111In-antimyosin antibody imaging for detection of myocardial infarction: a quantitative approach

The role of cardiovascular imaging techniques in the assessment of patients with acute chest pain

Chest pain is the most common presenting symptom of coronary artery disease. The assessment and appropriate management of patients with acute chest pain and non-diagnostic electrocardiograms (ECGs) remain a continuing clinical problem, with major logistic and financial implications for health-care providers. Cardiovascular imaging is at the forefront of health care, experiencing rapid changes over the recent years, particularly with the use of advanced medical technologies. Imaging techniques like acute rest myocardial perfusion imaging (MPI), echocardiography, electron beam computed tomography (CT), cardiac magnetic resonance imaging (MRI) and multi-detector CT (MDCT) have been used recently in the evaluation and triage of patients with chest pain in addition to the conventional investigations such as ECGs and cardiac biomarkers in the chest pain units. The annual potential cost savings, by incorporating the routine use of acute rest MPI in patients with low-to-moderate risk and non-diagnostic ECGs are substantial. The high negative predictive value of a normal resting MPI in patients with chest pain for myocardial infarction and future cardiac events is well established. Echocardiography is also considered to be useful but the technique is operator dependent and at present there is insufficient data to support its use. Cardiac MRI is expensive and time consuming and there is insufficient diagnostic and prognostic data to make it suitable for chest pain patients at present. There has been increasing interest in MDCT recently, especially with the advent of 64-slice CT but the sensitivity and specificity in chest pain patients are no better than MPI so far.

Imaging radiation induced muscular necrosis with antimyosin-scintigraphy and computed tomography

Radiations accidents involving high exposures require accurate assessment of radiation dose for correct surgical or medical management. Techniques involving computed tomography and antimyosin-antibody scintigraphy were evaluated in an experimental model of acute localized irradiation overexposure to 192Ir. Ten rabbits were exposed to a single dose of 192Ir gamma irradiation (120 Gy) on the back (right iliospinal muscle). Computed tomography and antimyosin-antibody scintigraphy results were compared with those in four control animals. Planar scintiscans (posterior views) were performed 48 h post-injection of antimyosin-antibody each week for 2 mo after exposure. An antimyosin uptake was observed in irradiated muscle five weeks after exposure and correlated with computed tomography and histopathology results, showing muscle necrosis. Biodistribution assessed at 7 and 9 wk post exposure confirmed antimyosin-antibody accumulation in damaged muscle. A semi-quantitative analysis of a region of interest over the uptake area in the irradiated muscle (on the right side) and a contralateral non-irradiated region of interest used as control showed that uptake was significantly higher in irradiated animals than in control animals (p < 0.02). Antimyosin-antibody scintiscans used in nuclear cardiology to explore ischemic heart disease, myocarditis or heart transplant rejection could be realized to assess the extent of muscle necrosis after trauma or radiation induced injury.

Cardiac myofibrillar proteins: biochemical markers to estimate myocardial injury

Ischaemic heart disease represents the most common of the serious health problems in the contemporary society and acute myocardial infarction (AMI) is the major cause of cardiovascular morbidity and death. The accurate localization and determination of the infarct size and the volume of myocardium at risk at the time of insult is crucial and vital for the choice of treatment. Initially the ischaemic cells are reversibly injured. However, if these changes are not reverted at the earliest, it results in the death of the myocyte. This irreversible myocyte necrosis travels transmurally towards epicardium in the form of a wavefront. A timely intervention during evolving infarct could reduce and delimit the infarct and preserve the left ventricular function. Enzyme analysis and electrocardiography (ECG) along with the clinical history of the patient is still considered to constitute a reliable triad in the diagnosis of myocardial infarction (MI). Efforts have been made to relate infarct size with the serum enzyme level changes without much success. In addition, a number of specialist techniques such as planar radioisotope imaging, single photon emission computed tomography (SPECT), positron emission tomography (PET), Echocardiography, Ventriculography and nuclear magnetic resonance (NMR) imaging have been devised to support diagnosis in the patients who show ambiguous symptoms and ECG findings. However most of these procedures are unavailable to the patients due to economic reasons while others have suffered due to non-availability of ideal radiopharmaceuticals. Major advances have been made in the methods based on immunological techniques to improve the detection and estimation of infarct. These methods are exclusively based upon the production and availability of specific antibodies against intracellular, cardiac specific components.

Myocardial indium-111 antimyosin uptake after uncomplicated coronary artery bypass surgery

The prevalence of myocardial damage after coronary artery bypass grafting is related to the criteria of its evaluation. Indium-111 monoclonal antimyosin antibody scintigraphy has been shown to be highly sensitive and specific for even small areas of myocardial necrosis or injury like those of myocarditis or transplant rejection. Our purpose was to evaluate, by using this method, myocardial damage after uncomplicated coronary artery bypass grafting. Uptake of this radio tracer was evaluated after coronary artery bypass grafting in 14 informed and consenting consecutive patients without previous myocardial infarction, with no post-surgical complications and a favorable postoperative course, following coronary artery bypass grafting for stable angina pectoris. Monoclonal antimyosin antibody indium-111 74 MBq (Myoscint Centocor) was injected on the third postoperative day; planar images in the anterior, left anterior oblique 45 degrees and 70 degrees projections were obtained 24 and 48 h later and analyzed for myocardial uptake. Indium-111 antimyosin uptake was present in 10 out of 14 patients (71.4%); it was diffuse in 6 and localized in 4. The ratio of the maximal counts in the myocardium to the counts in the adjacent lung background was measured and found elevated: 1.94 +/- 0.23, higher than the normal values reported in the literature. Indium-111 antimyosin uptake was clear in a group of patients after uncomplicated coronary artery bypass grafting. No correlation was observed between indium-111 antimyosin uptake or heart to lung ratio and creatine kinase, creatine kinase isoenzyme MB, glutamic oxalacetic transferase levels, duration of cardiopulmonary bypass or aortic cross-clamp time, while elevated serum beta myosin heavy chain fragments (IRMA Pasteur) were observed (1378 +/- 238 microU/l). This study suggests that some degree of myocardial damage, though silent, is common after coronary artery bypass grafting.

Quantitative 111In antimyosin antibody imaging to predict the age of myocardial infarction

To establish whether quantitative 111In antimyosin uptake can be used to predict infarct age, we studied the heart-lung ratio in 107 images from 90 patients at various intervals following a Q-wave infarction. Imaging was performed 24 hours following 111In antimyosin injection. The HLR was measured as the ratio of the maximum counts in the infarcted myocardium to the adjacent lung background. The ratio ranged from 1.26 to 3.87, and declined with increasing infarct age. Infarcts were classified on the basis of age as type I (less than 3 days old), type II (less than 14 days), and type III (less than 90 days). True positive and false positive rates (TPR and FPR), and test-likelihood ratio calculations were performed for HLR thresholds ranging from 1 to 4, for the three infarct types. A FPR of 0% and likelihood ratio of infinity was obtained at a HLR threshold of 2.3 for type I infarcts (TPR 40.8%); at a HLR threshold of 2 for type II infarcts (TPR 50.6%), and a threshold of 1.8 for type III infarcts (TPR 52.6%). The likelihood of each infarct type can be estimated directly from the HLR for values below the above thresholds. These results show that quantitative 111In-antimyosin imaging may be used to predict infarct age.

111In antimyosin antibody uptake is related to the age of myocardial infarction

The intensity of 111In antimyosin uptake is related to the type (Q wave or non-Q wave), size, and location of an acute myocardial infarction. To determine whether the uptake intensity is also related to the infarct age, and to establish the time frame during which 111In antimyosin uptake occurs postinfarction, we studied a quantitative measure of uptake intensity, the heart-lung (HL) ratio, in 90 consecutive patients at various intervals following a Q wave infarction. Imaging was performed 24 hours following 111In antimyosin injection. Uptake of antimyosin could be demonstrated up to 154 days postinfarction. The HL ratio was measured as the ratio of the maximum counts in the infarcted myocardium to the adjacent lung background, and was 1.93 +/- 0.51 (mean +/- SD) overall. The ratio declined exponentially with increasing age of infarct. Using nonlinear regression analysis, 47% of the total variance of the HL ratio could be attributed to age alone (p less than 0.001). Sequential antimyosin imaging was performed in nine patients, with the first study between 4 and 15 days, the second between 50 to 100 days, and the third between 125 to 270 days after the onset of chest pain. The HL ratios were (mean +/- SD) 1.77 +/- 0.25 for scans between 4 and 15 days, 1.54 +/- 0.12 for scans between 50 and 100 days (p less than 0.02), and 1.42 +/- 0.16 (p less than 0.05) for scans between 125 to 270 days, further establishing the progressive reduction in 111In antimyosin uptake with age of myocardial infarction.

Clinical role of indium-111 antimyosin imaging

Myocyte necrosis occurs in ischaemic, inflammatory and toxic heart diseases and can be detected by indium-111 antimyosin imaging. This allows a non-invasive evaluation of the site, extent and quantitation of the severity of myocardial necrosis. Simultaneous imaging of perfusion in patients with myocardial infarction allows the differentiation of necrosed and perfused areas and the varying degrees of mismatch and overlap, which has prognostic significance. 111In-antimyosin imaging is useful in the assessment of patients with unstable angina and in those for whom the diagnosis of infarction or unstable angina is not clear. In suspected myocarditis, a positive scan indicates the necessity for endomyocardial biopsy to confirm inflammation, whereas a negative scan makes the diagnosis of myocarditis unlikely. Antimyosin imaging is not useful as a marker of rejection in the 1 year post-transplant, but uptake after this period is associated with an increased rejection rate and is therefore an important tool in planning management strategies. Most patients on anthracycline treatment have demonstrable uptake, which is related to the cumulative dose and to the ejection fraction. Its role in this situation is as yet unclear. The use of new ligands and radioisotopes (99mTc) is likely to allow earlier imaging and produce improved quality.