Prognostic value of poststress left ventricular volume and ejection fraction by gated myocardial perfusion SPECT in women and men: gender-related differences in normal limits and outcomes.

BACKGROUND: Whether there are gender differences in the prognostic application of gated myocardial perfusion single photon emission computed tomography (SPECT) has not been assessed. METHODS AND RESULTS: Gender-specific normal limits of poststress volume and ejection fraction (EF) were obtained in 597 women and 824 men with a low likelihood of coronary artery disease and normal perfusion and were applied in a prognostic evaluation of 6713 patients (2735 women and 3978 men). Patients underwent rest thallium-201/stress technetium-99m sestamibi gated myocardial perfusion SPECT and were followed up for 35 +/- 14 months. The upper limit of the end-systolic volume (ESV) index was 27 mL/m2 in women and 39 mL/m2 in men, and the upper limit of the end-diastolic volume index was 60 mL/m2 in women and 75 mL/m2 in men. The lower limit of the EF was 51% in women and 43% in men. Gated SPECT variables provided incremental prognostic information in both genders. Women with severe ischemia and an EF lower than 51% or an ESV index greater than 27 mL/m2 were at very high risk of cardiac death or myocardial infarction (3-year event rates of 39.8% and 35.1%, respectively), whereas women with severe ischemia but an EF of 51% or greater or an ESV index of 27 mL/m2 or less were at intermediate or high risk (3-year event rates of 10.8% and 15.2%, respectively). CONCLUSION: Poststress EF and ESV index by gated myocardial perfusion SPECT provide comparable incremental prognostic information over perfusion in women and men. After separate criteria for abnormal EF and ESV index in women are used, the combination of severe ischemia and abnormal EF or ESV index identifies women at very high risk of cardiac events.     

Electrocardiogram-gated single-photon emission computed tomography versus cardiac magnetic resonance imaging for the assessment of left ventricular volumes and ejection fraction: a meta-analysis

OBJECTIVES: The purpose of this study was to evaluate the accuracy of electrocardiogram (ECG)-gated single-photon emission computed tomography (SPECT) for assessment of left ventricular (LV) end-diastolic volume (EDV), end-systolic volume (ESV) and ejection fraction (EF) compared with the gold standard of cardiac magnetic resonance imaging (MRI). BACKGROUND: Several comparisons of ECG-gated SPECT with cardiac MRI have been performed for evaluation of LV volumes and EF, but each has considered few subjects, thus leaving uncertainty about the frequency of discrepancies between the two methods. METHODS: We performed a meta-analysis of data on 164 subjects from nine studies comparing ECG-gated SPECT versus cardiac MRI. Data were pooled in correlation and regression analyses relating ECG-gated SPECT and cardiac MRI measurements. The frequency of discrepancies of at least 30 ml in EDV, 20 ml in ESV and 5% or 10% in EF and concordance for EF < or =40% versus >40% were determined. RESULTS: There was an overall excellent correlation between ECG-gated SPECT and cardiac MRI for EDV (r = 0.89), ESV (r = 0.92) and EF (r = 0.87). However, rates of discrepancies for individual subjects were considerable (37% [95% confidence interval [CI], 26% to 50%] for at least 30 ml in EDV; 35% [95% CI, 23% to 49%] for at least 20 ml in ESV; 52% [95% CI, 37% to 63%] for at least 5% in EF; and 23% [95% CI, 11% to 42%] for at least 10% in EF). The misclassification rate for the 40% EF cutoff was 11%. CONCLUSIONS: Electrocardiogram-gated SPECT measurements of EDV, ESV and EF show high correlation with cardiac MRI measurements, but substantial errors may occur in individual patients. Electrocardiogram-gated SPECT offers useful functional information, but cardiac MRI should be used when accurate measurement is required.     

Usefulness of combination post-stress dysfunction and perfusion imaging in technetium-99m-tetrofosmin myocardial scintigraphy

OBJECTIVES: Myocardial perfusion imaging has lower sensitivity for the diagnosis of coronary artery disease in patients with three-vessel disease. The presence of post-stress dysfunction of the left ventricle, evaluated by electrocardiography(ECG) gated single photon emission computed tomography(SPECT) with a quantitative gated SPECT program, was investigated in patients with coronary artery disease, and also whether combining post-stress dysfunction and myocardial perfusion imaging improved the diagnosis of coronary artery disease. METHODS: ECG gated technetium-99m-tetrofosmin SPECT was performed using a one day, stress and rest, protocol in 139 patients. SPECT and coronary angiography were performed within 1 month. The coronary artery disease group consisted of 89 patients: 43 with one-vessel disease(1VD), 28 with two-vessel disease(2VD), and 18 with three-vessel disease(3VD). The group with zero-vessel disease(0VD) consisted of 50 patients. According to post-stress and rest ejection fraction(EF) and end-systolic volume (ESV), post-stress dysfunction is defined as follows: rest EF--post-stress EF > or = 5% and post-stress ESV--rest ESV > or = 5 ml. RESULTS: In the coronary artery disease group, post-stress ESV was larger than rest ESV(37.8 +/- 26.4, 34.0 +/- 24.2 ml, p < 0.001), and post-stress EF was lower than rest EF (61.5 +/- 11.1%, 64.2 +/- 10.8%, p < 0.001). In the 0VD group, ESV and EF were the same for post-stress and rest (25.7 +/- 20.8, 26.2 +/- 21.6 ml, NS; 70.4 +/- 9.5%, 70.0 +/- 9.6%, NS). Post-stress dysfunction was 6.0% in the 0VD group and 30.3% in the coronary artery disease group(p < 0.001). Furthermore, post-stress dysfunction in the 2VD (35.7%) and 3VD(38.9%) groups was higher than that in the 0VD group(p < 0.01, p < 0.01). Sensitivity of coronary artery disease diagnosis by myocardial perfusion imaging was 75%. The combination of post-stress dysfunction and myocardial perfusion imaging improved sensitivity from 75% to 82%(p < 0.05), but reduced the specificity from 92% to 86%(p = 0.08). CONCLUSIONS: Post-stress dysfunction is a useful parameter for clinical diagnosis of coronary artery disease.     

Enhanced prognostic stratification of CAD patients with low ejection fraction by stress-rest Tc99m tetrofosmin gated-spect

OBJECTIVE: This study was performed to assess whether post-stress and rest functional parameters, as measured by gated-SPECT, provide additional predictive value for long-term prognosis, over clinical and perfusion data in patients (pts.) with low left ventricular ejection fraction (LVEF). METHODS: 647 consecutive pts. underwent stress/rest gated-SPECT, and 497 were followed for a mean period of 516 +/- 264 days. Segmental perfusion and motion/thickening (post-stress and rest) were analysed visually, while EF and LV volumes were calculated using an automatic algorithm (QGS). The post-stress and rest ratio were determined for both end-diastolic (EDV) and end-systolic volume (ESV), while the post-stress LVEF change was calculated subtracting rest-EF from stress-EF. RESULTS: 84/497 pts. showed rest EF < 40%, and 15/84 (18%) experienced a cardiac event (3 cardiac deaths, 1 infarction, 3 hospitalized angina and 9 late revascularizations). The perfusion and functional parameters were not significantly more compromised in pts. with cardiac events compared with pts. without events. Post-stress ESV was the only index significantly higher in pts. with low EF and events compared with pts. with low EF without events (150 +/- 72 ml vs. 123 +/- 53 ml, P = 0.02). Univariate Cox analysis of clinical, perfusion and functional data showed that the best predictor of cardiac events was stress-ESV (score 6.5, P = 0.01), followed by rest-ESV, rest-EDV, stress-EDV and stress-LVEF. Multivariate analysis demonstrated that the addition of stress-ESV to stress-EF, yielded a significant increase in the global chi2 in the prediction of hard events (cardiac death/infarction) (score 4.634, P = 0.03). CONCLUSION: In patients with depressed LVEF, stress-ESV was the only independent predictor of long-term outcome.     

心肌灌注显像对冠心病患者心脏不良事件预测价值的初步探讨

目的初步探讨心肌灌注显像可逆缺损与不可逆缺损对心脏不良事件的预测价值。方法追踪了５０例进行血运重建术治疗［冠状动脉旁路术（ＣＡＢＧ）或经皮冠状动脉腔内成形术（ＰＴＣＡ）］和７８例单纯药物治疗冠心病患者,并于术前或药物治疗前行冠状动脉造影、术后或药物治疗前进行了运动静息心肌灌注断层显像（ＳＰＥＣＴ）,随诊时间为６～１２０个月,平均（３６３±２２４）个月。结果１２８例患者ＳＰＥＣＴ示：可逆性缺损（心肌缺血）５２例,固定性缺损（心肌梗塞）２２例,正常５４例。随访期间发生心脏事件分别为３９例（７５％）、３例（１３６％）、４例（７４％）。单因素时序检验（Ｌｏｇｒａｎｋ）显示,可逆性缺损组与固定性缺损组、正常组对心脏事件的预测差异有显著性（Ｐ＜０００１）,固定性缺损（心肌梗塞）组与正常组差异无显著性。Ｃｏｘ回归分析表明：ＳＰＥＣＴ显像图上有可逆缺损（心肌缺血）是心脏事件的独立的预测因素（Ｐ＜０００１,风险比ＯＲ＝１５１,９５％的可信限ＣＩ为５２２～４２９０）。结论运动静息心肌灌注显像对心肌缺血、心肌梗塞后的心脏不良事件有较高的预测价值。     

Regional wall-motion abnormalities on post-stress electrocardiographic-gated technetium-99m sestamibi single-photon emission computed tomography imaging predict cardiac events.

BACKGROUND: The global left-ventricular (LV) ejection fraction (EF) is a powerful predictor of cardiac death (CD). There are limited data on the prognostic value of regional LV function. We examined the role of visually assessed regional wall motion in risk stratification for future cardiac events. METHODS AND RESULTS: A prospectively gathered database of 10,336 patients who underwent technetium (Tc)-99m sestamibi-gated single-photon emission computed tomography (SPECT) was analyzed. The summed stress score (SSS) and summed wall-motion score (SWMS) were calculated using a standard 17-segment model. The post-stress EF was generated using QGS software. The follow-up was 90.2% complete over 28.6 +/- 16 months. Patients with early (or=5) was an independent predictor of cardiac death (odds ratio = 1.78, 95% confidence interval = 1.11 to 2.85, P = .016). Among patients with an EF >or=45%, abnormal wall motion was the only gated SPECT variable that independently predicted cardiac death (odds ratio = 1.69, 95% confidence interval = 1.06 to 2.7, P = .028). In patients with an EF >or=45% and reversible perfusion defects, abnormal wall motion predicted an intermediate (2.2%/year) risk for CD, and a high (4.2%/year) risk for the combined endpoint of cardiac death and nonfatal MI. CONCLUSIONS: Regional LV function data from gated SPECT provide important prognostic information, and may identify a subgroup of patients with preserved EF and ischemia who are at significant risk for future cardiac events.     

Influence of the postexercise acquisition delay on the detection of functional abnormalities in sestamibi-gated SPECT.

BACKGROUND: Gated single photon emission computed tomography (SPECT) identifies functional changes produced by ischemia, but the influence of acquisition delay on their detection is not established. METHODS AND RESULTS: In 80 patients with known or suspected coronary artery disease, gated SPECT was acquired twice: first, less than 30 minutes after peak exercise (stress 1), and second, more than 45 minutes after peak exercise (stress 2). End-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF) were compared with perfusion. The relationship between the DeltaEF (stress EF - resting EF) and the summed difference score (SDS) was -0.443 (P < .0001) for stress 1 and -0.416 (P < .0001) for stress 2. In stress 1, EF increased in patients without inducible ischemia (SDS = 0) (57% +/- 10% vs 54% +/- 9% at rest, P < .02) and decreased in those with an SDS of 1 or greater (53% +/- 10.8% vs 55% +/- 9.6% at rest, P < .05). In stress 2, EF was unchanged in patients without ischemia (55.8% +/- 9.7%, P = .06) and decreased in the other patients (52.8% +/- 10.2%, P < .01). In patients without ischemia, both the EDV and ESV decreased significantly in stress 1 and were unchanged in stress 2. In patients with an SDS of 1 or greater, the EDV remained unchanged and the ESV minimally decreased in stress 1, whereas both volumes clearly and significantly increased in stress 2. CONCLUSIONS: The early acquisition of postexercise gated SPECT is slightly more effective in detecting ischemia-related functional changes; however, a delayed acquisition within 60 minutes still permits the detection of functional abnormalities in most patients.     

Prevalence and prognostic value of perfusion defects detected by stress technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography in asymptomatic patients with diabetes mellitus and no known coronary artery disease

Coronary artery disease (CAD) is the leading cause of morbidity and mortality in diabetics. Early diagnosis of CAD and identification of high-risk subgroups, followed by appropriate therapy, may therefore enhance survival. This study sought to determine the value of stress myocardial perfusion single-photon emission computed tomography (SPECT) with technetium-99m sestamibi to detect perfusion defects and predict cardiac events in asymptomatic diabetics. One hundred eighty asymptomatic diabetics without known CAD who underwent 2-day stress technetium-99m sestamibi SPECT were followed up for 36 +/- 18 months. End points were defined as hard (myocardial infarction or cardiac death) or total events (myocardial infarction, cardiac death, or late revascularization). Logistic regression analysis evaluated clinical variables, type of stress, exercise treadmill test (ETT), and SPECT as predictors of end points. Perfusion defects were found in 26% of patients (15% reversible, 6% mixed, and 5% fixed). Clinical or ETT variables were not associated with perfusion defect type or with hard events. However, male gender predicted total events (chi-square 3.3; p = 0.01). An abnormal SPECT significantly increased the risk of hard events (chi-square 5.4; p = 0.001) and total events (chi-square 7.4; p = 0.0001). Extensive defects determined the highest risk of total events (chi-square 18.8; p = 0.0001). Event rates increased according to SPECT: 2% of hard events per year and 5% of total events per year in patients with normal SPECT versus 9% per year and 38% per year, respectively, in those with abnormal SPECT. Importantly, a normal SPECT identified a relatively low-risk subgroup of patients. Thus, stress technetium-99m sestamibi SPECT was useful in evaluating asymptomatic diabetics for the presence of CAD, and effectively risk-stratified this population.     

Prognostic value of myocardial perfusion imaging in predicting outcome after renal transplantation

Cardiovascular disease is a significant cause of morbidity and mortality after renal transplantation. Pretransplant screening in a subset of these patients for occult coronary artery disease (CAD) may improve outcome. The objective of this study was to examine the outcome of 600 patients after renal transplantation for end-stage renal disease. Prospective outcome data were collected on 600 consecutive patients who had renal transplantation between 1996 and 1998 at our institution at 42 +/- 12 months after surgery. Stress single-photon emission computed tomographic (SPECT) myocardial perfusion imaging was performed in 174 patients before surgery, 136 (78%) of whom had diabetes mellitus. There were a total of 59 events: 17 cardiac deaths, 14 nonfatal myocardial infarctions, and 28 noncardiac deaths. There were 12 cardiac events and 11 noncardiac deaths among those who had SPECT myocardial perfusion imaging. In a multivariate analysis that included important risk factors, age (p = 0.03 and 0.003, respectively) and diabetes (p = 0.02 and 0.005, respectively) were the predictors of total events and cardiac events in patients who did not undergo stress SPECT perfusion imaging. In the subgroup who had stress perfusion imaging, an abnormal perfusion SPECT study was the only predictor of cardiac events (p = 0.006). The 42-month cardiac event-free survival rate was 97% in patients with normal SPECT images and 85% in patients with abnormal SPECT images (RR 5.04, 95% confidence interval 1.4 to 17.6, p = 0.006). Thus, there is a 2.8% event rate per year after renal transplantation, and approximately 50% of these events are noncardiac. In high-risk patients (most of whom had diabetes) with preoperative stress perfusion imaging, those with normal images had significantly lower cardiac events than those with abnormal images. These results have important implications in patient screening and postoperative management.     

Differences in left ventricular ejection fraction and volumes measured at rest and poststress by gated sestamibi SPECT.

BACKGROUND: Some studies suggested that the poststress left ventricle ejection fraction (LV EF) is lower than rest LV EF in patients with stress-induced ischemia. METHODS AND RESULTS: By using a 2-day protocol and 30 mCi Tc-99m sestamibi, LV EF, end-systolic volume (ESV), and end-diastolic volume (EDV) were measured with gated SPECT. Of 99 eligible patients, 91 had technically adequate studies. Poststress LV EF minus rest LV EF was defined as DeltaLV EF. DeltaEDV and DeltaESV were similarly defined. Rest and poststress LV EF (r = 0.89), EDV (r = 0.78), and ESV (r = 0.93) were highly correlated (P <.001). Rest LV EF, EDV, and ESV were not significantly different between patients with and without stress-induced ischemia. DeltaLV EF was significantly lower in patients with stress-induced ischemia (-3.5% +/- 4.5% vs -1.1% +/- 4.7%, P = .02). Mean LV EF poststress in ischemic patients was 55.0% +/- 10.5% vs 61.2% +/- 10.0% in nonischemic patients (P = .008). However, only 1 patient (3%) with ischemia had DeltaLV EF that exceeded the 95% confidence limit of DeltaLV EF for normal patients. Ischemia was significantly associated with increased DeltaEDV and DeltaESV (P < .01). CONCLUSIONS: Stress-induced ischemia is associated with poststress reduction in LV EF and increased poststress EDV and ESV. However, the effect of ischemia on the difference between poststress and rest EF measurements is modest and rarely exceeds the confidence limits in normal patients undergoing 2-day protocols. In most patients, poststress LV EF is an accurate reflection of rest LV EF.     

Validation of an algorithm for predicting cardiac events in renal transplant candidates

A 2-tiered noninvasive cardiac risk stratification algorithm was first evaluated in a test population with planar thallium myocardial perfusion imaging and subsequently in a validation population using single-photon emission computed tomographic (SPECT) thallium myocardial perfusion imaging. This study examines if SPECT imaging was as predictive of cardiac death as planar imaging and also if SPECT imaging predicted nonfatal cardiac events in the patient population. Renal transplant candidates were evaluated using a 2-tiered noninvasive cardiac risk stratification algorithm. The first tier of risk assessment utilized 5 variables: age >50 years, insulin-dependent diabetes mellitus, abnormal electrocardiogram, and a history of either angina or congestive heart failure. Patients without risk factors were considered low risk and underwent no further cardiac evaluation. Patients with > or =1 risk factor were considered high risk and underwent a second tier of risk assessment with planar (n = 95) or SPECT (n = 112) imaging. In the test population, 13 of 16 cardiac deaths (81%) occurred in high-risk patients with abnormal planar studies. In the validation group, all cardiac deaths (5 of 60) and nonfatal cardiac events (13 of 60) occurred in high-risk patients with abnormal SPECT studies. SPECT imaging was at least as predictive as planar imaging and also predicted nonfatal as well as fatal cardiac events. Pretransplant risk stratification by clinical variables identified low-risk patients who may not require further cardiac evaluation and high-risk patients with normal SPECT imaging who may not require angiography.     

Independent risk factors for progression of coronary atherosclerosis in hemodialysis patients

Not uncommonly, hemodialysis patients with normal results in myocardial perfusion tests can still have a cardiac event within 2 years of evaluation. We examined possible risk factors for progression of coronary atherosclerosis in hemodialysis patients. We prospectively evaluated ability of myocardial perfusion imaging carried out under pharmacologic stress to predict 2-year outcomes in 77 hemodialysis patients, specifically thallium-201 single-photon emission computed tomography (SPECT) using high-dose adenosine triphosphate as the stressor. The primary end-point was a cardiac event (cardiac death, non-fatal acute coronary syndrome, or hospitalization for acute ischemic heart failure). Factors independently influencing duration until a cardiac event in hemodialysis patients were identified using stepwise multiple regression analysis. Myocardial perfusion defects were shown in 36 patients. Patients with a perfusion defect were more likely to have cardiac events than those with normal perfusion (78% vs. 15%, P < 0.001). Time until occurrence of a cardiac event in hemodialysis patients showed a significant, independent association with known coronary artery disease [regression coefficient (RC) = -3.391, P = 0.046], elevated C-reactive protein (RC = -5.813, P = 0.005), and a reversible myocardial perfusion defect (RC = -7.386, P < 0.001). An analysis based on the 'best cut-off' of CRP as identified on the basis of the ROC curve augmented the positive and negative predict value of CRP for the prediction of coronary events to 65 and 74%, respectively. Myocardial perfusion SPECT and measuring the plasma concentration of CRP might be useful for the prediction of hemodialysis patients with progression of coronary atherosclerosis.     

Verification of the left ventricular ejection fraction from gated myocardial perfusion studies (GSPECT)

INTRODUCTION: The perfusion study (which may be obtained using SPECT or GSPECT technology within six hours of administration of the radionuclide Tc-99m-MIBI) reflects the regional blood supply to the left ventricular [LV] myocardium at the time of radionuclide administration (i.e. at rest, at peak exercise, or at peak vasodilatation), while the values of EF, EDV, and ESV measured using GSPECT are parameters of LV contractility at the time of image acquisition (i.e. at rest or in a nearresting state following exercise or vasodilatation). Planar radionuclide ventriculography [RNV] is, however, considered to be the most accurate method for calculating LVEF. AIMS: The main goal of the study was to compare the values of EF obtained by the most frequently used method, GSPECTQGS, and the reference method, RNV - taking into consideration various clinical scenarios (presence or absence of LV dilatation) and various conditions under which GSPECT was recorded (at rest, post-exercise, or post-dipyridamole). METHODS: Two hundred patients (145 males) aged 58+/-11 (18-80) with previously confirmed (n=166, of whom 108 had a history of myocardial infarction) or suspected (n=34) coronary artery disease were included in the study. Ranges of normal values for EF, EDV, and ESV were established based on a group of 26 'normal' subjects. LV dilatation was defined as an EDV >127 ml (at rest, measured by QGS) - this was present in 88 patients. Myocardial perfusion studies were obtained using GSPECT following administration of Tc-99m-MIBI at rest (all patients), as well as one hour after treadmill exercise (138 patients) or dipyridamole administration (48 patients). The resting RNV was conducted within three weeks of the GSPECT exam. The EF values obtained by QGS and RNV were compared for patients with and without LV dilatation. EF, EDV, and ESV values obtained by QGS were compared for resting patients, post-exercise, and post-dipyridamole. RESULTS: 1. The GSPECT EF values calculated using QGS software, at rest or one hour after treadmill exercise or dipyridamole administration, demonstrated, for the study population as a whole, a significant, strong correlation with the results obtained by the reference method, RNV (correlation coefficient, r> or =0.86). The correlation was stronger in patients with LV dilatation than in those without. Both in patients with and without LV dilatation the correlation of EF with RNV was slightly weaker for postexercise (relative to resting) and post-dipyridamole (relative to post-exercise) measurements. 2. QGS tended to underestimate the absolute values of EF, as compared to RNV. 3. In post-exercise and post-dipyridamole measurements, relative to the resting measurements (in patients with previously diagnosed or suspected coronary artery disease) the mean values of EF were lower while EDV and ESV were higher. CONCLUSIONS: In order to complement data on myocardial perfusion, the GSPECT-QGS technique should be optimally used to calculate LV contractility parameters at rest (as opposed to post-exercise or post-dipyridamole), and include a range of normal values for EF, EDV, and ESV, obtained using QGS. Of note, EF measurements by GSPECT are more accurate for dilated than non-dilated ventricles.     

Evidence for left ventricular remodeling after percutaneous coronary intervention: effect of percutaneous coronary intervention on left ventricular ejection fraction and volumes

BACKGROUND: Post-stress ejection fraction (EF), end-diastolic (EDV) and end-systolic (ESV) volumes by gated myocardial perfusion SPECT (MPS) are well validated, reproducible and of prognostic significance. However, little is known about the impact of percutaneous coronary intervention (PCI) on left ventricular volumes and remodeling. METHODS: Thirty-eight patients who underwent MPS before and 6 months after PCI were evaluated. MPS were interpreted deriving summed stress (SSS), rest (SRS) and difference (SDS = SSS-SRS; extent of ischemia) scores. EF, EDV and ESV were generated by QGS trade mark. Pre-PCI MPS were compared to post-PCI MPS. RESULTS: Single vessel disease was present in 63% of patients. PCI of one vessel was performed in 82% of patients. After 6 months, SSS (10.6 +/- 6.3 vs. 2.8 +/- 4.3, p < 0.001) and SDS (8.2 +/- 5.6 vs. 1.4 +/- 2.3, p < 0.001) had improved; however, EF did not change significantly (55 +/- 10 vs. 57 +/- 13, p = ns). Still, EDV (105 +/- 25 ml vs. 96 +/- 25 ml, p = 0.006) and ESV (49 +/- 19 ml vs. 41 +/- 18 ml, p = 0.001) were significantly reduced. CONCLUSION: Results of MPS documented the beneficial effect of PCI on symptoms and extent of ischemia. In addition, the findings showed a significant decrease in ESV and EDV after PCI as compared to pre-PCI findings which points to a positive effect on left ventricular remodeling even in the absence of significant changes in EF.     

Diagnostic value of left ventricular function after stress and at rest in the detection of multivessel coronary artery disease as assessed by electrocardiogram-gated SPECT.

BACKGROUND: Although transient left ventricular (LV) dilation is a well-known marker for extensive coronary artery disease (CAD), few studies have performed quantitative analysis of LV function after stress and at rest to detect extensive CAD. METHODS AND RESULTS: Poststress and resting gated single photon emission computed tomography (SPECT) was performed in 175 patients with suspected CAD. All of the patients underwent coronary angiography within 3 months of gated SPECT. In the 83 patients with multivessel CAD, the summed difference score was greater (9.2 +/- 7.0 vs 3.3 +/- 4.0, P < .0001), the poststress increase in end-systolic volume (ESV) was larger (7.0 +/- 8.0 mL vs -0.8 +/- 4.7 mL, P < .0001), and the poststress increase in ejection fraction (EF) was less (-4.7% +/- 5.4% vs -0.4% +/- 4.5%, P < .0001) than in the 92 patients with insignificant or single-vessel CAD. In the detection of multivessel CAD, a summed difference score of 9 or greater showed a sensitivity of 46% and specificity of 90%, whereas an increase in ESV of 5 mL or greater and a decrease in EF of 5% or greater after exercise had a sensitivity of 66% and 52%, respectively, and specificity of 87% and 83%, respectively. The multivariate discriminant analysis revealed that the combination of poststress increase in ESV, summed difference score, and diabetes mellitus best identified multivessel CAD, with a sensitivity of 72% and specificity of 84% (chi(2), 81.7). CONCLUSIONS: The addition of poststress and at-rest LV functional analysis by use of gated SPECT to conventional perfusion analysis helps to better identify patients with multivessel CAD.     

Effect of sex, age, and weight on ejection fraction and end-systolic volume reference limits in gated myocardial perfusion SPECT.

BACKGROUND: The left-ventricular ejection fraction (EF) and end-systolic volume (ESV) are strong predictors of prognosis for cardiac death. Gated myocardial perfusion single-photon emission computed tomography (gSPECT) may be used to measure ESV and EF. However, systematic differences may exist between referred populations. Our aim was to derive male and female reference limits for left-ventricular functional parameters, and determine the effect of age, weight, and body surface area (BSA). METHODS AND RESULTS: The ejection fraction and ESV were derived using QGS software for 127 patients with normal gSPECT studies. The lower reference limits of EF were 46.2% and 55.6% for men and women, respectively. The upper reference limits of ESV were 30.4 mL and 21.4 mL, and 15.7 mL/m(2) and 11.1 mL/m(2), when indexed to BSA for men and women, respectively. There was no correlation between EF and age, weight, or BSA (P > .05). There was a small decrease in ESV with age, and an increase with weight and BSA (P < .05). The sex-specific differences remained after adjusting for confounding variables. CONCLUSIONS: We demonstrated a significant sex difference for all functional parameters measured, and we established the influence of patient age and weight. Local reference limits for ESV and EF have been established, and the latter are transferable to other departments operating similar protocols.     

Resting echocardiography and quantitative dipyridamole technetium-99m sestamibi tomography in the identification of cardiac allograft vasculopathy and the prediction of long-term prognosis after heart transplantation.

AIMS: To evaluate the accuracy of echocardiography in conjunction with quantitative high-dose dipyridamole technetium-99m sestamibi tomography (SPECT) in detecting coronary allograft vasculopathy. METHODS AND RESULTS: Seventy-eight consecutive heart transplant recipients underwent echocardiography while at rest and high-dose dipyridamole SPECT within 48 h of a yearly angiogram. Resting wall motion abnormalities were considered significant if present in two or more segments. SPECT was considered abnormal in the presence of reversible/fixed defects. The coronary angiogram was normal in 53, showed non-significant coronary allograft vasculopathy in 13 and significant (> or = 50% stenosis) coronary allograft vasculopathy in 12 cases. Resting wall motion abnormalities were observed in nine cases and perfusion defects in 20. Echocardiography and SPECT were concordant in 59 cases (five positive and 54 negative); in these, accuracy was 100% for significant coronary allograft vasculopathy and 83% for any coronary allograft vasculopathy. Over 6.5+/-2 years, 17 patients suffered coronary allograft vasculopathy-related events, including death in six and retransplantation in three. Resting wall motion abnormalities, SPECT perfusion defects and angiographic coronary allograft vasculopathy were significant predictors of cardiac events. CONCLUSION: Normal resting wall motion at echocardiography coupled to normal stress myocardial perfusion, rules out the presence of significant coronary allograft vasculopathy in many heart transplant recipients. Conversely, resting wall motion abnormalities and perfusion defects strongly predict cardiac events. Therefore, a strategy which reserves angiography for patients with resting wall motion abnormalities and/or perfusion defects may be safe and cost-effective.     

Changed diastolic function at rest in patients with perfusion defects in exertion myocardial scintigraphy with TI-201

Myocardial perfusion scintigraphy with TI-201 after exercise allows distinction between areas of scar (irreversible defect) and areas of ischemia (reversible defects). Accordingly 4 major groups of patients can be identified: with normal perfusion pattern (Group I); with reversible ischemia (Group II); with scar of previous myocardial infarction (Group III); with both evidence of scar and ischemia (Group IV). Sixty-nine patients (59 m; 10 f; mean age 55.7 +/- 9 years) with suspected or demonstrated ischemic heart disease underwent stress TI-201 myocardial scintigraphy and on the basis of the scintigraphic results were assigned as follows: 11 to group 1, 14 to group II, 31 to group III and 13 to group IV. In order to investigate the behaviour of ventricular diastolic function in these different subsets, all the patients underwent subsequently a radionuclide angiography at rest (both first pass and equilibrium gated blood pool studies), which allowed the assessment of left ventricular ejection fraction (EF), peak filling rate (PFR)--as expression of diastolic function--and regional wall motion pattern. The values of EF and PFR were significantly reduced (p less than 0.05) in the patients with defects of perfusion (Groups II, III and IV) in comparison to the patients with normal perfusion (Group I); abnormal wall motion was found in 0 (I), 8 (II), 22 (III) and 7 (IV) patients. The diastolic function was more frequently altered (PFR less than 2.5 EDV/sec) than the systolic function (EF less than 50%) or regional wall motion, mainly in patients with reversible scintigraphic defects (prevalence of alterations in the groups II and IV: PFR: 78%, EF: 22%, abnormal wall motion: 56%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Detection of occult left ventricular dysfunction in patients without prior clinical history of myocardial infarction by technetium-99m sestamibi myocardial perfusion gated single-photon emission computed tomography

BACKGROUND: In the absence of a prior history of myocardial infarction (MI), left ventricular (LV) dysfunction is commonly due to hypertension, valvular heart disease, or hibernating myocardium. HYPOTHESIS: Since technetium-99m sestamibi gated single-photon emission computed tomography (SPECT) may be used to determine both stress/rest myocardial perfusion and resting LV function, we attempted to evaluate the ability of gated SPECT imaging to detect occult LV dysfunction. METHODS: We evaluated the ability of this technique to detect occult LV dysfunction among 179 patients without history MI and angiographically documented coronary artery disease (CAD). All patients underwent both gated SPECT and cardiac catheterization within a 6-month time period. Left ventricular volume and ejection fraction (EF) values were determined according to a previously validated technique using Simpson's rule. Normal limit values for LV volumes and EF were derived from a control population of 93 patients with normal coronary angiograms. RESULTS: Based on normal limit-derived criteria, 15% of the CAD study cohort had occult LV dysfunction (> 2 standard deviations below gender-specific normal limit means for LVEF). Mean LV end-diastolic volume index (EDVi) was significantly increased (p < 0.05) and LVEF decreased (p < 0.05) in patients with triple-vessel CAD. End-diastolic volume index was also increased in the cohort of patients with both hypertension and LV hypertrophy (LVH) (p < 0.05). However, multivariate logistic regression analysis revealed that only CAD extent, but not hypertension or LVH, was a significant predictor of occult LV dysfunction (p = 0.009). CONCLUSION: Occult LV dysfunction can be detected in patients with CAD by gating technetium-99m sestamibi SPECT studies, and its presence may signify the presence of extensive CAD.     

高龄患者三磷酸腺苷负荷心肌灌注断层显像的远期预后价值

目的 评价三磷酸腺苷(ATP)负荷~(99m)Tc-甲氧基异丁基异腈(MIBI)心肌灌注断层显像对高龄患者(≥80岁)的远期预后价值.方法 对265例行ATP负荷~(99m)Tc-MIBI心肌灌注断层显像的患者(84.2±3.6)岁,随访(36.7±22.8)个月.观察心脏事件[心源性死亡、非致死性心肌梗死(MI)、不稳定性心绞痛、心力衰竭住院及经皮冠状动脉介入治疗术]和恶性心脏事件(心源性死亡和非致死性MI).结果 根据心肌灌注显像将患者分为固定或混合性缺损组、可逆性减低及缺损组、正常显像组,各组心脏事件发生率为50,0%、31.3%、6.2%(P<0.05),恶性心脏事件发生率分别为27.8%、6.0%、0.7%(P<0.05).Cox多元回归分析显示异常心肌灌注显像是预测高龄患者发生心脏事件和恶性心脏事件的独立危险因子(P<0.05).结论 ATP负荷~(99m)Tc-MIBI心肌灌注断层显像正常的高龄患者预后良好,心肌显像异常患者心脏事件和恶性心脏事件的发生率明显增加,存在固定或混合性缺损的患者预后更差,其检查对于高龄患者心脏事件风险的评估有较高的临床参考价值.