived from quantitative gated technetium-99m tetrofosmin SPECT imaging can adequately be used for cardiac risk assessment. Using quantitative gated SPECT, female patients with an LVEF < 52% or an SSS > or = 22 are at increased risk for subsequent hard events. Furthermore, patients with an SSS > or = 14 are at increased risk for any cardiac events.
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Affiliation(s)
- Yves G C J America
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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Wexler O, Yoder SR, Elder JL, Mackin ML, Chen L, Mixon L, Schwartz RG. Effect of gender on cardiovascular risk stratification with ECG gated SPECT left ventricular volume indices and ejection fraction. J Nucl Cardiol 2009; 16:28-37. [PMID: 19152126 DOI: 10.1007/s12350-008-9000-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2007] [Revised: 08/28/2008] [Accepted: 09/12/2008] [Indexed: 11/28/2022]
Abstract
BACKGROUND Optimal gender-specific risk prediction using ECG-gated SPECT left ventricular (LV) volumes and ejection fraction (EF) remains undefined despite reported gender differences in baseline LV function. METHODS ECG-gated SPECT studies of 891 consecutively referred patients (43% women) were evaluated for LV end-systolic and diastolic volume indices (ESVI, EDVI) and EF. Effects of gender on prediction of hard cardiac events (HCE) and the combined endpoint of all-cause mortality or non-fatal infarction (ACMMI) were evaluated. RESULTS Women had smaller ESVI (37 vs 55 mL/m(2)), EDVI (78 vs 99 mL/m(2)), and higher LVEF (56 vs 47%, P < 0.0001 for each) with equivalent rates of HCE (6.1%) and ACMMI (11.8%). HCE risk started at smaller ESVI and EDVI in women compared to men (P < or = 0.05 for each). In women, ESVI 37 mL/m(2) provided maximum HCE prediction compared to 53 mL/m(2) in men. A 1 mL/m(2) increase in ESVI was associated with a 2.9% increased HCE risk in women (P < 0.0001) and a 0.9% increased ACMMI risk in men (P = 0.03). Women with ESVI > 35 mL/m(2) had HCE HR 12.0 compared to women with ESVI < 23 mL/m(2). CONCLUSION LV volume indices and LVEF predict subsequent morbid clinical events in men and women. In women, risk of subsequent events started at smaller LV volume indices compared to men despite similar risk profiles.
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Affiliation(s)
- Orren Wexler
- University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 679-N, Rochester, NY 14642, USA.
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Lertsburapa K, Ahlberg AW, Bateman TM, Katten D, Volker L, Cullom SJ, Heller GV. Independent and incremental prognostic value of left ventricular ejection fraction determined by stress gated rubidium 82 PET imaging in patients with known or suspected coronary artery disease. J Nucl Cardiol 2008; 15:745-53. [DOI: 10.1007/bf03007355] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Accepted: 05/25/2008] [Indexed: 11/30/2022]
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Defining myocardial infarction by cardiac computed tomography. Int J Cardiovasc Imaging 2008; 24:891-3. [DOI: 10.1007/s10554-008-9355-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2008] [Accepted: 08/04/2008] [Indexed: 10/21/2022]
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Stirrup J, Underwood SR. Non-invasive imaging of coronary artery disease. Br J Hosp Med (Lond) 2008; 69:152-7. [PMID: 18422224 DOI: 10.12968/hmed.2008.69.3.28752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Non-invasive imaging of the heart is an expanding field in cardiology and appropriate test selection depends on the clinical question and test availability. This article reviews the role of single photon emission computed tomography myocardial perfusion scintigraphy, positron emission tomography and multi-detector computed tomography.
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Affiliation(s)
- Jim Stirrup
- Royal Brompton and Harefield NHS Trust, London SW3 6NP
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de Mattos AM, Siedlecki A, Gaston RS, Perry GJ, Julian BA, Kew CE, Deierhoi MH, Young C, Curtis JJ, Iskandrian AE. Systolic dysfunction portends increased mortality among those waiting for renal transplant. J Am Soc Nephrol 2008; 19:1191-6. [PMID: 18369087 DOI: 10.1681/asn.2007040503] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Individuals waiting for a renal transplant experience excessive cardiovascular mortality, which is not fully explained by the prevalence of ischemic heart disease in this population. Overt heart failure is known to increase the mortality of patients with ESRD, but the impact of lesser degrees of ventricular systolic dysfunction is unknown. For examination of the association between left ventricular ejection fraction(LVEF) and mortality of renal transplant candidates, the records of 2718 patients evaluated for transplantation at one institution were reviewed. During 6355 patient-years (median 27 mo) of follow-up, 681 deaths occurred. Patients with systolic dysfunction (LVEF <or= 0.40) had significantly lower survival than those with higher systolic function (median 49 +/- 3.1 versus 72 +/- 4.0 mo; P 0.001) but had similar survival to patients with ischemia (48 +/- 2.5 mo). Multivariate modeling showed that those with systolic dysfunction were nearly twice as likely to die as those with normal systolic function, adjusted for risk factors including diabetes, left ventricular hypertrophy, and ischemia (adjusted hazard ratio 1.7; 95%confidence interval 1.43 to 2.07). In addition, a graded, reverse association between LVEF and mortality was identified. In conclusion, systolic dysfunction is strongly associated with mortality, in a graded manner, in renal transplant candidates.
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Affiliation(s)
- Angelo M de Mattos
- Divisions of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
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Symptom-limited exercise combined with dipyridamole stress: prognostic value in assessment of known or suspected coronary artery disease by use of gated SPECT imaging. J Nucl Cardiol 2008; 15:42-56. [PMID: 18242479 DOI: 10.1016/j.nuclcard.2007.09.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Accepted: 09/10/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND Combining vasodilator and exercise stress reduces noncardiac side effects, improves image quality, and enhances the detection of ischemia, compared with suboptimal exercise or vasodilator stress alone. However, prognostic data with combined protocols are limited. METHODS AND RESULTS Consecutive patients (n = 2064) who underwent symptom-limited exercise and dipyridamole stress with gated single-photon emission computed tomography (SPECT) imaging, without early revascularization, were studied. Subsequent cardiac death or nonfatal myocardial infarction was related to exercise and gated SPECT variables. Cox proportional hazards regression modeling was performed to identify predictors of adverse outcome. Annualized event rates in patients with normal and abnormal images were 0.96% and 2.71%, respectively (P < .001). With abnormal imaging, annualized event rates were 0.86% and 3.13% in patients with average to high and fair or poor functional capacity, respectively (P = .019). Abnormal imaging, a severely reduced post-stress ejection fraction, transient ischemic dilation, and fair or poor functional capacity emerged as predictors of adverse outcome. Accordingly, patients were stratified into low-risk, intermediate-risk, and high-risk cohorts with annualized event rates of 0.94%, 2.24%, and 8.19%, respectively (P < .001 in any two-way comparison). CONCLUSIONS A protocol that combines symptom-limited exercise and dipyridamole stress with gated SPECT imaging provides highly effective risk stratification for adverse outcomes.
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Kapetanopoulos A, Ahlberg AW, Taub CC, Katten DM, Heller GV. Regional wall-motion abnormalities on post-stress electrocardiographic-gated technetium-99m sestamibi single-photon emission computed tomography imaging predict cardiac events. J Nucl Cardiol 2008; 14:810-7. [PMID: 18022107 DOI: 10.1016/j.nuclcard.2007.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Accepted: 07/13/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND The global left-ventricular (LV) ejection fraction (EF) is a powerful predictor of cardiac death (CD). There are limited data on the prognostic value of regional LV function. We examined the role of visually assessed regional wall motion in risk stratification for future cardiac events. METHODS AND RESULTS A prospectively gathered database of 10,336 patients who underwent technetium (Tc)-99m sestamibi-gated single-photon emission computed tomography (SPECT) was analyzed. The summed stress score (SSS) and summed wall-motion score (SWMS) were calculated using a standard 17-segment model. The post-stress EF was generated using QGS software. The follow-up was 90.2% complete over 28.6 +/- 16 months. Patients with early (<or=60 days) revascularization were censored, leaving 8,767 for analysis. A multivariate analysis demonstrated that abnormal wall motion (SWMS >or=5) was an independent predictor of cardiac death (odds ratio = 1.78, 95% confidence interval = 1.11 to 2.85, P = .016). Among patients with an EF >or=45%, abnormal wall motion was the only gated SPECT variable that independently predicted cardiac death (odds ratio = 1.69, 95% confidence interval = 1.06 to 2.7, P = .028). In patients with an EF >or=45% and reversible perfusion defects, abnormal wall motion predicted an intermediate (2.2%/year) risk for CD, and a high (4.2%/year) risk for the combined endpoint of cardiac death and nonfatal MI. CONCLUSIONS Regional LV function data from gated SPECT provide important prognostic information, and may identify a subgroup of patients with preserved EF and ischemia who are at significant risk for future cardiac events.
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Brown TLY, Merrill J, Volokh L, Bengel FM. Determinants of the response of left ventricular ejection fraction to vasodilator stress in electrocardiographically gated 82rubidium myocardial perfusion PET. Eur J Nucl Med Mol Imaging 2007; 35:336-42. [PMID: 17912523 DOI: 10.1007/s00259-007-0603-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Accepted: 09/04/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE Myocardial perfusion imaging with (82)Rb PET allows for ECG-gated studies to be obtained early after radiotracer injection, capturing ventricular function close to peak pharmacologic action of dipyridamole. This is different from gated SPECT and may potentially provide additional diagnostic information. We sought to identify potential correlates of the PET-derived ejection fraction response to vasodilator stress. METHODS One hundred ten consecutive patients undergoing (82)Rb PET myocardial perfusion imaging during evaluation for coronary artery disease were included. Using a GE Discovery STRx PET-CT scanner, ECG-gated images (eight bins) were obtained at rest and 4 min after dipyridamole infusion, 90 s after infusion of 1,480-2,220 MBq of (82)Rb. Summed rest, stress, and difference scores (SRS, SSS, and SDS) were determined using a five-point scoring system and 20-segment model. Ejection fraction was calculated using automated QGS software. RESULTS Significant reversibility (SDS > or = 4) was found in 23 patients (21%). Mean LVEF in all patients was 47 +/- 13% at rest and 53 +/- 13% during dipyridamole. LVEF increased in 89 patients, and decreased in 17 patients during vasodilation. The change in LVEF was inversely correlated with SDS (r = -0.26; p = 0.007). Additionally, it was inversely correlated with resting LVEF (r = -0.20; p = 0.03) and SSS (r = -0.25; p = 0.009). No significant correlations were observed with SRS, heart rate, blood pressure, age, hypertension, hypercholesterolemia, or pretest likelihood of disease. At multivariate regression analysis, SDS was an independent predictor of the change in LVEF. CONCLUSIONS Gated (82)Rb PET during pharmacologic stress allows for assessment of the functional response to vasodilation. The magnitude of LVEF increase is determined by stress perfusion/reversible perfusion defects. Functional response to hyperemia may thus be incorporated in future evaluations of diagnostic and prognostic algorithms based on (82)Rb PET.
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Affiliation(s)
- Tracy L Y Brown
- Department of Radiology and Radiological Sciences, Division of Nuclear Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
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Abstract
Although myocardial perfusion imaging is an established, noninvasive method for assessing risk in patients with suspected or known coronary artery disease, its usefulness in assessing the asymptomatic patient with diabetes mellitus has not been established. In the published literature, 16% to 56% of asymptomatic diabetes mellitus patients have stress myocardial perfusion-induced abnormalities. In prospective, unbiased populations, the prevalence of perfusion abnormalities are between 15% and 30%. The prognostic value of perfusion imaging in asymptomatic diabetes mellitus has been demonstrated. In diabetic patients with a normal perfusion scan, the yearly cardiac event rate is 1.2% to 2%, compared with 1% in the nondiabetic population. In patients with an abnormal myocardial perfusion scan, the cardiac event risk is increased three- to eightfold compared with patients with a normal scan. The severity of the perfusion abnormality is related to outcome. Prospective, randomized studies are required to demonstrate the efficacy of a strategy of stress myocardial perfusion imaging in asymptomatic diabetes mellitus patients.
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Affiliation(s)
- Michael Freeman
- St. Michael's Hospital, University of Toronto, Toronto, Ontario.
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Singh B, Bateman TM, Case JA, Heller G. Attenuation artifact, attenuation correction, and the future of myocardial perfusion SPECT. J Nucl Cardiol 2007; 14:153-64. [PMID: 17386377 DOI: 10.1016/j.nuclcard.2007.01.037] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Sciagrà R. The expanding role of left ventricular functional assessment using gated myocardial perfusion SPECT: the supporting actor is stealing the scene. Eur J Nucl Med Mol Imaging 2007; 34:1107-22. [PMID: 17384947 DOI: 10.1007/s00259-007-0405-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Gating of single-photon emission computed tomography (SPECT) has significantly improved the reliability and diagnostic accuracy of myocardial perfusion imaging. The functional parameters derived from this technique, mainly left ventricular volumes and ejection fraction, have been demonstrated to be accurate and reproducible. They are able to increase the detection of severe and extensive coronary artery disease and show a significant incremental prognostic power over perfusion abnormalities. Therefore, the importance given to gated SPECT functional data has progressively grown. DISCUSSION This circumstance has further expanded the indications for myocardial perfusion imaging and strengthened its position among the different imaging modalities. Moreover, several studies show that the evaluation of ventricular function may have a leading part in justifying the execution of perfusion scintigraphy in various clinical conditions. AIM Aim of this review is to describe this evolution of gated SPECT functional assessment from a supporting rank with respect to perfusion, to a main actor position in the field of cardiac imaging.
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Affiliation(s)
- Roberto Sciagrà
- Nuclear Medicine Unit, Department of Clinical Physiopathology, University of Florence, Viale Morgagni 85, 50134 Florence, Italy.
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Metz LD, Beattie M, Hom R, Redberg RF, Grady D, Fleischmann KE. The Prognostic Value of Normal Exercise Myocardial Perfusion Imaging and Exercise Echocardiography. J Am Coll Cardiol 2007; 49:227-37. [PMID: 17222734 DOI: 10.1016/j.jacc.2006.08.048] [Citation(s) in RCA: 323] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Revised: 08/23/2006] [Accepted: 08/28/2006] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The purpose of this work was to determine the prognostic value of normal exercise myocardial perfusion imaging (MPI) tests and exercise echocardiography tests, and to determine the prognostic value of these imaging modalities in women and men. BACKGROUND Exercise MPI and exercise echocardiography provide prognostic information that is useful in the risk stratification of patients with suspected coronary artery disease (CAD). METHODS We searched the PubMed, Cochrane, and DARE databases between January 1990 and May 2005, and reviewed bibliographies of articles obtained. We included prospective cohort studies of subjects who underwent exercise MPI or exercise echocardiography for known or suspected CAD, and provided data on primary outcomes of myocardial infarction (MI) and cardiac death with at least 3 months of follow-up. Secondary outcomes (unstable angina, revascularization procedures) were abstracted if provided. Studies performed exclusively in patients with CAD were excluded. RESULTS The negative predictive value (NPV) for MI and cardiac death was 98.8% (95% confidence interval [CI] 98.5 to 99.0) over 36 months of follow-up for MPI, and 98.4% (95% CI 97.9 to 98.9) over 33 months for echocardiography. The corresponding annualized event rates were 0.45% per year for MPI and 0.54% per year for echocardiography. In subgroup analyses, annualized event rates were <1% for each MPI isotope, and were similar for women and men. For secondary events, MPI and echocardiography had annualized event rates of 1.25% and 0.95%, respectively. CONCLUSIONS Both exercise MPI and exercise echocardiography have high NPVs for primary and secondary cardiac events. The prognostic utility of both modalities is similar for both men and women.
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Affiliation(s)
- Louise D Metz
- Department of Medicine, New York University School of Medicine, New York, New York, USA
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Myocardial Perfusion Imaging Utilizing Single Photon Emission Computed Tomography Techniques. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_37] [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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