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Lindow T, Ekström M, Brudin L, Carlén A, Elmberg V, Hedman K. Typical angina during exercise stress testing improves the prediction of future acute coronary syndrome. Clin Physiol Funct Imaging 2021; 41:281-291. [PMID: 33583090 DOI: 10.1111/cpf.12695] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 01/08/2021] [Accepted: 02/08/2021] [Indexed: 01/09/2023]
Abstract
INTRODUCTION The prognostic value of angina during exercise stress testing is controversial, possibly due to previous studies not differentiating typical from non-typical angina. We aimed to assess the prognostic value of typical angina alone, or in combination with ST depression, during exercise stress testing for predicting cardiovascular events. METHODS We conducted a prospective observational cohort study including all patients who performed a clinical exercise stress test at the department of Clinical Physiology, Kalmar County Hospital between 2005 and 2012. The association between typical angina/ST depression and incident acute coronary syndrome (ACS) and cardiovascular mortality were analysed using Cox regression for long-term and 1-year follow-up. RESULTS Out of 11605 patients (median follow-up 6.7 years), 623 (5.4%) developed ACS and 319 (2.7%) died from cardiovascular causes. Compared to patients with no angina and no ST depression, typical angina and ST depression were associated with increased risk of future ACS; hazard ratio (HR) 3.5 ([95%CI] 2.6-4.7). This association was even stronger for ACS within one year (typical angina with and without concomitant ST depression; HR 20.8 (13.9-31.3) and 9.7 (6.1-15.4), respectively). Concordance statistics for ST depression in predicting ACS during long-term follow-up was 0.58 (0.56-0.60) and 0.69 (0.65-0.73) for ACS within one year, and 0.64 (0.62-0.66) and 0.77 (0.73-0.81), respectively, when typical angina was added to the model. CONCLUSIONS Typical angina during exercise stress testing is predictive of future ACS, especially in combination with ST depression, and during the first year after the test.
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Affiliation(s)
- Thomas Lindow
- Department of Clinical Physiology, Växjö Central Hospital, Clinical Sciences, Clinical Physiology, Department of Research and Development, Lund University, Region Kronoberg, Sweden
| | - Magnus Ekström
- Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Lars Brudin
- Department of Clinical Physiology, Kalmar County Hospital, Kalmar, Sweden
| | - Anna Carlén
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Viktor Elmberg
- Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund University, Lund, Sweden.,Department of Clinical Physiology, Blekinge Hospital, Karlskrona, Sweden
| | - Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Diagnostic value of myocardial SPECT to detect in-stent restenosis after drug-eluting stent implantation. Int J Cardiovasc Imaging 2012; 28:2125-34. [PMID: 22395666 DOI: 10.1007/s10554-012-0036-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 02/21/2012] [Indexed: 10/28/2022]
Abstract
Different angiographic patterns and restenosis rate may affect diagnostic value of single-photon emission computed tomography (SPECT) in the era of drug-eluting stents (DES). We aimed to determine the ability of myocardial SPECT to detect in-stent restenosis (ISR) in patients treated with DES compared to that of patients treated with bare metal stent (BMS). We evaluated 228 consecutive patients who underwent 6 months follow-up SPECT and coronary angiography (CAG) after stent implantation. In 228 patients, 354 vessels were treated with stent implantation (BMS, n = 105; DES, n = 249) and 65 (18.4%) vessels showed ISR (angiographic % diameter stenosis ≥ 50%) at the 6-month follow-up CAG. In patients with BMS-ISR (n = 37), restenosis was primarily diffuse (70.3%), whereas patients with DES-ISR (n = 28) exhibited more focal restenosis (53.6%, p = 0.028). The sensitivity and specificity of myocardial SPECT did not differ significantly between patients with BMS and those with DES (BMS vs. DES: sensitivity 56.8 vs. 39.3%, p = 0.163; specificity 72.1 vs. 76.5%, p = 0.460). Evaluation of 71 false positive and 33 false negative lesions showed that the most common cause of false-positive results in SPECT was the perfusion decrease which improved but not disappeared compared with the baseline (46 among 71 vascular territories). Despite different patterns of restenosis and ISR rates, the diagnostic value of SPECT did not differ between BMS and DES. Further study looking at ISR in larger number of patients and using other protocol such as Fleming-Harrington Redistribution Wash-in Washout may give additional information.
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Abstract
Myocardial perfusion single photon emission-computed tomography (MPS) has been one of the most important and common non-invasive diagnostic cardiac test. Gated MPS provides simultaneous assessment of myocardial perfusion and function with only one study. With appropriate attention to the MPS techniques, appropriate clinical utilization and effective reporting, gated MPS will remain a useful diagnostic test for many years to come. The aim of this article is to review the basic techniques of MPS, a simplified systematic approach for study interpretation, current clinical indications and reporting. After reading this article the reader should develop an understanding of the techniques, interpretation, current clinical indications and reporting of MPS studies.
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Affiliation(s)
- Ahmed Fathala
- Department of Cardiac Imaging and Nuclear Medicine, Medical Imaging Service, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
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Galassi AR, Marzá F, Azzarelli S, Tomasello SD. Role of Stress Myocardial Scintigraphy in the Evaluation of Incompletely Revascularized Post-PCI Patients. INTERNATIONAL JOURNAL OF MOLECULAR IMAGING 2011; 2011:180936. [PMID: 21941646 PMCID: PMC3177365 DOI: 10.1155/2011/180936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Revised: 03/21/2011] [Accepted: 06/14/2011] [Indexed: 11/17/2022]
Abstract
Percutaneous coronary intervention (PCI) is actually the most used method of revascularization. Although complete revascularization remains a desirable goal, it may not be possible or not easy to plan in many patients. Thus, incomplete revascularization might be a preferred treatment strategy in selected patient categories. Stress myocardial scintigraphy, because of its high diagnostic accuracy and prognostic value and its ability to assess location and extent of myocardial ischemia regardless of symptoms as well as to evaluate patients who are unable to exercise or who have uninterpretable electrocardiogram, is of paramount importance for clinical decision making in patients with multivessel disease and incomplete revascularization.
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Affiliation(s)
- Alfredo R. Galassi
- Department of Internal Medicine and Systemic Disease, Clinical Division of Cardiology, Ferrarotto Hospital, University of Catania, Via Antonello da Messina 75 Acicastello, 95021 Catania, Italy
| | - Francesco Marzá
- Department of Internal Medicine and Systemic Disease, Clinical Division of Cardiology, Ferrarotto Hospital, University of Catania, Via Antonello da Messina 75 Acicastello, 95021 Catania, Italy
| | - Salvatore Azzarelli
- Division of Cardiology, Cannizzaro Hospital, Via Messina 829, 95126 Catania, Italy
| | - Salvatore D. Tomasello
- Department of Internal Medicine and Systemic Disease, Clinical Division of Cardiology, Ferrarotto Hospital, University of Catania, Via Antonello da Messina 75 Acicastello, 95021 Catania, Italy
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Georgoulias P, Valotassiou V, Tsougos I, Demakopoulos N. Myocardial Perfusion SPECT Imaging in Patients after Percutaneous Coronary Intervention. Curr Cardiol Rev 2011; 6:98-103. [PMID: 21532775 PMCID: PMC2892082 DOI: 10.2174/157340310791162677] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Revised: 01/06/2010] [Accepted: 02/25/2010] [Indexed: 11/22/2022] Open
Abstract
Coronary artery disease (CAD) is the most prevalent form of cardiovascular disease affecting about 13 million Americans, while more than one million percutaneous transluminal intervention (PCI) procedures are performed annually in the USA. The relative high occurrence of restenosis, despite stent implementation, seems to be the primary limitation of PCI. Over the last decades, single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), has proven an invaluable tool for the diagnosis of CAD and patients’ risk stratification, providing useful information regarding the decision about revascularization and is well suited to assess patients after intervention. Information gained from post-intervention MPI is crucial to differentiate patients with angina from those with exo-cardiac chest pain syndromes, to assess peri-intervention myocardial damage, to predict-detect restenosis after PCI, to detect CAD progression in non-revascularized vessels, to evaluate the effects of intervention if required for occupational reasons and to evaluate patients’ long-term prognosis. On the other hand, chest pain and exercise electrocardiography are largely unhelpful in identifying patients at risk after PCI. Although there are enough published data demonstrating the value of myocardial perfusion SPECT imaging in patients after PCI, there is still debate on whether or not these tests should be performed routinely.
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The value of stress single-photon emission computed tomography imaging performed routinely at 6 months in asymptomatic patients for predicting angiographic restenosis after successful direct percutaneous intervention for acute ST elevation myocardial infarction. Coron Artery Dis 2008; 19:89-97. [DOI: 10.1097/mca.0b013e3282f0a288] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Elhendy A, Schinkel AFL, van Domberg RT, Bax JJ, Valkema R, Poldermans D. Non-invasive diagnosis of in stent stenosis by stress 99m technetium tetrofosmin myocardial perfusion imaging. Int J Cardiovasc Imaging 2006; 22:657-62. [PMID: 16628382 DOI: 10.1007/s10554-006-9087-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2006] [Accepted: 03/01/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND The aim of this study was to assess the accuracy of stress 99m technetium tetrofosmin myocardial perfusion imaging for the diagnosis of in stent stenosis (ISS). METHODS We studied 72 patients who underwent exercise or dobutamine stress 99m technetium tetrofosmin imaging, 0.9+/-0.5 years after percutaneous coronary interventions in which stents were deployed. Coronary angiography was performed within 3 months of the stress test. ISS was defined as > or =50% stenosis in a coronary segment with previous stenting. Significant coronary artery disease (CAD) was defined as > or =50% stenosis within or outside the stented coronary segment. RESULTS The stent was deployed in 1 coronary artery in 52 patients, and in 2 coronary arteries in 20 patients (a total of 92 detected in 42 (58%) patients (51 stents). Reversible perfusion abnormalities were present in 34 of patients with ISS (sensitivity=81%, CI 70-94). Regional sensitivity for diagnosis of stenosis per stent was 76% (CI 65-88), specificity was 83% (CI 71-94) and accuracy was 79% (CI 69-85). Reversible perfusion abnormalities were detected in > or =2 vascular distributions in 15 of 22 patients with multi-vessel CAD and in 5 of 50 patients without (sensitivity for identifying multivessel CAD=68%, CI 50-89; specificity=90%, CI 82-98; and accuracy=83%, CI 75-90). CONCLUSION Stress 99m technetium tetrofosmin myocardial perfusion imaging is a useful non-invasive technique for the diagnosis of in stent stenosis and extent of CAD in patients with previous percutaneous coronary artery interventions.
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Affiliation(s)
- Abdou Elhendy
- Thoraxcenter, University Hospital Rotterdam, Rotterdam, The Netherlands.
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Chalela WA, Kreling JC, Falcão AM, Hueb W, Moffa PJ, Pereyra PLA, Ramires JAF. Exercise stress testing before and after successful multivessel percutaneous transluminal coronary angioplasty. Braz J Med Biol Res 2006; 39:475-82. [PMID: 16612470 DOI: 10.1590/s0100-879x2006000400007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Controversy exists regarding the diagnostic accuracy, optimal technique, and timing of exercise testing after percutaneous coronary intervention. The objectives of the present study were to analyze variables and the power of exercise testing to predict restenosis or a new lesion, 6 months after the procedure. Eight-four coronary multi-artery diseased patients with preserved ventricular function were studied (66 males, mean age of all patients: 59 +/- 10 years). All underwent coronary angiography and exercise testing with the Bruce protocol, before and 6 months after percutaneous coronary intervention. The following parameters were measured: heart rate, blood pressure, rate-pressure product (heart rate x systolic blood pressure), presence of angina, maximal ST-segment depression, and exercise duration. On average, 2.33 lesions/patient were treated and restenosis or progression of disease occurred in 46 (55%) patients. Significant increases in systolic blood pressure (P = 0.022), rate-pressure product (P = 0.045) and exercise duration (P = 0.003) were detected after the procedure. Twenty-seven (32%) patients presented angina during the exercise test before the procedure and 16 (19%) after the procedure. The exercise test for the detection of restenosis or new lesion presented 61% sensitivity, 63% specificity, 62% accuracy, and 67 and 57% positive and negative predictive values, respectively. In patients without restenosis, the exercise duration after percutaneous coronary intervention was significantly longer (460 +/- 154 vs 381 +/- 145 s, P = 0.008). Only the exercise duration permitted us to identify patients with and without restenosis or a new lesion.
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Affiliation(s)
- W A Chalela
- Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
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Elhendy A, Tsutsui JM, O'Leary EL, Xie F, Majeed F, Porter TR. Evaluation of restenosis and extent of coronary artery disease in patients with previous percutaneous coronary interventions by dobutamine stress real-time myocardial contrast perfusion imaging. Heart 2006; 92:1480-3. [PMID: 16606862 PMCID: PMC1861022 DOI: 10.1136/hrt.2005.086140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To assess the accuracy of real-time myocardial contrast perfusion imaging (MCPI) for the diagnosis of restenosis and extent of coronary artery disease (CAD) in patients with previous percutaneous coronary intervention (PCI). METHODS 56 patients were studied 1.9 (SD 1.4) years after PCI. They underwent MCPI with commercially available ultrasound contrast agents (Optison or Definity) at rest and at peak dobutamine-atropine stress. Coronary angiography was performed within one month. Significant CAD was defined as >or= 50% stenosis in >or= 1 major epicardial coronary artery. Significant restenosis was defined as >or= 50% stenosis in a coronary segment with previous intervention. RESULTS Reversible perfusion abnormalities were detected in 40 of 43 patients with significant CAD and in 4 of 13 patients without (overall sensitivity 93%, 95% CI 85% to 99%; specificity 69%, 95% CI 44% to 94%; and accuracy 88%, 95% CI 79% to 96%). Significant restenosis in >or= 1 coronary artery with previous PCI was detected in 38 (68%) patients. Reversible perfusion abnormalities were present in 35 of them (sensitivity 92%, 95% CI 84% to 99%). Reversible perfusion abnormalities were detected in >or= 2 vascular distributions in 20 of 28 patients with multivessel CAD and in 3 of 28 patients without (sensitivity 71%, 95% CI 55% to 88%; specificity 89%, 95% CI 78% to 99%; and accuracy 80%, 95% CI 70% to 91%). Restenosis was detected in 41 coronary arteries. Sensitivity of MCPI for regional diagnosis of restenosis was 73% (95% CI 60% to 87%), specificity was 75% (95% CI 60% to 90%), and accuracy was 74% (95% CI 64% to 84%). CONCLUSION Dobutamine stress MCPI is a useful technique for the evaluation of restenosis and extent of CAD after PCI.
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Affiliation(s)
- A Elhendy
- Department of Internal Medicine, Section of Cardiology, University of Nebraska Medical Center, Omaha, Nebraska, USA.
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Hirata K, Watanabe H, Otsuka R, Fujimoto K, Tokai K, Yamagishi H, Yoshiyama M, Yoshikawa J. Noninvasive Diagnosis of Restenosis by Transthoracic Doppler Echocardiography After Percutaneous Coronary Intervention: Comparison With Exercise Tl-SPECT. J Am Soc Echocardiogr 2006; 19:165-71. [PMID: 16455420 DOI: 10.1016/j.echo.2005.08.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2005] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Noninvasive methods that have the ability to accurately detect restenosis have been desired in the selection of patients requiring further angiographic evaluation. The present study sought to evaluate the diagnostic potential of transthoracic Doppler echocardiography (TTDE), a noninvasive method for evaluating coronary flow velocity reserve (CFVR), in detecting restenosis after percutaneous coronary intervention (PCI). METHODS We studied 107 consecutive patients 6 months after undergoing successful PCI on the left anterior descending coronary artery (LAD) lesions for relief of angina pectoris. The flow velocity in the distal LAD was measured by TTDE both at rest and during intravenous infusion of adenosine triphosphate. CFVR was calculated as the ratio of hyperemic to basal mean diastolic flow velocities. We defined a reversible perfusion defect in exercise Tl-201 single-photon emission computed tomography (SPECT) as restenosis. The CFVR measurements by TTDE were compared with the results of SPECT. RESULTS Complete TTDE data were acquired for 105 of the 107 study patients. A contrast agent was used to obtain adequate Doppler signals in 29 patients. Of the 105 patients, there were 18 patients with abnormal perfusion (group A) and 87 patients with normal perfusion (group B) in the LAD territories on Tl-201 SPECT. CFVR was greater in group B than in group A (1.7 +/- 0.5 vs. 3.7 +/- 0.8, P < 0.0001, respectively). There were 17 patients with CFVR < 2 and 88 patients with CFVR > or = 2. CFVR < 2 predicted restenosis determined by Tl-201 SPECT, with a sensitivity of 94% and a specificity of 100%. CONCLUSIONS Noninvasive measurement of CFVR by TTDE accurately reflects the physiological severity of coronary narrowing due to restenosis after PCI. This method has possibility of reducing the number of unnecessary coronary angiographies after PCI.
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Affiliation(s)
- Kumiko Hirata
- Department of Internal Medicine and Cardiology, Osaka City University School of Medicine, Osaka, Japan
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Kitta Y, Nakamura T, Kodama Y, Takano H, Umetani K, Fujioka D, Saito Y, Kawabata KI, Obata JE, Ichigi Y, Mende A, Kugiyama K. Endothelial Vasomotor Dysfunction in the Brachial Artery Is Associated With Late In-Stent Coronary Restenosis. J Am Coll Cardiol 2005; 46:648-55. [PMID: 16098430 DOI: 10.1016/j.jacc.2005.04.055] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2005] [Revised: 04/19/2005] [Accepted: 04/25/2005] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study examined whether endothelial dysfunction in the brachial artery might be associated with late in-stent restenosis (ISR) after percutaneous coronary intervention (PCI). BACKGROUND Simple and noninvasive identification of late ISR might help to select patients who require further angiographic evaluation. METHODS Endothelium-dependent flow-mediated dilation (FMD) of the brachial artery was measured before (initial FMD) and at six months (follow-up FMD) after PCI in 141 consecutive patients who had elective and successful PCI with bare metal stents in de novo lesions of native coronary arteries for symptomatic coronary artery disease. Follow-up angiography was performed at six months after PCI in all patients. RESULTS With multivariate logistic regression analysis, the impairment (< or = 4.8% dilation from baseline diameter) of FMD at follow-up showed the strongest association with late ISR (defined as > 50% diameter stenosis, n = 46) independently of other clinical and angiographic variables known to be associated with ISR (odds ratio 7.4, 95% confidence interval 2.8 to 19.2, p < 0.001), whereas the initial FMD did not have the association. The sensitivity of impaired FMD at follow-up (69%) in detecting ISR was higher than chest pain during the follow-up period (45%), with comparable specificity. The impaired FMD in combination with the chest pain increased the sensitivity to 90%. CONCLUSIONS The impairment of FMD in the brachial artery at the time of follow-up was independently and closely associated with late ISR in native coronary arteries. The noninvasive assessment of FMD at the time of follow-up might be useful for identification of late ISR.
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Affiliation(s)
- Yoshinobu Kitta
- Department of Internal Medicine II, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Yamanashi, Japan
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Cicala S, Galderisi M, Guarini P, D'Errico A, Innelli P, Pardo M, Scognamiglio G, de Divitiis O. Transthoracic coronary flow reserve and dobutamine derived myocardial function: a 6-month evaluation after successful coronary angioplasty. Cardiovasc Ultrasound 2004; 2:26. [PMID: 15581428 PMCID: PMC539289 DOI: 10.1186/1476-7120-2-26] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2004] [Accepted: 12/06/2004] [Indexed: 01/09/2023] Open
Abstract
After percutaneous transluminal coronary angioplasty (PTCA), stress-echocardiography and gated single photon emission computerized tomography (g-SPECT) are usually performed but both tools have technical limitations. The present study evaluated results of PTCA of left anterior descending artery (LAD) six months after PTCA, by combining transthoracic Doppler coronary flow reserve (CFR) and color Tissue Doppler (C-TD) dobutamine stress. Six months after PTCA of LAD, 24 men, free of angiographic evidence of restenosis, underwent standard Doppler-echocardiography, transthoracic CFR of distal LAD (hyperemic to basal diastolic coronary flow ratio) and C-TD at rest and during dobutamine stress to quantify myocardial systolic (Sm) and diastolic (Em and Am, Em/Am ratio) peak velocities in middle posterior septum. Patients with myocardial infarction, coronary stenosis of non-LAD territory and heart failure were excluded. According to dipyridamole g-SPECT, 13 patients had normal perfusion and 11 with perfusion defects. The 2 groups were comparable for age, wall motion score index (WMSI) and C-TD at rest. However, patients with perfusion defects had lower CFR (2.11 ± 0.4 versus 2.87 ± 0.6, p < 0.002) and septal Sm at high-dose dobutamine (p < 0.01), with higher WMSI (p < 0.05) and stress-echo positivity of LAD territory in 5/11 patients. In the overall population, CFR was related negatively to high-dobutamine WMSI (r = -0.50, p < 0.01) and positively to high-dobutamine Sm of middle septum (r = 0.55, p < 0.005). In conclusion, even in absence of epicardial coronary restenosis, stress perfusion imaging reflects a physiologic impairment in coronary microcirculation function whose magnitude is associated with the degree of regional functional impairment detectable by C-TD.
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Affiliation(s)
- Silvana Cicala
- Cardioangiology Unit, Department of Clinical and Experimental Medicine, Federico II University Hospital Naples, Italy
| | - Maurizio Galderisi
- Cardioangiology Unit, Department of Clinical and Experimental Medicine, Federico II University Hospital Naples, Italy
| | - Pasquale Guarini
- Division of Cardiology, "Villa dei Fiori" Hospital Naples, Italy
| | - Arcangelo D'Errico
- Cardioangiology Unit, Department of Clinical and Experimental Medicine, Federico II University Hospital Naples, Italy
| | - Pasquale Innelli
- Cardioangiology Unit, Department of Clinical and Experimental Medicine, Federico II University Hospital Naples, Italy
| | - Moira Pardo
- Cardioangiology Unit, Department of Clinical and Experimental Medicine, Federico II University Hospital Naples, Italy
| | | | - Oreste de Divitiis
- Cardioangiology Unit, Department of Clinical and Experimental Medicine, Federico II University Hospital Naples, Italy
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Giedd KN, Bergmann SR. Myocardial perfusion imaging following percutaneous coronary intervention: the importance of restenosis, disease progression, and directed reintervention. J Am Coll Cardiol 2004; 43:328-36. [PMID: 15013110 DOI: 10.1016/j.jacc.2003.09.032] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2003] [Revised: 08/25/2003] [Accepted: 09/09/2003] [Indexed: 11/25/2022]
Abstract
Percutaneous coronary intervention (PCI) has become a mainstay in the treatment of patients with coronary artery disease. Currently, more than one million coronary angioplasty and stent implantation procedures are performed annually. Although increasingly complex lesions and higher risk patients are being successfully treated percutaneously, restenosis and disease progression continue to cause significant morbidity. Restenosis occurs in approximately one-third of patients, one-half of who remain asymptomatic, while disease progression occurs at rates approaching 7% per year. Despite technological advances, unadjusted mortality rates have actually increased since the mid-1980s, and the current annual risk of a major adverse cardiac event following PCI is 5% to 7%. Although randomized clinical trials are needed to more definitively show a benefit, when performed six or more months following PCI, myocardial perfusion imaging reliably identifies patients most at risk of a poor long-term outcome. Directed reintervention can have a salutary impact on the prognosis of these patients. In view of recent data showing a positive impact of imaging and reintervention in patients after PCI, current guidelines should be reassessed.
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Affiliation(s)
- Kenneth N Giedd
- Division of Cardiology, Department of Medicine, College of Physicians and Surgeons of Columbia University, 630 West 168th Street, New York, NY 10032, USA.
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Lan C, Chen SY, Chiu SF, Hsu CJ, Lai JS, Kuan PL. Poor functional recovery may indicate restenosis in patients after coronary angioplasty. Arch Phys Med Rehabil 2003; 84:1023-7. [PMID: 12881828 DOI: 10.1016/s0003-9993(03)00031-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate whether poor response to exercise training can detect restenosis in asymptomatic patients after percutaneous transluminal coronary angioplasty (PTCA). DESIGN Case-control study. SETTING A hospital-based outpatient cardiac rehabilitation program in Taiwan. PARTICIPANTS Sixteen patients aged 49.7+/-7.8 years who had undergone PTCA and completed a 3-month exercise program. Patients were separated into a restenosis group (n=7; age, 46.4+/-9.8y) and a nonrestenosis group (n=9; age, 52.3+/-12.9y), according to their angiography follow-up results. The interval between PTCA and angiography ranged from 6 months to 2 years. INTERVENTION Bicycle exercise workouts were conducted 3 times a week during rehabilitation, with exercise intensity adjusted to each patient's ventilatory threshold. MAIN OUTCOME MEASURES A graded exercise test with gas analysis was conducted before training, at 6 weeks and at 3 months after training, to evaluate the sequential changes of cardiorespiratory function. RESULTS After 3 months of training, the nonrestenosis group showed an increase of 30.4% in peak oxygen uptake (Vo(2)peak, P<.05), 13.7% in peak oxygen pulse (P<.05), 22.2% in peak rate-pressure product (P<.05), and 13.6% in peak work rate (P<.05). Most of the improvement occurred within the first 6 weeks of training. The restenosis group did not show significant increase in these variables. At the ventilatory threshold, the nonrestenosis group also displayed a significant increase of Vdot;o(2), oxygen pulse, and work rate. However, the restenosis group showed no improvement after training. CONCLUSION Functional recovery appears to be a good indicator of restenosis for patients after PTCA. A poor response to exercise can be noted within 6 weeks of training in PTCA patients with restenosis.
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Affiliation(s)
- Ching Lan
- Departments of Physical Medicine and Rehabilitation, National Tiwan Unviersity Hospital, Taipei, Taiwan.
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Pizzuto F, Voci P, Mariano E, Puddu PE, Chiavari PA, Romeo F. Noninvasive coronary flow reserve assessed by transthoracic coronary Doppler ultrasound in patients with left anterior descending coronary artery stents. Am J Cardiol 2003; 91:522-6. [PMID: 12615253 DOI: 10.1016/s0002-9149(02)03298-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Noninvasive measurement of coronary flow reserve (CFR) (hyperemic/flow velocity ratio at rest) by transthoracic Doppler echocardiography showed normalization of flow in the left anterior descending (LAD) coronary artery early after stenting. We hypothesized that noninvasive CFR may reveal in-stent restenosis at follow-up. Therefore, we studied 134 patients, 0 to 72 months after successful proximal-middle LAD stenting, and 38 controls. LAD flow velocity was measured by transthoracic Doppler echocardiography during 90 seconds venous adenosine infusion (140 microg/kg/min). CFR was measured in diastole. According to angiography, patients who received stents were divided into 3 groups: group I, <50% LAD in-stent restenosis (n = 83); group II, nonsignificant (50% to 69%) LAD in-stent restenosis (n = 17); and group III, significant (> or = 70%) LAD in-stent restenosis (n = 34). LAD CFR was similar in group I and controls (2.90 +/- 0.58 vs 3.05 +/- 0.81; p = NS), it was slightly lower in group II (2.42 +/- 0.33) compared with controls and group I (p <0.001 vs both), and clearly abnormal (<2) in group III (1.38 +/- 0.48) compared with controls, and groups I and II (p <0.001). A CFR <2 had 91% sensitivity, 95% specificity, and 96% positive and 97% negative predictive values to detect significant stenosis in patients with LAD stents. Our data show that noninvasive Doppler assessment of CFR allows identification of significant LAD in-stent restenosis, based on a cut-off value of <2.
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Beygui F, Le Feuvre C, Helft G, Maunoury C, Metzger JP. Myocardial viability, coronary flow reserve, and in-hospital predictors of late recovery of contractility following successful primary stenting for acute myocardial infarction. Heart 2003; 89:179-83. [PMID: 12527673 PMCID: PMC1767565 DOI: 10.1136/heart.89.2.179] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess the relation between myocardial viability, coronary flow reserve, and recovery of myocardial contractility after stenting for acute myocardial infarction. DESIGN Consecutive sample prospective study. SETTING University hospital. PATIENTS 41 patients with single vessel disease and successful primary stenting for a first acute myocardial infarction. INTERVENTIONS (201)Tl single photon emission computed tomography, contrast ventriculography, and intracoronary Doppler performed 7 (1) days after primary stenting. MAIN OUTCOME MEASURES Regional contractility recovery assessed by contrast ventriculography at 6 (1) months' follow up. RESULTS On univariate analysis, contractility recovery was correlated to prereperfusion anterograde and collateral flow grades (r = 0.41, p = 0.03 and r = 0.55, p = 0.0004), viability index (r = 0.55, p = 0.04), peak creatine kinase concentrations (r = -0.55, p = 0.0005), left ventricular ejection fraction (r = 0.45, p = 0.005), end diastolic pressure (r = -0.62, p < 0.0001), end systolic volume index (r = -0.47, p = 0.01), and the extent of hypokinetic area (r = -0.48, p = 0.003), but not the coronary flow reserve. On multivariate analysis, independent predictors of late contractility recovery were prereperfusion anterograde and collateral flow grades and viability index. Relative coronary flow reserve, reflecting the culprit vessel's microvascular function, was correlated only to the extent of the infarct risk area (r = -0.45, p = 0.003). CONCLUSIONS Independent predictors of contractility recovery between the seventh day and the sixth month after successful stenting for acute myocardial infarction are prereperfusion anterograde and collateral flows and myocardial viability. The culprit vessel's microvascular dysfunction is independent of myocardial viability and contractility and correlated to the extent of "jeopardised microvasculature".
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Affiliation(s)
- F Beygui
- Adult Cardiology Department, Necker University Hospital, 149, Rue de Sévres, 75015, Paris, France.
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