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Berkovitch A, Naimushin A, Shlomo N, Matetzky S, Beigel R, Naroditsky M, Asher E, Rozen E, Goldenberg I, Klempfner R, Goldkorn R. Poor outcome among patients undergoing myocardial perfusion imaging with intermediate-zone troponin. Intern Emerg Med 2022; 17:655-663. [PMID: 33638094 DOI: 10.1007/s11739-021-02668-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 02/10/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intermediate zone troponin elevation is defined as one to five times the upper limit of normal. Approximately half the patients presenting with chest pain to the emergency department have initial intermediate zone troponin. OBJECTIVES We aimed to investigate the long-term outcome of patients hospitalized with chest pain and intermediate zone troponin elevation. METHODS We investigated 8269 patients hospitalized in a tertiary center with chest pain. All patients had serial measurements of troponin during hospitalization. Patients were divided into three groups based on their initial troponin levels: negative troponin (N = 6112), intermediate zone troponin (N = 1329) and positive troponin (N = 828). All patients underwent myocardial perfusion imaging (MPI) as part of the initial evaluation. RESULTS Mean age of the study population was 68 ± 11, of whom 36% were women. Patients with an intermediate zone troponin were older, more likely to be males, and with significantly more cardiovascular co-morbidities. Multivariate analysis adjusted for age, gender, cardiovascular risk factors, and abnormal MPI result found that patients with intermediate zone troponin had a 70% increased risk of re-hospitalization at 1 year (HR 1.70, 95%CI 1.48-1.96, p-value < 0.001) and 5.3 times higher risk of total mortality at 1-year (HR 5.33, 95%CI 3.65-7.78, p-value < 0.001). sub-group analysis found that among the intermediate zone troponin group, patients with double intermediate zone troponin had the poorest outcome. CONCLUSIONS Intermediate zone troponin elevation is an independent risk factor associated with adverse outcomes and therefore patients with an initial value in this range should be closely monitored and aggressively managed.
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Affiliation(s)
- Anat Berkovitch
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, 52621, Tel Hashomer, Israel.
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Alexey Naimushin
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, 52621, Tel Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Nir Shlomo
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, 52621, Tel Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Shlomi Matetzky
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, 52621, Tel Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Roy Beigel
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, 52621, Tel Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Michael Naroditsky
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, 52621, Tel Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Elad Asher
- Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - Eli Rozen
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, 52621, Tel Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ilan Goldenberg
- The University of Rochester Medical Center, New York, NY, USA
| | - Robert Klempfner
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, 52621, Tel Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ronen Goldkorn
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, 52621, Tel Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Sharma V, Mughal L, Dimitropoulos G, Sheikh A, Griffin M, Moss A, Notghi A, Pandit M, Connolly DL, Varma C, Kirchhof P. The additive prognostic value of coronary calcium score (CCS) to single photon emission computed tomography myocardial perfusion imaging (SPECT-MPI)-real world data from a single center. J Nucl Cardiol 2021; 28:2086-2096. [PMID: 31797319 DOI: 10.1007/s12350-019-01965-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 01/07/2023]
Abstract
AIMS Single-photon emission computed tomography myocardial perfusion imaging [SPECT-MPI] is a functional test for coronary ischemia. We aimed to assess the additive prognostic value of coronary calcium score (CCS) to SPECT-MPI in stable patients. METHODS This study is a retrospective analysis of 655 patients who underwent SPECT-MPI with CCS (2012 to 2017). Receiver operator characteristic (ROC) identified CCS cutoff value for all-cause mortality: CCS+ if > cutoff value and MPI+ if ≥ 5% total perfusion defect (TPD). Patients were divided into 1 MPI-/CCS-; 2 MPI+/CCS-; 3 MPI-/CCS+; 4 MPI+/CCS+ and compared. Cox proportional hazard analysis identified predictors of mortality. RESULTS CCS cutoff for all-cause mortality was > 216 (C statistic 0.756, P < 0.0001). In MPI+ groups, mean TPD was similar (13.4% and 13.1% respectively) but mortality was higher in the CCS+ (12.5% vs. 4.8%, P = 0.22) as was the severe LV systolic dysfunction (8.0% vs. 0%, P = 0.095). In MPI- groups, mean TPD was similar (0.7% and 0.9% respectively) but all-cause mortality was higher in the CCS+ (10.7% vs. 1.6%, P < 0.0001) as was severe LVSD (2.9 % vs. 0.3% P = 0.016). Age, smoking, renal impairment ,and CCS > 216 were independent predictors of mortality. CONCLUSIONS Patients with raised CCS on SPECT-MPI have increased mortality and poor LV function despite a negative MPI.
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Affiliation(s)
- Vinoda Sharma
- Birmingham City Hospital, SWBH NHS Trust, Dudley Road, Birmingham, B18 7QH, United Kingdom.
| | - Lal Mughal
- Birmingham City Hospital, SWBH NHS Trust, Dudley Road, Birmingham, B18 7QH, United Kingdom
| | | | - Awais Sheikh
- Birmingham City Hospital, SWBH NHS Trust, Dudley Road, Birmingham, B18 7QH, United Kingdom
| | - Michael Griffin
- Birmingham City Hospital, SWBH NHS Trust, Dudley Road, Birmingham, B18 7QH, United Kingdom
| | - Alexandra Moss
- Birmingham City Hospital, SWBH NHS Trust, Dudley Road, Birmingham, B18 7QH, United Kingdom
| | - Alp Notghi
- Birmingham City Hospital, SWBH NHS Trust, Dudley Road, Birmingham, B18 7QH, United Kingdom
| | - Manish Pandit
- Birmingham City Hospital, SWBH NHS Trust, Dudley Road, Birmingham, B18 7QH, United Kingdom
| | - Derek L Connolly
- Birmingham City Hospital, SWBH NHS Trust, Dudley Road, Birmingham, B18 7QH, United Kingdom
| | - Chetan Varma
- Birmingham City Hospital, SWBH NHS Trust, Dudley Road, Birmingham, B18 7QH, United Kingdom
| | - Paulus Kirchhof
- Birmingham City Hospital, SWBH NHS Trust, Dudley Road, Birmingham, B18 7QH, United Kingdom
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Worden NE, Lindower PD, Burns TL, Chatterjee K, Weiss RM. A second look with prone SPECT myocardial perfusion imaging reduces the need for angiography in patients at low risk for cardiac death or MI. J Nucl Cardiol 2015; 22:115-22. [PMID: 24980454 DOI: 10.1007/s12350-014-9934-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 05/27/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Correction for soft tissue signal attenuation can improve the diagnostic accuracy of single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). The aim of this study was to correlate SPECT-MPI findings with clinical outcomes in patients who underwent stress imaging in the supine position, who also underwent "second look" stress imaging in the prone position. METHODS Patients without perfusion abnormalities were considered Normal (N = 270). Those with apparent supine stress perfusion abnormalities which all resolved during prone imaging formed the Normal-Prone group (N = 309). Patients with matched perfusion abnormalities during both supine and prone stress imaging were considered Abnormal (N = 169). RESULTS During follow-up (187 ± 96 days), utilization rates for invasive coronary angiography were similar for Normal vs Normal-Prone patients (3.5% vs 3.8%; P = NS), but were significantly higher in Abnormal patients (42.4%, P < .0001). Coronary revascularization occurred in 0.78%, 0.64%, and 17.7% of Normal, Normal-Prone, and Abnormal patients, respectively (P < .001). Cardiac death or myocardial infarction occurred in 2.2%, 2.3%, and 6.3% of Normal, Normal-Prone, and Abnormal patients, respectively (P = .02). CONCLUSIONS Second look SPECT-MPI identifies patients at low risk for death or myocardial infarction, who infrequently require invasive coronary angiography.
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Affiliation(s)
- Nicole E Worden
- Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, USA.
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Lüdemann L, Schmitt B, Podrabsky P, Schnackenburg B, Böck J, Gutberlet M. Usage of the T1 effect of an iron oxide contrast agent in an animal model to quantify myocardial blood flow by MRI. Eur J Radiol 2007; 62:247-56. [PMID: 17188443 DOI: 10.1016/j.ejrad.2006.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2006] [Revised: 11/30/2006] [Accepted: 12/01/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND To present a new method for fully quantitative analysis of myocardial blood flow (MBF) using magnetic resonance imaging. The first pass of an intravascular iron oxide contrast medium can be used to quantify myocardial perfusion. The technique was validated in an animal model using colored microspheres. MATERIALS AND METHODS In six pigs, a tracking catheter was positioned in the left anterior descending artery (LAD). Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) was performed on a 1.5-T scanner using a hybrid gradient-echo/echoplanar imaging (GRE-EPI) sequence. Regional myocardial blood flow (rMBF) was altered by either inducing vasodilatation with adenosine or creating coronary artery obstruction. The T(1) effect of a superparamagnetic iron oxide-based contrast medium (Resovist) administered at a dose of 8 micromol/kg was used. Upslope, time-to-peak and peak intensity were calculated from the signal intensity-time curves and absolute rMBF using the Kety-Schmidt equation; results were compared to those obtained using colored microspheres. RESULTS The mean rMBF calculated by MRI was 1.49 (+/-6.91, quartile width) ml/min/g versus 3.21 (+/-1.61) ml/min/g measured by means of microspheres under resting conditions. rMBF increased to a mean of 6.21 (+/-2.83) ml/min/g versus 4.22 (+/-1.70) ml/min/g under adenosine and was reduced to zero flow in total occlusion. Linear regression showed the best correlation for upslope (R=0.714), time-to-peak (R=0.626) and the Kety-Schmidt equation (R=0.584). CONCLUSIONS The T(1) effect of an iron oxide-based contrast medium allows determination of rMBF when using the Kety-Schmidt equation. The results are similar to those obtained with the standard of reference, colored micropheres, but not better than the results of the semiquantitative approach.
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Affiliation(s)
- Lutz Lüdemann
- Department of Radiology and Nuclear Medicine, Charité-Universitätmedizin Berlin, Campus Virchow-Klinikum, Germany.
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Nakajo H, Kumita SI, Cho K, Kumazaki T. Three-dimensional registration of myocardial perfusion SPECT and CT coronary angiography. Ann Nucl Med 2005; 19:207-15. [PMID: 15981674 DOI: 10.1007/bf02984607] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE In this study, we describe a new technique for three-dimensional registration of CT coronary angiography (CTCA) and gated myocardial perfusion SPECT. METHODS Twelve patients with known or suspected CAD who underwent CTCA and gated SPECT were enrolled retrospectively. Coronary arteries and their branches were traced using CTCA data manually and reconstructed in three-dimensions. Gated SPECT data were registered and mapped to a left ventricle binary model extracted from CTCA data using manual, rigid and nonrigid registration methods. RESULTS Three-dimensional reconstruction and volume visualization of both modalities were successfully achieved for all patients. All 3 registration methods gave better quality based on visual inspection, and nonrigid registration gave significantly better results than the other registration methods (p < 0.05). The cost function for three-dimensional registration using nonrigid registration (235.3 +/- 13.9) was significantly better than those of manual and rigid registration (218.5 +/- 15.3 and 223.7 +/- 17.0, respectively). Inter-observer reproducibility error was within acceptable limits for all methods, and there were no significant difference among the methods. CONCLUSION This technique of image registration may assist the integration of information from gated SPECT and CTCA, and may have clinical application for the diagnosis of ischemic heart disease.
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Affiliation(s)
- Hidenobu Nakajo
- Department of Radiology, Center for Advanced Medical Technology, Nippon Medical School, Tokyo, Japan
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