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Nicolau JC, Feitosa Filho GS, Petriz JL, Furtado RHDM, Précoma DB, Lemke W, Lopes RD, Timerman A, Marin Neto JA, Bezerra Neto L, Gomes BFDO, Santos ECL, Piegas LS, Soeiro ADM, Negri AJDA, Franci A, Markman Filho B, Baccaro BM, Montenegro CEL, Rochitte CE, Barbosa CJDG, Virgens CMBD, Stefanini E, Manenti ERF, Lima FG, Monteiro Júnior FDC, Correa Filho H, Pena HPM, Pinto IMF, Falcão JLDAA, Sena JP, Peixoto JM, Souza JAD, Silva LSD, Maia LN, Ohe LN, Baracioli LM, Dallan LADO, Dallan LAP, Mattos LAPE, Bodanese LC, Ritt LEF, Canesin MF, Rivas MBDS, Franken M, Magalhães MJG, Oliveira Júnior MTD, Filgueiras Filho NM, Dutra OP, Coelho OR, Leães PE, Rossi PRF, Soares PR, Lemos Neto PA, Farsky PS, Cavalcanti RRC, Alves RJ, Kalil RAK, Esporcatte R, Marino RL, Giraldez RRCV, Meneghelo RS, Lima RDSL, Ramos RF, Falcão SNDRS, Dalçóquio TF, Lemke VDMG, Chalela WA, Mathias Júnior W. Brazilian Society of Cardiology Guidelines on Unstable Angina and Acute Myocardial Infarction without ST-Segment Elevation - 2021. Arq Bras Cardiol 2021; 117:181-264. [PMID: 34320090 PMCID: PMC8294740 DOI: 10.36660/abc.20210180] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- José Carlos Nicolau
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Gilson Soares Feitosa Filho
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Centro Universitário de Tecnologia e Ciência (UniFTC), Salvador, BA - Brasil
| | - João Luiz Petriz
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
| | | | | | - Walmor Lemke
- Clínica Cardiocare, Curitiba, PR - Brasil
- Hospital das Nações, Curitiba, PR - Brasil
| | | | - Ari Timerman
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | - José A Marin Neto
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, SP - Brasil
| | | | - Bruno Ferraz de Oliveira Gomes
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
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- Hospital do Coração (HCor), São Paulo, SP - Brasil
- Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Edson Stefanini
- Escola Paulista de Medicina da Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | | | - Felipe Gallego Lima
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - José Maria Peixoto
- Universidade José do Rosário Vellano (UNIFENAS), Belo Horizonte, MG - Brasil
| | - Juliana Ascenção de Souza
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Lilia Nigro Maia
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP - Brasil
| | | | - Luciano Moreira Baracioli
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luís Alberto de Oliveira Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luis Augusto Palma Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Luiz Carlos Bodanese
- Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | | | - Marcelo Bueno da Silva Rivas
- Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Múcio Tavares de Oliveira Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Nivaldo Menezes Filgueiras Filho
- Universidade do Estado da Bahia (UNEB), Salvador, BA - Brasil
- Universidade Salvador (UNIFACS), Salvador, BA - Brasil
- Hospital EMEC, Salvador, BA - Brasil
| | - Oscar Pereira Dutra
- Instituto de Cardiologia - Fundação Universitária de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | - Otávio Rizzi Coelho
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | | | | | - Paulo Rogério Soares
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - Roberto Esporcatte
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Talia Falcão Dalçóquio
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - William Azem Chalela
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Wilson Mathias Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
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Panahi Y, Pishgoo B, Dadjou Y, Mehdirad M, Soflaei SS, Sahebkar A. Efficacy and Safety of Dorocontin(®) versus Sustac(®) in the Treatment of Stable Angina Pectoris: A Randomized, Double-Blind Comparative Trial. Sci Pharm 2015; 82:815-24. [PMID: 26171326 PMCID: PMC4475798 DOI: 10.3797/scipharm.1406-16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/16/2014] [Indexed: 11/29/2022] Open
Abstract
Background: Development of generic drugs has numerous benefits in terms of cost-efficiency and availability. Slow-release nitroglycerin is a vasodilator drug commonly prescribed for patients with angina pectoris. Objective: The objective of this study was to compare the efficacy and safety of generic slow-release nitroglycerin (Dorocontin®) with that of the innovator brand (Sustac®) in patients with stable angina pectoris. Methods: In this randomized, double-blind comparative trial, 110 patients were allocated to Dorocontin® (n=67) or Sustac® (n=43) at a dose of 6.4 mg TID, for a total period of two months. Maximum endurable MET (metabolic equivalent of task), MPI (myocardial perfusion imaging), along with changes in the ECG and biomarkers of renal (serum creatinine, BUN) and hepatic (AST, ALT, and ALP) function, lipid profile (total cholesterol, LDL-C, HDL-C, VLDL-C, and triglycerides), electrolytes (Na+ and K+), CBC-diff (RBC, WBC, Plt, Hb, Hct, MCV, MCH, MCHC, and RDW), and FBS were assessed at the baseline and at the end of the trial. The frequency of adverse events during the course of the trial was also recorded. Results: Apart from a significantly greater reduction in maximum ST depression in the Sustac® versus the Dorocontin® group (p=0.03), none of the functional (MET, MPI, and ECG) and paraclinical (renal function, hepatic function, lipid profile, electrolytes, and FBS) parameters significantly differed between the study groups. The mean Hb (p=0.035), Hct (p=0.045), and MCH (p=0.032) were decreased by the end of the trial in the Sustac®, but not in the Dorocontin® group, whilst there was no change in other CBC-diff parameters. Reported adverse events were not serious and included headache, vertigo, gastrointestinal upset, and orthostatic hypotension. The frequency of these adverse events was comparable between the study groups. Conclusion: The findings of the present trial showed comparable efficacy and safety of the generic and innovator products of slow-release nitroglycerin in the management of stable angina pectoris.
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Affiliation(s)
- Yunes Panahi
- Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Bahram Pishgoo
- Cardiovascular Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran. ; Department of Cardiology, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Yahya Dadjou
- Cardiovascular Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran. ; Department of Cardiology, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Manouchehr Mehdirad
- Cardiovascular Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran. ; Department of Cardiology, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Sara Saffar Soflaei
- Neurogenic Inflammation Research Center, Department of Modern Sciences and Technologies, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. ; Cardiometabolic Research Centre, Royal Perth Hospital, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
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Nabi F, Chang SM, Xu J, Gigliotti E, Mahmarian JJ. Assessing risk in acute chest pain: The value of stress myocardial perfusion imaging in patients admitted through the emergency department. J Nucl Cardiol 2012; 19:233-43. [PMID: 22147618 DOI: 10.1007/s12350-011-9484-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 11/05/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND To prospectively assess the clinical value of stress-gated myocardial single photon emission computed tomography (SPECT) for triaging patients admitted through the emergency department (ED) with acute chest pain (ACP). METHODS Prospective, observational cohort study in 1,576 consecutive patients who were evaluated for ACP over a 29-month period. Stress SPECT was performed within 24 hours of admission from the ED. Analysis included quantification of total and ischemic left ventricular perfusion defect size (PDS). Cardiac events were defined as an acute coronary syndrome during the index hospitalization or in follow-up over 7.3 ± 2.8 months. RESULTS Eighty-five cardiac events occurred in 77 patients (4.9%). SPECT was abnormal in 135 patients (8.6%) of whom 83 (61.5%) had a reversible defect. Event rates were significantly higher in patients with an abnormal (40%) versus a normal (1.6%) SPECT (P < .0001); and in those with a (1) large (>15%) versus small (≤15%) PDS (50.0% vs 33.7%, P = .05) and (2) large (>10%) versus small (≤10%) ischemic PDS (87.5% vs 42.4%, P < .0001, respectively). SPECT best predicted cardiac events by multivariate analysis. The addition of SPECT to clinical variables significantly improved overall risk prediction (global χ(2) 103.6 vs 207.1, P < .001). CONCLUSIONS Stress SPECT can accurately assess risk in a heterogeneous group of patients with ACP of unclear cardiac etiology, and beyond that provided by a clinical risk assessment alone. Our results support the use of stress SPECT for identifying very low-risk ACP patients with normal study results who can be safely discharged home.
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Affiliation(s)
- Faisal Nabi
- Methodist DeBakey Heart and Vascular Center and The Methodist Hospital Research Institute, The Methodist Hospital, Houston, TX 77030, USA
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Affiliation(s)
- John J Mahmarian
- Department of Cardiology, Methodist DeBakey Heart Center, The Methodist Hospital, Houston, TX 77030, USA.
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Dakik HA, Hwang WS, Jafar A, Kimball K, Verani MS, Mahmarian JJ. Prognostic value of quantitative stress myocardial perfusion imaging in unstable angina patients with negative cardiac enzymes and no new ischemic ECG changes. J Nucl Cardiol 2005; 12:32-6. [PMID: 15682363 DOI: 10.1016/j.nuclcard.2004.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Limited data are available on the value of quantitative stress myocardial perfusion imaging (MPI) in patients with unstable angina. In this report we sought to study the long-term prognostic value of quantitative stress MPI in patients hospitalized with unstable angina with no new ischemic electrocardiographic changes and negative cardiac enzymes. METHODS AND RESULTS The study population consisted of 136 patients who were hospitalized at the Methodist Hospital, Houston, Tex, with unstable angina and subsequently underwent MPI before discharge. Cox proportional hazards (regression) analysis was performed to identify clinical and MPI predictors of hard cardiac events (death or nonfatal myocardial infarction). During a mean follow-up of 31 +/- 17 months, 20 patients (15%) sustained either cardiac death (n = 12) or nonfatal myocardial infarction (n = 8). The significant multivariate predictors of cardiac events were the total perfusion defect size ( P = .002), the presence of reversible perfusion defects ( P = .01), and the presence of multiple perfusion defects ( P = .03). The perfusion defect size was significantly larger in patients with events than in those without events (21% +/- 20% vs 12% +/- 14%, P = .002). Kaplan-Meier analysis showed that cardiac events were much more likely to develop in patients with defects involving 15% or more of the left ventricle than in those with defects involving less than 15% of the left ventricle ( P = .003). CONCLUSIONS In patients hospitalized with unstable angina with no new ischemic electrocardiographic changes and negative cardiac enzymes, quantitative stress MPI provides powerful prognostic information that can be used in the risk stratification of these patients.
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Affiliation(s)
- Habib A Dakik
- Division of Cardiology, American University of Beirut, Lebanon.
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Brown KA. Evaluation of the unstable angina patient in 2005: is there still a role for noninvasive risk stratification? J Nucl Cardiol 2005; 12:9-11. [PMID: 15682360 DOI: 10.1016/j.nuclcard.2004.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Travin MI. The role of stress myocardial perfusion imaging in the risk stratification of patients with remote myocardial infarction. J Nucl Cardiol 2004; 11:656-9. [PMID: 15592187 DOI: 10.1016/j.nuclcard.2004.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Underwood SR, Anagnostopoulos C, Cerqueira M, Ell PJ, Flint EJ, Harbinson M, Kelion AD, Al-Mohammad A, Prvulovich EM, Shaw LJ, Tweddel AC. Myocardial perfusion scintigraphy: the evidence. Eur J Nucl Med Mol Imaging 2004; 31:261-91. [PMID: 15129710 PMCID: PMC2562441 DOI: 10.1007/s00259-003-1344-5] [Citation(s) in RCA: 304] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This review summarises the evidence for the role of myocardial perfusion scintigraphy (MPS) in patients with known or suspected coronary artery disease. It is the product of a consensus conference organised by the British Cardiac Society, the British Nuclear Cardiology Society and the British Nuclear Medicine Society and is endorsed by the Royal College of Physicians of London and the Royal College of Radiologists. It was used to inform the UK National Institute of Clinical Excellence in their appraisal of MPS in patients with chest pain and myocardial infarction. MPS is a well-established, non-invasive imaging technique with a large body of evidence to support its effectiveness in the diagnosis and management of angina and myocardial infarction. It is more accurate than the exercise ECG in detecting myocardial ischaemia and it is the single most powerful technique for predicting future coronary events. The high diagnostic accuracy of MPS allows reliable risk stratification and guides the selection of patients for further interventions, such as revascularisation. This in turn allows more appropriate utilisation of resources, with the potential for both improved clinical outcomes and greater cost-effectiveness. Evidence from modelling and observational studies supports the enhanced cost-effectiveness associated with MPS use. In patients presenting with stable or acute chest pain, strategies of investigation involving MPS are more cost-effective than those not using the technique. MPS also has particular advantages over alternative techniques in the management of a number of patient subgroups, including women, the elderly and those with diabetes, and its use will have a favourable impact on cost-effectiveness in these groups. MPS is already an integral part of many clinical guidelines for the investigation and management of angina and myocardial infarction. However, the technique is underutilised in the UK, as judged by the inappropriately long waiting times and by comparison with the numbers of revascularisations and coronary angiograms performed. Furthermore, MPS activity levels in this country fall far short of those in comparable European countries, with about half as many scans being undertaken per year. Currently, the number of MPS studies performed annually in the UK is 1,200/million population/year. We estimate the real need to be 4,000/million/year. The current average waiting time is 20 weeks and we recommend that clinically appropriate upper limits of waiting time are 6 weeks for routine studies and 1 week for urgent studies.
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Affiliation(s)
- S R Underwood
- Imperial College London, Royal Brompton Hospital, London, UK.
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Klocke FJ, Baird MG, Lorell BH, Bateman TM, Messer JV, Berman DS, O'Gara PT, Carabello BA, Russell RO, Cerqueira MD, St John Sutton MG, DeMaria AN, Udelson JE, Kennedy JW, Verani MS, Williams KA, Antman EM, Smith SC, Alpert JS, Gregoratos G, Anderson JL, Hiratzka LF, Faxon DP, Hunt SA, Fuster V, Jacobs AK, Gibbons RJ, Russell RO. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). J Am Coll Cardiol 2003; 42:1318-33. [PMID: 14522503 DOI: 10.1016/j.jacc.2003.08.011] [Citation(s) in RCA: 483] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Klocke FJ, Baird MG, Lorell BH, Bateman TM, Messer JV, Berman DS, O'Gara PT, Carabello BA, Russell RO, Cerqueira MD, St John Sutton MG, DeMaria AN, Udelson JE, Kennedy JW, Verani MS, Williams KA, Antman EM, Smith SC, Alpert JS, Gregoratos G, Anderson JL, Hiratzka LF, Faxon DP, Hunt SA, Fuster V, Jacobs AK, Gibbons RJ, Russell RO. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). Circulation 2003; 108:1404-18. [PMID: 12975245 DOI: 10.1161/01.cir.0000080946.42225.4d] [Citation(s) in RCA: 498] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Elhendy A, Schinkel A, Bax JJ, van Domburg RT, Poldermans D. Long-term prognosis after a normal exercise stress Tc-99m sestamibi SPECT study. J Nucl Cardiol 2003; 10:261-6. [PMID: 12794624 DOI: 10.1016/s1071-3581(02)43219-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Patients with a normal stress technetium 99m sestamibi study were shown to have a favorable outcome at intermediate-term follow-up. However, long-term survival has not been studied. The aim of this study was to evaluate the incidence and predictors of mortality and cardiac events at long-term follow-up after a normal exercise stress sestamibi study. Methods and results We studied 218 patients (mean age, 53 +/- 10 years, 108 men) who had normal myocardial perfusion assessed by Tc-99m sestamibi single photon emission computed tomography at rest and during symptom-limited bicycle exercise stress test. Endpoints during a follow-up period of 7.4 +/- 1.8 years were hard cardiac events (cardiac death and nonfatal myocardial infarction) and all-cause mortality. During follow-up, 13 patients died of various causes (cardiac death in 1 patient). Ten patients had nonfatal myocardial infarction (a total of 11 hard cardiac events). By multivariate analysis, independent predictors of cardiac events were history of coronary artery disease (chi(2) = 5, P =.03) and lower exercise heart rate (chi(2) = 12, P =.001). Independent predictors of all-cause mortality were age (chi(2) = 4, P =.05) and exercise heart rate (chi(2) = 5, P =.03). The annual mortality rate was 0.6% in the first 5 years and 1.8% between the sixth and eighth years. The annual hard cardiac event rate was 0.7% in the first 5 years and 1.5% between the sixth and eighth years. Receiver operating characteristic curves identified an exercise heart rate lower than 130 beats/min as the cutoff value that separated patients with regard to their risk for mortality and hard cardiac events. CONCLUSIONS It is concluded that the annual mortality and cardiac event rate is less than 1% during 5-year follow-up after a normal exercise sestamibi study. Therefore repeated testing would not be required unless there is a change in symptoms. Follow-up should be closer in patients with a history of coronary artery disease and in those who fail to achieve an exercise heart rate of 130 beats/min or greater.
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Affiliation(s)
- Abdou Elhendy
- Throraxcenter, University Hospital-Dijkzigt, Totterdam, The Netherlands.
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Paré C. [Can be useful to assess whether dobutamine echocardiography can induce myocardial damage for diagnostic and prognostic purposes in coronary artery disease?]. Rev Esp Cardiol 2002; 55:463-5. [PMID: 12015923 DOI: 10.1016/s0300-8932(02)76635-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Calnon DA, McGrath PD, Doss AL, Harrell FE, Watson DD, Beller GA. Prognostic value of dobutamine stress technetium-99m-sestamibi single-photon emission computed tomography myocardial perfusion imaging: stratification of a high-risk population. J Am Coll Cardiol 2001; 38:1511-7. [PMID: 11691532 DOI: 10.1016/s0735-1097(01)01565-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES This work was undertaken to define the intrinsic cardiac risk of the patient population referred for dobutamine stress perfusion imaging and to determine whether dobutamine technetium-99m ((99m)Tc)-sestamibi single-photon emission computed tomography (SPECT) imaging is capable of risk stratification in this population. BACKGROUND In animal models, dobutamine attenuates the myocardial uptake of (99m)Tc-sestamibi resulting in underestimation of coronary stenoses. Therefore, we hypothesized that the prognostic value of dobutamine stress (99m)Tc-sestamibi SPECT myocardial perfusion imaging might be impaired, owing to reduced detection of coronary stenoses. METHODS We reviewed the clinical outcome of 308 patients (166 women, 142 men) who underwent dobutamine stress SPECT (99m)Tc-sestamibi imaging at our institution from September 1992 through December 1996. RESULTS During an average follow-up of 1.9 +/- 1.1 years, there were 33 hard cardiac events (18 myocardial infarctions [MI] and 15 cardiac deaths) corresponding to an annual cardiac event rate of 5.8%/year, which is significantly higher than the event rate for patients referred for exercise SPECT imaging at our institution (2.2%/year). Event rates were higher after an abnormal dobutamine (99m)Tc-sestamibi SPECT study (10.0%/year) than after a normal study (2.3%/year) (p < 0.01), even after adjusting for clinical variables. In the subgroup (n = 29) with dobutamine-induced ST-segment depression and abnormal SPECT imaging, the prognosis was poor, with annual cardiac death and nonfatal MI rates of 7.9% and 13.2%, respectively. CONCLUSIONS Patients referred for dobutamine perfusion imaging are a high-risk population, and dobutamine stress (99m)Tc-sestamibi SPECT imaging is capable of risk stratification in these patients.
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Affiliation(s)
- D A Calnon
- Cardiovascular Division, Department of Medicine, Charlottesville, Virginia 22908-0158, USA
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Borm JJJ, Bouwsma H, van der Wall EE, Pauwels EKJ. The prognostic value of myocardial perfusion scintigraphy: investigators, are you (mis)leading us? Eur J Nucl Med Mol Imaging 2001; 28:1439-46. [DOI: 10.1007/s002590100606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Borm JJ, Bouwsma H, van der Wall EE, Pauwels EK. The prognostic value of myocardial perfusion scintigraphy: investigators, are you (mis)leading us? EUROPEAN JOURNAL OF NUCLEAR MEDICINE 2001; 28:1299-305. [PMID: 11585287 DOI: 10.1007/s002590100557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cortadellas J, Figueras J, Aguadé S, Castell J, González T, Soler Soler J. [Prognostic value of cardiac perfusion scintigraphy associated with the dobutamine test in acute coronary syndromes]. REVISTA ESPANOLA DE MEDICINA NUCLEAR 2001; 20:82-9. [PMID: 11333816 DOI: 10.1016/s0212-6982(01)71932-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This study aimed to establish the value of myocardial ischemia induced by the dobutamine infusion test associated to 99m technetium isonitrile single photon emission computed tomography in patients with unstable angina or non Q-wave infarction during the first days in the Coronary Care Unit. METHODS Fifty three patients with unstable coronary syndromes and common medical treatment were studied with a moderate-dose dobutamine test (5 to 20 microgram/Kg/min) using a 99mTc-MIBI SPECT. The results were correlated with the incidence of recurrent angina, infarction, death or revascularization. RESULTS The dobutamine test induced a reversible perfusion defect in 36 patients (68%) and angina in 12 of them (12/36, 33%). However, the patients who had a positive test had a similar incidence of events as those with a negative test (58% vs 59%). Thus, while the sensitivity of the dobutamine test to identify patients at risk was relatively high (68%), its specificity (32%) and its negative predictive value (41%) were low. The patients with dobutamine-induced angina, however, had a higher scintigraphy score (3.0 +/- 1,7 vs 1.6 +/- 1.8, p < 0.02) and a higher incidence of recurrent angina (8/12, 67% vs 13/41, 31%, p < 0.04) than those without, at a comparable double product. CONCLUSIONS In conventionally treated patients with unstable coronary syndromes, the specificity of the inducible scintigraphic ischemia with moderate dose of dobutamine performed during the first days is too low to be used as a marker for in-hospital events. However, inducible angina with dobutamine suggests an extensive jeopardized area and/or a particularly reduced ischemic threshold.
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Affiliation(s)
- J Cortadellas
- Servicio de Cardiología Hospital General Vall d'Hebron, Barcelona
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19
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Guideline for the management of patients with acute coronary syndromes without persistent ECG ST segment elevation. British Cardiac Society Guidelines and Medical Practice Committee and Royal College of Physicians Clinical Effectiveness and Evaluation Unit. Heart 2001; 85:133-42. [PMID: 11156660 PMCID: PMC1729608 DOI: 10.1136/heart.85.2.133] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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20
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Yao SS, Rozanski A. Principal uses of myocardial perfusion scintigraphy in the management of patients with known or suspected coronary artery disease. Prog Cardiovasc Dis 2001; 43:281-302. [PMID: 11235845 DOI: 10.1053/pcad.2001.20466] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The use of myocardial perfusion single photon emission computed tomography (SPECT) has undergone considerable expansion and evolution over the past 2 decades. Although myocardial perfusion imaging was first conceived as a noninvasive diagnostic tool for determining the presence or absence of coronary artery disease, its prognostic value is now well established. Thus, identification of patients at risk for future cardiac events has become a primary objective in the noninvasive evaluation of patients with chest pain syndromes and among patients with known coronary artery disease. In particular, the ability of myocardial perfusion SPECT to identify patients at low (< 1%), intermediate (1% to 5%) or high (> 5%) risk for future cardiac events is essential to patient management decisions. Moreover, previous studies have conclusively shown the incremental prognostic value of myocardial perfusion SPECT over clinical and treadmill exercise data in predicting future cardiac events. This report addresses the current role and new developments, with respect to the use of myocardial perfusion imaging, in determining patient risk for cardiac events and the cost-effective integration of such information into patient management decisions.
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Affiliation(s)
- S S Yao
- Department of Medicine, St Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY 10019, USA
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21
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Brown KA. Reason over reflex in acute ischemic syndromes: the case for a rational application of invasive procedures:. J Nucl Cardiol 2000; 7:388-91. [PMID: 10958282 DOI: 10.1067/mnc.2000.108031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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22
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Castillo Moreno JA, Florenciano Sánchez R, Molina Laborda E, Jiménez Pascual M, García Urruticoechea P, Egea Beneyto S, Ortega Bernal J. [Low risk stress test in patients with unstable angina: does it imply a favorable prognosis?]. Rev Esp Cardiol 2000; 53:783-90. [PMID: 10944970 DOI: 10.1016/s0300-8932(00)75158-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Affiliation(s)
- Y Yeghiazarians
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
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24
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Verani MS. Stress myocardial perfusion imaging versus echocardiography for the diagnosis and risk stratification of patients with known or suspected coronary artery disease. Semin Nucl Med 1999; 29:319-29. [PMID: 10534234 DOI: 10.1016/s0001-2998(99)80019-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Stress perfusion imaging and stress echocardiography (ECHO) are both very useful for assessment of diagnosis and risk stratification of patients with coronary artery disease (CAD). Both techniques have been well validated during exercise and inotropic stress, but coronary vasodilation stress is better used in combination with perfusion imaging. The overall sensitivity for detection of CAD is slightly higher by single photon emission computed tomography (SPECT) than by two-dimensional (2D) ECHO during all stress modalities, whereas the specificity is slightly higher by ECHO, although the differences in general are not statistically significant. SPECT, however, appears to be superior to ECHO in the diagnosis of isolated circumflex stenosis, as well as for the correct identification of multivessel CAD. A substantially greater amount of information is available regarding risk stratification with SPECT than with 2D ECHO. Although the data suggest that both techniques are very useful for risk stratification of patients with stable CAD, after myocardial infarction, and for preoperative risk stratification, the risk for cardiac events is lower in the presence of a normal stress SPECT study than of a normal stress ECHO.
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Affiliation(s)
- M S Verani
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
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25
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Mandalapu BP, Amato M, Stratmann HG. Technetium Tc 99m sestamibi myocardial perfusion imaging: current role for evaluation of prognosis. Chest 1999; 115:1684-94. [PMID: 10378569 DOI: 10.1378/chest.115.6.1684] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Like 201Tl imaging, technetium Tc 99m sestamibi (MIBI) myocardial imaging can be used with exercise and pharmacologic testing to assess the presence of coronary artery disease. An increasing body of literature indicates that MIBI can also be used to assess risk of future cardiac events such as myocardial infarction or death. This article summarizes the current status of MIBI imaging for evaluating prognosis in patients with known or suspected coronary artery disease.
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Affiliation(s)
- B P Mandalapu
- Department of Cardiology, St. Louis Veterans Administration Medical Center, MO 63106, USA
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Dhond MR, Donnell K, Singh S, Garapati S, Whitley TB, Nguyen T, Bommer W. Value of negative dobutamine stress echocardiography in predicting long-term cardiac events. J Am Soc Echocardiogr 1999; 12:471-5. [PMID: 10359918 DOI: 10.1016/s0894-7317(99)70083-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED To determine the value of negative dobutamine stress echocardiography (DSE) results in predicting subsequent long-term cardiac event rates, we retrospectively reviewed all dobutamine stress echocardiograms performed at our institution over a 3-year period (1992-1994). Follow-up was accomplished through the completion of a detailed questionnaire compiled from data obtained through chart review and direct telephone contact. Information regarding death also was determined by referencing patient data with mortality data available on the World Wide Web. Event rates were determined for hard (myocardial infarction [MI] or cardiac death) and soft (hospitalization for angina and/or congestive heart failure, coronary angioplasty, or coronary bypass surgery) cardiac events occurring after the negative DSE results for up to 7 years after the test. Negative test results were defined as those showing no new or worsening wall motion abnormalities after either a normal resting echocardiogram (normal-negative [NN]) or an abnormal segmental resting echocardiogram (fixed-negative [FN]). RESULTS Of the 346 interpretable tests, 224 were negative for inducible wall motion abnormalities, with 171 NN and 53 FN. In the NN group, the MI rate was 1.5% per patient/year, and the mortality rate was 0.13% per patient/year. In the FN group, the MI rate was 0.7% per patient/year, and the mortality rate was 0% per patient/year. CONCLUSIONS DSE results in both NN and FN groups predict a very low subsequent hard event rate and mortality for up to 5 years after the test.
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Affiliation(s)
- M R Dhond
- Division of Cardiovascular Medicine, University of California, Davis, Medical Center, Sacramento, California 95817, USA
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Zaacks SM, Liebson PR, Calvin JE, Parrillo JE, Klein LW. Unstable angina and non-Q wave myocardial infarction: does the clinical diagnosis have therapeutic implications? J Am Coll Cardiol 1999; 33:107-18. [PMID: 9935016 DOI: 10.1016/s0735-1097(98)00553-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The goal of this review is to reevaluate the unstable coronary syndromes in the setting of new therapies and biochemical markers. BACKGROUND Patients with acute coronary syndromes comprise a large subset of many cardiology practices. Patients with unstable angina (UA) and non-Q wave myocardial infarction (NQMI) may sustain a small amount of myocardial loss but have significant amounts of viable, yet ischemic, myocardium, placing them at high risk for future cardiac events. In the past, enzyme differentiation of NQMI from UA was considered important to assess prognosis and direct therapy. METHODS Manuscripts published in peer-reviewed journals over the past three decades were reviewed and selected for this review. Recent abstracts were also considered and cited where appropriate. RESULTS In the late 1990's, although UA and NQMI remain parts of a spectrum, it is apparent that the distinction between these two entities is no longer sufficient to identify high risk patients; rather, specific electrocardiographic changes, aspects of the clinical history, newer biochemical markers, and angiographic findings help to better distinguish higher risk individuals from a large patient population with unstable coronary syndromes and these factors usually determine therapy. CONCLUSIONS Based on these results, it is likely that newer therapies such as glycoprotein IIb/IIIa receptor antagonists, low molecular weight heparins, and coronary stents will be directed toward these high risk patients.
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Affiliation(s)
- S M Zaacks
- Rush Heart Institute and Rush Medical College, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612, USA
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Stratmann HG, Mark AL, Amato M, Wittry MD, Younis LT. Risk stratification with pre-hospital discharge exercise technetium-99m sestamibi myocardial tomography in men after acute myocardial infarction. Am Heart J 1998; 136:87-93. [PMID: 9665223 DOI: 10.1016/s0002-8703(98)70186-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Exercise thallium-201 imaging early after acute myocardial infarction (MI) may provide information concerning risk of future cardiac events. The prognostic value of exercise technetium-99m sestamibi (MIBI) single-photon emission computed tomography in such patients has not been established. METHODS AND RESULTS Submaximal exercise stress testing with MIBI tomography was done before hospital discharge in 134 consecutive men after acute MI. Patients were monitored for occurrence of late cardiac events (nonfatal MI or cardiac death). Coronary revascularization was done in 31 patients (23%) < or = 3 months after testing. Nonfatal MI or cardiac death occurred in 30 (23%) of the overall group of 133 patients monitored (mean 35+/-19 months) and in 25 (25%) of the 102 patients treated medically. A history of congestive heart failure, failure to reach 85% of age-predicted maximal heart rate, and an isolated fixed MIBI defect were associated with significantly increased risk (p < 0.05) of a late cardiac event in both groups of patients. A reversible MIBI defect was not associated with increased risk. In a multivariable Cox proportional hazards model, only a history of congestive heart failure (relative risk 4.2, 95% confidence interval [CI] 1.7 to 10.4, p < 0.002) and an isolated fixed MIBI defect (relative risk 2.1, 95% CI 1.1 to 4.3, p < 0.05) were independent predictors of increased risk in the total group of 133 patients. In the 102 patients treated medically, only a history of congestive heart failure (relative risk 4.9, 95% CI 1.9 to 13.1) and achievement of 85% of age-predicted maximal heart rate (relative risk 0.13, 95% CI 0.02 to 0.9) were independent predictors of risk. CONCLUSIONS Early post-MI submaximal exercise testing with MIBI tomography provides limited prognostic information for late cardiac events. An isolated fixed MIBI defect is associated with increased risk but not as strongly as other variables, particularly a history of congestive heart failure.
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Affiliation(s)
- H G Stratmann
- Department of Cardiology, St. Louis Veterans Administration Medical Center, MO 63106, USA
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29
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Iskander S, Iskandrian AE. Risk assessment using single-photon emission computed tomographic technetium-99m sestamibi imaging. J Am Coll Cardiol 1998; 32:57-62. [PMID: 9669249 DOI: 10.1016/s0735-1097(98)00177-6] [Citation(s) in RCA: 282] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES This review summarizes the results of single-photon emission computed tomographic (SPECT) technetium-99m (Tc-99m) tracer imaging in patients with stable symptoms, patients with acute coronary syndromes, patients undergoing major non-cardiac surgery and patients with chest pain in the emergency department. BACKGROUND Previous studies have examined the prognostic value of stress thallium imaging in several subsets of patients with ischemic heart disease. At present, >50% of myocardial perfusion studies are performed with technetium-labeled tracers in the United States. Furthermore, there is a shift from diagnostic to the prognostic utility of stress testing. There are important differences between technetium-labeled tracers and thallium-201. It is therefore important to review the prognostic value of technetium-labeled tracers. METHODS We analyzed published reports in English on risk assessment using Tc-99m perfusion tracers. Results. The largest experience is in patients with stable symptoms, comprising >12,000 patients in 14 studies. In these patients, normal stress SPECT sestamibi images were associated with an average annual hard event rate of 0.6% (death or nonfatal myocardial infarction [MI]). In contrast, patients with abnormal images had a 12-fold higher event rate (7.4% annually). Both fixed and reversible defects are prognostically important, and quantitative analysis shows increased risk in relation to the severity of the abnormality. These results are similar to those obtained with thallium-201. CONCLUSIONS Patients with stable chest pain syndromes and normal stress SPECT sestamibi images have a very low risk of death or nonfatal MI. It is highly unlikely that coronary revascularization can improve survival in such patients. Patients with abnormal images have an intermediate to high risk for future cardiac events, depending on the degree of the abnormality. Further prospective studies comparing aggressive medical therapy with coronary revascularization in these patients are warranted.
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Affiliation(s)
- S Iskander
- Department of Medicine, MCP-Hahnemann School of Medicine, Allegheny University of the Health Sciences, Philadelphia, Pennsylvania 19102, USA
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Abstract
This review considers a number of recent important developments in nuclear medicine, and possible future introductions, priority being given to those products which are most likely to find a place in clinical practice. This includes both novel radiopharmaceuticals and progress with new types of imaging equipment. Three areas are chosen as being of particular importance: brain imaging, heart imaging, and diagnosis and therapy of cancer. In the brain, the clinical value of imaging regional cerebral blood flow and certain aspects of the neuroreceptor/neurotransmitter system are discussed. Cardiac imaging is considered in the light of recent work on diagnosis and risk assessment, investigating the hibernating myocardium, and the possible place of fatty acid imaging. Both diagnosis and therapy of cancer are increasingly important, and the use of radionuclides in these areas in considered.
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Affiliation(s)
- C M Medley
- Amersham International plc, Buckinghamshire, UK
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31
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Radensky PW, Hilton TC, Fulmer H, McLaughlin BA, Stowers SA. Potential cost effectiveness of initial myocardial perfusion imaging for assessment of emergency department patients with chest pain. Am J Cardiol 1997; 79:595-9. [PMID: 9068515 DOI: 10.1016/s0002-9149(96)00822-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Previous investigations have confirmed the diagnostic and predictive usefulness of initial single-photon emission computed tomography (SPECT) myocardial perfusion imaging using technetium-99m sestamibi in the evaluation of emergency department patients with chest pain. Patients with a normal SPECT perfusion scan performed during chest pain have an excellent short-term prognosis, and may be candidates for expeditious cardiac evaluation or outpatient management. However, there are limited data regarding the cost effectiveness of this technique. This analysis models the potential cost effectiveness of this procedure. In the current investigation we compared 2 model strategies for management of emergency department patients with typical chest pain and a normal or nondiagnostic electrocardiogram (ECG). In 1 model strategy, (the technetium-99m sestamibi SPECT myocardial perfusion imaging [SCAN] strategy), the decision whether to admit or discharge a patient from the emergency department is based on results of initial technetium-99m sestamibi SPECT myocardial imaging. Patients with normal scans are discharged; others are admitted. In the second model strategy, (the NO SCAN strategy), the decision whether or not to admit a patient is based on a combination of clinical and electrocardiographic variables. Patients with > or = 3 cardiac risk factors or an abnormal ECG are admitted; others are discharged. Adverse cardiac events were prospectively defined as cardiac death, nonfatal myocardial infarction, or the need for acute coronary intervention. Costs were assigned using data derived from 102 patients who underwent SPECT myocardial perfusion imaging and an additional 107 emergency department patients with ongoing chest pain who either underwent or were eligible for initial SPECT myocardial perfusion imaging. Mean (+/- SE) costs were highest among hospital admitted patients who experienced an adverse cardiac event ($21,375 +/- $2,733) and lowest in patients discharged from the emergency department ($715 +/- 71). Mean costs per patient of the SCAN strategy and NO SCAN strategy were $5,019 versus $6,051, respectively. These results were stable in a sensitivity analysis across a range of costs and predictive values. Thus, the SCAN model strategy for initial management of emergency department patients with typical ongoing angina and a normal or nondiagnostic ECG using initial myocardial perfusion imaging with technetium-99m sestamibi appears to be safe, accurate, and potentially cost effective. Validation of these preliminary retrospective observations will require further prospective investigation.
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Affiliation(s)
- P W Radensky
- Health Law Department, McDermott, Will and Emery, Miami, Florida 33131, USA
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Stratmann HG, Younis LT, Wittry MD, Amato M, Mark AL, Miller DD. Effect of the stress level achieved during symptom-limited exercise technetium-99m sestamibi myocardial tomography on the detection of coronary artery disease. Clin Cardiol 1996; 19:787-92. [PMID: 8896911 DOI: 10.1002/clc.4960191006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The stress level achieved during exercise thallium 201 myocardial imaging may influence its sensitivity for detecting coronary artery disease (CAD). The effect of exercise adequacy on the accuracy of technetium-99m sestamibi (MIBI) imaging has not been studied. HYPOTHESIS The study was undertaken to assess the effect of exercise level achieved on sensitivity for detecting CAD. METHODS A consecutive series of 250 patients (mean age 60 +/- 10 years) with CAD by angiography underwent symptom-limited exercise MIBI single-photon emission computed tomography. Single-vessel CAD was found in 66 patients, double-vessel CAD in 84, triple-vessel CAD in 80, and left main disease in 20. RESULTS No significant differences were found in sensitivities of an abnormal MIBI scan or a reversible defect among 102 patients reaching 85% of age-predicted heart rate and 148 who did not (82 vs. 89% and 66 vs. 70%, respectively, p = NS). Patients (n = 128) able to exercise < or = 6 min had a higher incidence of abnormal scans and reversible defects than 122 patients with a greater exercise duration (91 vs. 82% and 75 vs. 61%, respectively, both p < 0.05). Sensitivity of an abnormal MIBI scan for multivessel disease was greater than for single-vessel disease in patients who achieved > or = 85% of age-predicted heart rate (91 vs. 59%, p < 0.01) and in those who exercised > 6 min (89 vs. 66%, p < 0.01). No significant differences in the sensitivities of an abnormal MIBI study for multivessel versus single-vessel CAD were seen in patients achieving lower peak levels of exercise. Sensitivity of ischemic ST depression was lower than that of MIBI tomography at all levels of exercise. CONCLUSIONS The sensitivity of exercise MIBI tomography for angiographic CAD is relatively independent of the peak heart rate achieved. Exercise duration of > 6 min is associated with a significantly higher MIBI abnormality rate than a duration of > 6 min, possibly reflecting the effect of myocardial ischemic burden on exercise ventricular function. Regardless of level of stress or its duration, exercise MIBI tomography improves the sensitivity for CAD detection compared with stress-induced ischemic ST depression.
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Affiliation(s)
- H G Stratmann
- Department of Internal Medicine, St. Louis Veterans Administration Medical Center, Missouri 63106, USA
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Stratmann HG, Younis LT, Wittry MD, Amato M, Miller DD. Dipyridamole technetium-99m sestamibi myocardial tomography in patients evaluated for elective vascular surgery: prognostic value for perioperative and late cardiac events. Am Heart J 1996; 131:923-9. [PMID: 8615311 DOI: 10.1016/s0002-8703(96)90174-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Dipyridamole thallium-201 myocardial imaging can provide information regarding risk of perioperative cardiac events in patients being considered for vascular surgery. The value for this purpose of myocardial imaging with technetium-99m sestamibi (MIBI), a radiotracer with biokinetic and imaging properties different from thallium-201, has not been established. To this end the prognostic value of dipyridamole MIBI tomography for perioperative and late cardiac events was evaluated in 229 consecutive patients being considered for elective vascular surgery. Vascular surgery was done < or = 3 months after testing in 197 of these patients. Perioperative cardiac events (cardiac death, nonfatal myocardial infarction, unstable angina, or ischemic pulmonary edema) occurred in 9 (5%) patients. The rate of such events was 3% in patients with normal MIBI results, 5% in those with abnormal results, and 6% in patients with a reversible MIBI defect (both p = NS). When patients with abnormal MIBI results who had preoperative cardiac interventions (coronary revascularization or an increase in antiischemic medical therapy) were compared with with those who did not, no significant differences in the occurrence of perioperative cardiac events were found between these two groups either. A group of 172 medically treated patients who survived vascular surgery and did not have a nonfatal perioperative cardiac event was then monitored (mean 21 +/- 14 months) for the occurrence of a serious late cardiac event (nonfatal myocardial infarction or cardiac death). Event-free survival (Mantel-Cox) was significantly less in patients with abnormal studies compared with those with normal scan results. Late cardiac events occurred in 26 (15%) patients, with those having an abnormal MIBI result showing a significantly greater event rate than those with normal results (26% vs 4%, p < 0.0001). The rate of late cardiac events was 33% in patients with a reversible MIBI defect (p < 0.001) and 23% in those with a fixed defect (p < 0.03). Independent Cox multivariable predictors of increased risk of late cardiac events were a history of diabetes mellitus (relative risk [RR] 2.2, 95% confidence interval [CI] 1.0 to 4.9), an abnormal MIBI study (RR 3.7, 95% CI 1.2 to 11.4), and a reversible MIBI defect (RR 2.7, 95% CI 1.2 to 6.1). We conclude that, although its ability to assess increased perioperative cardiac risk remains uncertain, dipyridamole MIBI tomography does provide important prognostic information regarding the risk of serious cardiac events in patients having vascular surgery. The presence of an abnormal MIBI result, specifically one demonstrating a reversible perfusion defect, is associated with significantly increased risk.
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Affiliation(s)
- H G Stratmann
- Department of Internal Medicine, St. Louis Veterans Administration Medical Center, MO 63106, USA
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