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Sim EWJ, Yew MS. Transient ischaemic dilation ratio thresholds in patients with zero coronary calcium score undergoing exercise or dipyridamole stress SPECT myocardial perfusion imaging using a cadmium-zinc-telluride camera. EUROPEAN HEART JOURNAL. IMAGING METHODS AND PRACTICE 2023; 1:qyad013. [PMID: 39044788 PMCID: PMC11195783 DOI: 10.1093/ehjimp/qyad013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/20/2023] [Indexed: 07/25/2024]
Abstract
Aims Transient ischaemic dilation (TID) is a marker of underlying extensive coronary artery disease (CAD) during myocardial perfusion imaging (MPI). The cut-off for a normal TID ratio (TIDr) value is often derived from a cohort of individuals with no apparent CAD. Varying criteria have been used to define the absence of CAD. We aim to derive TIDr cut-offs using patients with normal MPI and coronary artery calcium (CAC) score of zero, and compare the TIDr obtained from different software packages. Methods and results We studied 232 patients with zero CAC and normal MPI undergoing exercise or dipyridamole stress using either a 1- or 2-day protocol. All patients were scanned in the supine position with a cadmium-zinc-telluride camera. TIDr was automatically generated using quantitative perfusion SPECT (QPS) software initially, and subsequently using Myometrix for comparison. The TIDr cut-offs calculated using the mean + 2 standard deviation were 1.29 and 1.24 for the 1- and 2-day protocol groups, respectively. In patients undergoing a 2-day protocol, dipyridamole stress resulted in significantly higher mean TIDr when compared to exercise stress (1.07 ± 0.13 vs. 1.01 ± 0.12, P = 0.035). Myometrix-derived TIDr were also significantly lower compared to QPS-derived values for most protocols except for 2-day exercise stress. Conclusion This study is the first to derive TIDr threshold values using a normal population defined by zero CAC and normal MPI. TIDr was found to vary depending on stress modality, protocol as well as the software used.
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Affiliation(s)
- Eran Wen Jun Sim
- Department of Cardiology, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, 308433Singapore
| | - Min Sen Yew
- Department of Cardiology, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, 308433Singapore
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2
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Lanza GA. Diagnostic Approach to Patients with Stable Angina and No Obstructive Coronary Arteries. Eur Cardiol 2019; 14:97-102. [PMID: 31360230 PMCID: PMC6659043 DOI: 10.15420/ecr.2019.22.2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/04/2019] [Indexed: 01/24/2023] Open
Abstract
The diagnosis of microvascular angina (MVA) is usually considered in patients presenting with angina symptoms and evidence of MI on non-invasive stress tests but normal coronary arteries at angiography. A definitive diagnosis of MVA, however, would require the presence of coronary microvascular dysfunction. Several invasive (e.g. intracoronary Doppler wire recording and thermodilution) and non-invasive (e.g. PET, cardiac MRI, transthoracic Doppler echocardiography) methods can be applied to obtain a diagnosis. Both endothelium-dependent and -independent coronary microvascular dilator function, as well as increased microvascular constrictor activity, should be investigated. The main issues in the assessment of clinical and diagnostic findings in patients with suspected MVA are discussed and a diagnostic approach is suggested.
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Affiliation(s)
- Gaetano Antonio Lanza
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Cardiology Institute Rome, Italy
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Sareen N, Ananthasubramaniam K. Left main coronary artery disease: A review of the spectrum of noninvasive diagnostic modalities. J Nucl Cardiol 2016; 23:1411-1429. [PMID: 26487011 DOI: 10.1007/s12350-015-0152-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 04/15/2015] [Indexed: 11/29/2022]
Abstract
Medically managed significant left main (LM) stem disease has been considered a determinant of increased cardiac mortality approaching 50% at 3-year follow-up. Despite the clinical significance of LM disease, studies comparing the various diagnostic modalities, especially noninvasive, are sparse. Clinicians, particularly imagers, should be aware of the strengths and weaknesses of existing modalities to diagnose LM disease as integrating many clues (history, symptoms, electrocardiogram, and stress hemodynamics are essential to suspect this diagnosis and proceed to the next step). Here we review the existing data on the current role of electrocardiography, nuclear myocardial perfusion imaging (single photon emission computed tomography and positron emission tomography), stress echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging in diagnostic evaluation of LM disease. Wherever applicable we have extended our discussion to multivessel coronary artery disease encompassing scenarios where LMS can present as LM equivalent with or without extensive multivessel coronary artery disease.
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Affiliation(s)
- Nishtha Sareen
- Department of Cardiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
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4
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Lanza GA. Angina Pectoris and Myocardial Ischemia in the Absence of Obstructive Coronary Artery Disease: Role of Diagnostic Tests. Curr Cardiol Rep 2016; 18:15. [DOI: 10.1007/s11886-015-0688-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Lehtinen M, Schildt J, Ahonen A, Nikkinen P, Lauerma K, Sinisalo J, Kankuri E, Vento A, Pätilä T, Harjula A. Combining FDG-PET and 99mTc-SPECT to predict functional outcome after coronary artery bypass surgery. Eur Heart J Cardiovasc Imaging 2015; 16:1023-30. [PMID: 25762563 DOI: 10.1093/ehjci/jev032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 02/03/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS Single-photon emission computed tomography (SPECT) and positron emission tomography (PET) are suggested to improve clinical decision-making in ischaemic cardiomyopathy. Here, we present a unique cohort of patients who underwent nuclear medicine studies and cardiac magnetic resonance imaging (MRI) both before and 1 year after coronary artery bypass (CABG) surgery to assess benefit from surgery. METHODS AND RESULTS Before CABG, we applied three quantitative techniques using (18)F-fluorodeoxyglucose-PET and (99m)technetium-tetrofosmin-SPECT with a software tool to measure defects with hypoperfused but viable and non-viable myocardium in 15 patients. One method used solely PET, two others combined PET and SPECT at different thresholds. As a reference, we used change in left-ventricular (LV) function and volume by MRI. Preoperatively, ischaemic but viable areas detected by the method with a 10% threshold combining PET-SPECT and the PET-only method correlated significantly with preoperative regional wall thickening (WT; P = 0.03 and P = 0.005, respectively). When compared with global functional outcome (change in LV ejection fraction) and LV remodelling (change in end-diastolic volume) 1 year postoperatively, no correlation appeared with preoperative PET- or PET-SPECT-derived viable or non-viable tissue. Neither was any correlation observable between local change in WT and local preoperative defect size evaluated by any of these three methods. CONCLUSION Preoperatively, PET and PET-SPECT with 10% threshold detected dysfunctional myocardium, but all analysis methods failed to predict 1-year functional outcome assessed by MRI. In patients with three-vessel disease and heart failure, SPECT perfusion and PET viability study results show substantial heterogeneity; this should be considered when selecting patients for revascularization.
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Affiliation(s)
- Miia Lehtinen
- Department of Cardiothoracic Surgery, Heart and Lung Center, Helsinki University Central Hospital, Haartmaninkatu 4, Helsinki 00029 HUS, Finland
| | - Jukka Schildt
- Division of Nuclear Medicine, HUS Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Aapo Ahonen
- Division of Nuclear Medicine, HUS Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Päivi Nikkinen
- Division of Nuclear Medicine, HUS Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Kirsi Lauerma
- Division of Roentgenology, HUS Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Juha Sinisalo
- Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Esko Kankuri
- Institute of Biomedicine, Pharmacology, University of Helsinki, Helsinki, Finland
| | - Antti Vento
- Department of Cardiothoracic Surgery, Heart and Lung Center, Helsinki University Central Hospital, Haartmaninkatu 4, Helsinki 00029 HUS, Finland
| | - Tommi Pätilä
- Department of Cardiothoracic Surgery, Heart and Lung Center, Helsinki University Central Hospital, Haartmaninkatu 4, Helsinki 00029 HUS, Finland
| | - Ari Harjula
- Department of Cardiothoracic Surgery, Heart and Lung Center, Helsinki University Central Hospital, Haartmaninkatu 4, Helsinki 00029 HUS, Finland Institute of Biomedicine, Pharmacology, University of Helsinki, Helsinki, Finland
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Yokota S, Ottervanger JP, Mouden M, Timmer JR, Knollema S, Jager PL. Prevalence, location, and extent of significant coronary artery disease in patients with normal myocardial perfusion imaging. J Nucl Cardiol 2014; 21:284-90. [PMID: 24469846 DOI: 10.1007/s12350-013-9837-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/27/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND False-negative myocardial perfusion imaging (MPI) can by due to left main (LM) or three-vessel disease causing "balanced ischemia". However, so far prevalence of LM or three-vessel-disease in patients with normal MPI is unclear. We assessed prevalence, location, and extent of significant coronary artery disease (CAD) in patients with normal MPI. METHODS Between 2006 and 2010, 256 patients with normal MPI who had invasive angiography because of persisting or worsening of the same initial symptoms were studied. Significant CAD was defined as stenosis > 70% or LM > 50%. RESULTS A total of 93 patients (36%) had significant CAD. Significant CAD was observed more frequently in males, higher age and those with typical angina complaints. Significant LM disease was present in 7%, three-vessel disease in 10%, two-vessel disease in 22%, and single vessel disease (not left main) in 61%. In those with single vessel disease, the location was the LAD in 40%, the RCA in 30%, and the LCX in 30%. CONCLUSIONS In selected patients with normal MPI, one-third had significant CAD. The majority of these patients had single vessel disease (not left main). LM or three vessel disease, causing "balanced ischemia", is a less common cause of false-negative MPI.
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Affiliation(s)
- Shu Yokota
- Department of Cardiology, Isala Klinieken, Dokter Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
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Ladapo JA, Blecker S, Elashoff MR, Federspiel JJ, Vieira DL, Sharma G, Monane M, Rosenberg S, Phelps CE, Douglas PS. Clinical implications of referral bias in the diagnostic performance of exercise testing for coronary artery disease. J Am Heart Assoc 2013; 2:e000505. [PMID: 24334965 PMCID: PMC3886773 DOI: 10.1161/jaha.113.000505] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Exercise testing with echocardiography or myocardial perfusion imaging is widely used to risk-stratify patients with suspected coronary artery disease. However, reports of diagnostic performance rarely adjust for referral bias, and this practice may adversely influence patient care. Therefore, we evaluated the potential impact of referral bias on diagnostic effectiveness and clinical decision-making. METHODS AND RESULTS Searching PubMed and EMBASE (1990-2012), 2 investigators independently evaluated eligibility and abstracted data on study characteristics and referral patterns. Diagnostic performance reported in 4 previously published meta-analyses of exercise echocardiography and myocardial perfusion imaging was adjusted using pooled referral rates and Bayesian methods. Twenty-one studies reported referral patterns in 49 006 patients (mean age 60.7 years, 39.6% women, and 0.8% prior history of myocardial infarction). Catheterization referral rates after normal and abnormal exercise tests were 4.0% (95% CI, 2.9% to 5.0%) and 42.5% (36.2% to 48.9%), respectively, with odds ratio for referral after an abnormal test of 14.6 (10.7 to 19.9). After adjustment for referral, exercise echocardiography sensitivity fell from 84% (80% to 89%) to 34% (27% to 41%), and specificity rose from 77% (69% to 86%) to 99% (99% to 100%). Similarly, exercise myocardial perfusion imaging sensitivity fell from 85% (81% to 88%) to 38% (31% to 44%), and specificity rose from 69% (61% to 78%) to 99% (99% to 100%). Summary receiver operating curve analysis demonstrated only modest changes in overall discriminatory power but adjusting for referral increased positive-predictive value and reduced negative-predictive value. CONCLUSIONS Exercise echocardiography and myocardial perfusion imaging are considerably less sensitive and more specific for coronary artery disease after adjustment for referral. Given these findings, future work should assess the comparative ability of these and other tests to rule-in versus rule-out coronary artery disease.
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Affiliation(s)
- Joseph A Ladapo
- Department of Population Health, New York University School of Medicine, New York, NY
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Thomas D, Al-Mallah M, Govindarajulu U, Forman DE, Mora S, Di Carli MF, Dorbala S. Value of reserve pulse pressure in improving the risk stratification of patients with normal myocardial perfusion imaging. Eur Heart J 2013; 34:2074-81a. [PMID: 23539339 DOI: 10.1093/eurheartj/eht102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS To evaluate the incremental prognostic value of reserve-pulse pressure (reserve-PP: exercise-PP minus rest-PP) to standard risk factors among patients with suspected coronary artery disease (CAD) but normal exercise myocardial perfusion imaging (MPI). METHODS AND RESULTS We studied 4269 consecutive symptomatic patients without known CAD who were referred for exercise MPI but had normal MPI results (mean age 58 ± 12 years, 56% females, 84% referred for evaluation of chest pain or dyspnoea, 95% with intermediate pretest likelihood of CAD). There were 202 deaths over 5.1 ± 1.4 years of follow-up. Reserve-PP was abnormal (<44 mmHg increase in PP from rest) in 1894 patients (44%). Patients with an abnormal reserve-PP had a higher risk of death compared with patients with normal reserve-PP [hazard ratio (HR): 2.47, 95% CI, 1.8-3.3]. In multivariable models adjusting for age, sex, ejection fraction, medications, heart rate recovery, Duke treadmill score (DTS), and rest-PP, each 10 mmHg lower reserve-PP was associated with a 20.6% increase in risk-adjusted mortality (adjusted HR 0.83, 95% CI 0.76-0.91). Models incorporating reserve-PP significantly reclassified risk compared with models without these parameters (net reclassification index 14.3%, P = 0.0007; integrated discrimination index 0.69, P = 0.01). CONCLUSION In patients without a history of CAD and a normal MPI, an abnormal reserve-PP identified and reclassified those at higher risk of death independent of known risk factors and DTS.
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Affiliation(s)
- Deepak Thomas
- The Noninvasive Cardiovascular Imaging Program, Department of Medicine (Cardiology), Brigham and Women's Hospital, Boston, MA 02115, USA
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Normal Tc-99m Tetrofosmin Cardiac SPECT Images With Three-Vessel Coronary Artery Disease. Clin Nucl Med 2010; 35:944-7. [DOI: 10.1097/rlu.0b013e3181f9de68] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Practical considerations for 1-day stress-only myocardial perfusion protocol. J Am Coll Cardiol 2010; 55:2610-1; author reply 2612-3. [PMID: 20513607 DOI: 10.1016/j.jacc.2010.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 02/15/2010] [Indexed: 11/27/2022]
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Systematic Strategy of Prophylactic Coronary Angiography Improves Long-Term Outcome After Major Vascular Surgery in Medium- to High-Risk Patients. J Am Coll Cardiol 2009; 54:989-96. [DOI: 10.1016/j.jacc.2009.05.041] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 05/04/2009] [Accepted: 05/11/2009] [Indexed: 11/22/2022]
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