冠状动脉介入治疗对老年女性多支病变的长期临床疗效观察

目的评价老年女性多支冠状动脉病变患者经皮冠状动脉介入治疗(PCI)后的长期临床疗效。方法分析1995年8月～2004年11月行PCI治疗的354例多支病变老年女性(≥65岁)患者和247例非老年女性(<65岁)患者的临床特征、冠状动脉病变特征、围术期并发症和随访期间主要不良心脑血管事件(MACCE)发生率的差异。结果老年组高血压病和脑血管病的比例明显高于非老年组患者(P<0.05)。两组介入治疗的病例成功率、靶病变成功率、手术并发症无显著性差异。老年组成功PCI的332例患者随访12～96个月(56.0±19.0个月),无症状存活276例(83.1%),151例患者复查冠脉造影,24例(15.9%)发生再狭窄,总MACCE率12.7%(42/332);非老年组236例接受随访,无症状存活192例(81.4%),123例患者复查冠脉造影,17例(13.8%)发生再狭窄,总MACCE率11.0%(26/236),与老年组比较无显著性差异。结论PCI治疗老年女性多支病变的成功率高,严重并发症发生率低,长期临床疗效与非老年女性患者相似。     

Gated Tc-99m sestamibi SPECT versus stress-rest SPECT in detecting coronary artery disease: correlation with coronary angiography in patients without myocardial infarction

PURPOSE: It is possible to simultaneously evaluate wall thickening and perfusion abnormalities with radionuclide techniques that use tracers such as Tc-99m MIBI. We presumed that detection of wall thickening by gated MIBI SPECT imaging in the presence of a stress-induced perfusion defect correlates with reversibility of that defect on resting images. Therefore, the aim of our study was to analyze, in patients without myocardial infarction, resting wall thickening and stress perfusion imaging as an alternative to conventional stress-rest imaging. METHODS AND RESULTS: The patients (n = 44) underwent an exercise (n = 37) or pharmacologic (n = 7) stress protocol. All patients had previous coronary angiography within 3 months. Stress-rest MIBI SPECT and gated MIBI SPECT studies were analyzed by visual scoring. The sensitivity and specificity of segmental analysis of both stress-rest MIBI SPECT perfusion and gated MIBI SPECT studies for the overall detection of coronary artery disease were, respectively, 71% and 96%. For patient evaluation for detection of coronary artery disease, stress-rest MIBI SPECT perfusion and gated MIBI SPECT studies showed a sensitivity rate of 96% for both and specificity rates of 84% and 79%, respectively. CONCLUSIONS: Our data revealed close agreement between reversible perfusion defects on stress-rest MIBI SPECT scans and significant wall thickening on gated MIBI SPECT stress images in patients without previous myocardial infarction (95%). Gated MIBI SPECT stress, without resting studies, which provide an assessment of wall motion and wall thickening, potentially allows stress defect reversibility to be evaluated in patients without previous myocardial infarction.     

药物洗脱支架治疗老年女性多支冠脉病变的临床研究

目的探讨药物洗脱支架(DES)治疗老年女性多支冠状动脉病变的疗效及安全性。方法2002年10月～2005年6月经冠脉造影证实为多支冠状动脉病变老年(≥65岁)女性患者387例,均行经皮冠状动脉介入治疗(PCI),其中DES组139例,普通金属支架(BMS)组248例。比较两组支架术后近期及远期的临床疗效。结果DES组糖尿病患者的比例明显高于BMS组(42.4%vs29.8%,P<0.05)。两组高血压病和心功能不全的比例、冠状动脉病变的严重程度、PCI成功率及并发症发生率均无统计学差异。对371例患者随访6～36个月(20.8±12.6个月),DES组和BMS组造影随访率分别为53.7%和56.1%,无明显差异(P>0.05),但DES组复查造影再狭窄率和主要不良心脏事件(MACE)发生率均明显低于BMS组(分别为4.2%vs15.8%和7.5%vs17.3%,P<0.05)。结论老年女性多支病变患者应用多枚DES的成功率高,严重并发症少,术后再狭窄率低,长期临床疗效良好。     

Stress/rest myocardial perfusion scintigraphy in patients without significant coronary artery disease

Aim  

To define the prognostic impact of stress myocardial perfusion scintigraphy (MPS) in patients with angiographic exclusion of significant coronary artery disease.     

MR-based coronary artery blood velocity measurements in patients without coronary artery disease

To evaluate the feasibility of MR-based coronary blood velocity measurements (MRvenc) in patients without coronary artery disease (CAD). Eighty-three patients with angiographically excluded CAD received MRvenc of the proximal segments of both coronary arteries (CAs). Using a retrospectively ECG-gated breath-hold phase-contrast FLASH sequence with high temporal resolution, flow data were technically acquirable in 137/166 (83%) CAs. Quantification and analysis of blood velocities in systole and diastole of both CAs were performed. Biphasic velocity profiles were found in 83/100 CAs. Median systolic and diastolic velocities differed significantly in LCA (19 cm/s, 24 cm/s; P<0.0001) and RCAs (14 cm/s, 16 cm/s; P<0.01). The diastolic/systolic velocity ratio was calculated in LCAs and RCAs with a median of 1.3 and 1.1, respectively. The velocity profiles of the remaining CAs were monophasic (17 CAs) or revealed severe alterations of the physiologic velocity profile with reduced flow undulations and steady velocities (37 CAs). Optimized clinical MRvenc is feasible to quantify blood velocities in the CAs. Potential indications are (1) non-invasive monitoring of patients after aortic valve reconstruction as well as (2) detection of asymptomatic CAD patients.     

Determination of extent and location of coronary artery disease in patients without prior myocardial infarction by thallium-201 tomography with pharmacologic stress.

Seventy-six patients undergoing pharmacologic stress 201TI tomography and coronary angiography within 14 +/- 12 days were studied to determine how well coronary artery disease extent and location could be determined by this scintigraphic technique. No patient had prior myocardial infarction or revascularization. Scintigrams were scored visually and quantitatively. Angiographic lesions > or = 50% were considered significant. Receiver operating characteristic curves were generated for the scintigrams against the angiographic gold standard. Predictive accuracies were determined and compared with the quantitative results. Predictive accuracy was 0.49 for visual and 0.58 for computer identification of single-vessel disease, 0.52 for both visual and computer identification of multivessel disease, 0.64 for both in correctly localizing left anterior descending artery disease, 0.78 versus 0.70 for the right coronary artery and 0.72 versus 0.68 for the left circumflex artery. For the overall detection of disease, the predictive accuracies were 0.79 and 0.80. Although high diagnostic accuracy for detection of coronary artery disease by this approach has been previously documented, the assessment of extent of disease in patients without prior myocardial infarction appears limited.     

Imaging of myocardial sympathetic innervation with metaiodobenzylguanidine

The sympathetic nervous system has profound influences on myocardial function and pathophysiology. The heart is densely innervated with sympathetic nerves, which are distributed on a regional basis. Heterogeneity of myocardial sympathetic innervation, or autonomic imbalance, has long been hypothesized as a major mechanism underlying sudden cardiac death. Only in the past few years has it been possible to evaluate abnormalities in heart innervation in the intact animal. Recent developments in cardiac imaging have lead to the ability to map the distribution of the sympathetic nerves in vivo, with radiolabeled metaiodobenzylguanidine. As a result, pathophysiologic mechanisms that relate alterations in sympathetic nerve activity to disease processes are now being explored.     

Myocardial sympathetic innervation, function, and oxidative metabolism in non-infarcted myocardium in patients with prior myocardial infarction

Objective

The purpose of this study was to investigate the relationship between sympathetic innervation, contractile function, and the oxidative metabolism of the non-infarcted myocardium in patients with prior myocardial infarction.

Methods

In 19 patients (14 men, 5 women, 65 ± 9 years) after prior myocardial infarction, sympathetic innervation was assessed by ¹¹C-hydroxyephedrine (HED) positron emission tomography (PET). Oxidative metabolism was quantified using ¹¹C-acetate PET. Left ventricular systolic function was measured by echocardiography with speckle tracking technique.

Results

The ¹¹C-HED retention was positively correlated with left ventricular ejection fraction (LVEF) (r = 0.566, P < 0.05), and negatively with peak longitudinal strain in systole in the non-infarcted myocardium (r = ?0.561, P < 0.05). Kmono, as an index of oxidative metabolism, was significantly correlated with rate pressure product (r = 0.649, P < 0.01), but not with ¹¹C-HED retention (r = 0.188, P = 0.442). Furthermore, there was no significant correlation between Kmono and LVEF (r = 0.106, P = 0.666) or peak longitudinal strain in systole (r = ?0.256, P = 0.291) in the non-infarcted myocardium. When the patients were divided into two groups based on the median value of left ventricular end-systolic volume index (LVESVI) (41 mL), there were no significant differences in age, sex, and rate pressure product between the groups. However, the large LVESVI group (>41 mL) was associated with reduced ¹¹C-HED retention and peak longitudinal strain in systole, whereas Kmono was similar between the groups.

Conclusions

This study indicates that remodeled LV after myocardial infarction is associated with impaired sympathetic innervation and function even in the non-infarcted myocardial tissue. Furthermore, oxidative metabolism in the non-infarcted myocardium seems to be operated by normal regulatory mechanisms rather than pre-synaptic sympathetic neuronal function.     

Acetazolamide induced myocardial ischemia in patients with severe coronary artery disease

Acetazolamide (ACZ)-augmented brain SPECT is commonly used for evaluating cerebral vascular reserve in patients with cerebrovascular disease. ACZ may cause myocardial ischemia in patients with coronary artery disease. To evaluate the risk of induction of myocardial ischemia with ACZ-augmented myocardial SPECT, we performed combined ACZ-augmented Tl-201 myocardial SPECT (ACZ-myo SPECT) with Tc-99m HMPAO brain SPECT in patients with severe coronary artery disease.Methods: Nine patients underwent combined ACZ-myo SPECT with Tc-99m HMPAO brain SPECT. (1) For qualitative analysis, SPECT images were divided into 13 segments to calculate the total defect scores. (2) Six ROIs were placed on the slices in the myocardial SPECT short-axis images and the regional uptake ratio was obtained as the ratio of the mean counts in the myocardium to the maximal count in the slice. The total defect score and regional uptake ratio of ACZ-myo SPECT were compared with those of early and delayed dipyridamole T1-201 myocardial SPECT (DP-T1 SPECT) images.Results: (1) In the 21 coronary artery territories with coronary stenosis ≧ 75%, the total defect score in ACZ-myo SPECT, early and delayed DP-T1 SPECT images were 3.52 ± 4.14*, 4.19 ± 4.65* and 2.25 ± 3.34, respectively (*: p < 0.05 vs. delayed DP-Tl SPECT images). (2) In 44 of 54 ROIs with coronary stenosis ≧75%, the regional uptake ratio of ACZ-myo SPECT, early and delayed DP-Tl SPECT images were 0.670 ± 0.166**, 0.677 ± 0.194**, 0.721 ± 0.178, respectively (**: p < 0.01 vs. delayed DP-Tl SPECT images). Systolic blood pressure fell at 11 min after ACZ infusion without electrocardiographic ST-T changes or chest pain.Conclusion: As ACZ has the potential to cause myocardial ischemia, ACZ-augmented brain SPECT should be performed with caution in patients with severe coronary artery disease associated with cerebrovascular disease.     

Rest perfusion defects in patients with no history of myocardial infarction predict the presence of a critical coronary artery stenosis

BACKGROUND: The rest/stress sequence in myocardial perfusion single photon emission computed tomography (SPECT) (MPS) permits evaluation of rest images before stress testing, allowing the identification of unexpected perfusion defects (PDs). We sought to study the angiographic correlates of these resting PDs. METHODS AND RESULTS: This study comprised 139 consecutive patients with no history of myocardial infarction referred for MPS whose stress test was canceled because of the observation of unexpected resting PDs (rest group). Of these, 60 patients (43.2%) were referred for angiography after MPS (6.0 +/- 11.5 days). Angiographic referral rates and results were compared with those of a diagnostic population (n = 3565) who demonstrated stress-induced PDs (stress group) on rest/stress MPS. The mean age in the rest group was 73 +/- 12.5 years, and 73% were men. The frequency of referral for angiography was higher in the rest group (43.2% vs 19.8%, P <.0001). In addition, the rest group more frequently had significant coronary artery disease (CAD) (>/=70%) (95% vs 80%, P =.008) and critical CAD (>/=90%) (80% vs 66%, P =.038). CONCLUSION: The rest/stress sequence for MPS enables the identification of patients with unexpected resting PD, usually resulting from critical CAD, in whom unnecessary stress testing can be avoided.     

Predictive value of dipyridamole thallium imaging in a patient with myocardial bridging but without fixed obstructive coronary artery disease.

Both dipyridamole and exercise-201Tl imaging are sensitive, specific and of prognostic value in patients with suspected coronary artery disease, following myocardial infarction, and undergoing major noncardiac surgery. Though reported sensitivities and specificities vary widely from 60% to 100%, the consensus is that both are between 80% and 90% for both dipyridamole and exercise studies (23). Moreover, when compared directly in the same study populations, the two have equal sensitivities and specificities (9,11,13,23). Transient thallium perfusion abnormalities are the most consistent predictors of adverse cardiac events and have more predictive power than clinical and angiographic parameters. Thallium reversibility may be a better predictor of adverse cardiac events than angiography since it represents more of a physiologic rather than a purely anatomic evaluation of the heart. It is difficult to make an exact comparison of some of the studies in the literature because they use different patient populations, sometimes define coronary stenosis in different ways, may have different cardiac endpoints and may not differentiate between reversible and fixed thallium perfusion defects. Exercise has the advantage of a graded examination and more experience historically and is of importance in a detailed study of cardiopulmonary hemodynamics, as in cardiac transplantation. Dipyridamole is more useful in patients who cannot achieve symptom-limited, submaximal exercise. It may also be more useful for patients who are bedridden or have peripheral vascular disease. Angina occurs less frequently with dipyridamole.(ABSTRACT TRUNCATED AT 250 WORDS)     

Regional heterogeneity in cardiac sympathetic innervation in acute myocardial infarction: relationship with myocardial oedema on magnetic resonance

Purpose

To assess the relationships between myocardial structure and function on cardiac magnetic resonance (CMR) imaging and sympathetic tone on ¹²³I-metaiodobenzylguanidine (¹²³I-MIBG) scintigraphy early after myocardial infarction (MI).

Methods

Ten patients underwent ¹²³I-MIBG and ^99mTc-tetrofosmin rest cadmium zinc telluride scintigraphy 4?±?1 days after MI. The segmental left ventricular (LV) relative radiotracer uptake of both ^99mTc-tetrofosmin and early ¹²³I-MIBG was calculated. The day after scintigraphy, on CMR imaging, the extent of ischaemia-related oedema and of myocardial fibrosis (late gadolinium enhancement, LGE) was assessed. Accordingly, the extent of oedema and LGE was evaluated for each segment and segmental wall thickening determined. Based on LGE distribution, LV segments were categorized as "infarcted" (56 segments), "adjacent" (66 segments) or "remote" (48 segments).

Results

Infarcted segments showed a more depressed systolic wall thickening and greater extent of oedema than adjacent segments (p?<?0.001) and remote segments (p?<?0.001). Interestingly, while uptake of ^99mTc-tetrofosmin was significantly depressed only in infarcted segments (p?<?0.001 vs. both adjacent and remote segments), uptake of ¹²³I-MIBG was impaired not only in infarcted segments (p?<?0.001 vs. remote) but also in adjacent segments (p?=?0.024 vs. remote segments). At the regional level, after correction for ^99mTc-tetrofosmin and LGE distribution, segmental ¹²³I-MIBG uptake (p?<?0.001) remained an independent predictor of ischaemia-related oedema.

Conclusion

After acute MI the regional impairment of sympathetic tone extends beyond the area of altered myocardial perfusion and is associated with myocardial oedema.     

Intracoronary myocardial perfusion imaging: patterns in patients with coronary artery disease

Myocardial imaging following the intracoronary injection of radiolabeled particles is used to identify transmural scars in patients being evaluated for coronary atherosclerosis. Selective imaging of the microcirculation derived from each major coronary vessel is accomplished using a dual radionuclide technique. This report illustrates the various normal and abnormal imaging patterns encountered in patients with coronary artery disease. The regional myocardial nomenclature proposed by the American Heart Association Council on Cardiovascular Surgery is used. Correlation of the nuclear study with the contrast arteriogram and ventriculogram is essential for identifying both transmural scars and regions of collateral circulation. The procedure is safe and can be performed during routine coronary angiography.     

Scintigraphic assessment of regional cardiac sympathetic nervous system in patients with single-vessel coronary artery disease

In coronary artery disease, the cardiac sympathetic nervous system is closely associated with myocardial ischemia. I-123 metaiodobenzylguanidine (MIBG) imaging allows us to assess the cardiac sympathetic nervous system regionally. One-hundred and eleven patients with single-vessel disease underwent regional quantitative analysis of MIBG imaging before successful percutaneous transluminal coronary angioplasty (PTCA), and repeat angiography 6 months after PTCA. Based on the results of the follow-up left ventriculogram, patients were divided into 3 groups: 39 angina pectoris (AP), 48 prior myocardial infarction without asynergy (MI without asynergy) and 24 prior myocardial infarction with asynergy (MI with asynergy). AP and MI without asynergy had significant correlations between uptake parameters and regional washout in the territory of diseased vessels, among which the severity score in AP was the most closely correlated with regional washout (r = 0.79, p < 0.0001). These correlations disappeared in MI with asynergy. To compare regional MIBG parameters in the territory of the diseased vessel as well as in the territories of the other major coronary arteries among the 3 groups, we examined MIBG parameters in 57 patients with left anterior descending artery (LAD) disease selected from among the study patients. Regional washout in the territory of the LAD was significantly higher in the MI without asynergy group than in the other two groups. The left circumflex artery (LCX) region showed significantly reduced MIBG uptake and an increased extent score in the MI with asynergy group compared with the AP group, although only a difference in the extent score existed between the MI with asynergy group and the AP group in the right coronary artery (RCA) region. In addition, the global ejection fraction before PTCA showed a significant negative correlation with each regional washout rate. In this way, regional quantitative analysis of MIBG imaging can detect the regional differences in the cardiac sympathetic nervous system in coronary artery disease, which may be associated with the degree of regional left ventricular dysfunction due to myocardial ischemia.     

不同介入治疗策略对急性ST段抬高性心肌梗死合并 多支病变患者长期预后影响

目的比较急性ST段抬高型心肌梗死(STEMI)患者行不完全血运重建与完全血运重建临床预后情况。方法回顾性分析自2010年1月至2015年8月经北部战区总医院急诊绿色通道行经皮冠状动脉介入治疗(PCI)治疗的1 897例STEMI合并多支冠状动脉血管病变(MVD)患者的临床资料。按PCI策略将所有患者分为不完全血运重建组(n=1 538)与完全血运重建组(n=359)。主要观察终点为术后2年内的主要心脑血管不良事件(MACCE),次要终点为1年和2年净不良临床事件。结果不完全血运重建组术后1年MACCE发生率为6.8%(104/1 538),高于完全血运组的3.9%(14/359),两组比较,差异有统计学意义(P<0.05);不完全血运重建组术后2年MACCE发生率为9.0%(139/1 538)、全因死亡发生率为5.7%(88/1 538),高于完全血运组的5.6%(20/359)、3.1%(11/359),两组比较,差异均有统计学意义(P<0.05)。结论对于合并MVD的急诊STEMI患者,住院期间内完全血运重建策略可以显著改善其远期临床预后,降低死亡风险。     

Effects of carvedilol on myocardial sympathetic innervation in patients with chronic heart failure.

Carvedilol is a beta-blocking agent with antioxidant properties that has been shown to improve survival in chronic heart failure (CHF). Previous open-label studies have suggested that its use may have positive effects on the abnormalities of cardiac sympathetic innervation integrity and functioning. The present study aimed to test the hypothesis that carvedilol exerts its beneficial effects on hemodynamics in parallel with an action on myocardial sympathetic activity and with its antioxidant property. METHODS: A randomized, multicenter, double-blind, placebo-controlled study of carvedilol was conducted on 64 CHF patients. Patients underwent-before and after 6 mo of therapy with either carvedilol or placebo-measurements of cardiac sympathetic activity, circulating catecholamine level, and hemodynamic indices. Myocardial meta-(123)I-iodobenzylguanidine ((123)I-MIBG) uptake was used to assess the changes in myocardial sympathetic activity. The antioxidant properties of the plasma were assessed by measuring the percentage of nonhemolyzed erythrocytes and the volume of plasma capable of inhibiting 50% of hemolysis after an oxidative stress. Echographic left ventricular (LV) diameters, radionuclide LV ejection fraction (LVEF), and exercise cardiopulmonary capacity were measured to evaluate the hemodynamic response. RESULTS: End-diastolic and end-systolic LV diameters decreased (both P < 0.05) and LVEF increased (P = 0.03) in the carvedilol group, whereas these parameters remained unchanged in the placebo group. Carvedilol did not alter the submaximal exercise cardiopulmonary capacity or the circulating catecholamine level. The beneficial hemodynamic effects in the carvedilol group were associated with an increase in myocardial (123)I-MIBG uptake as assessed by both planar and tomographic imaging (P < 0.01). Carvedilol had no detectable effect on antioxidant properties of the plasma. CONCLUSION: The benefits of carvedilol on resting hemodynamics appear to be associated with a partial recovery of cardiac adrenergic innervation functioning without detectable antioxidant effect in the plasma.     

Mental stress-induced myocardial ischemia in coronary artery disease patients with left ventricular dysfunction

Background  Reduced left ventricular ejection fraction (LVEF) is a risk factor for poor outcomes in patients with coronary artery disease (CAD). Mental stress-induced myocardial ischemia (MSIMI) also identifies a subset of CAD patients at increased risk for future cardiovascular events. Susceptibility to MSIMI in patients with CAD and reduced LVEF is unknown. Methods and Results  We enrolled 182 patients (67 women) with a mean age of 64 years and a documented history of CAD in this study. Baseline resting ejection fraction was determined by use of technetium 99m sestamibi gated single photon emission computed tomography. Abnormal LVEF was defined as less than 45% for men and less than 50% for women (based on published norms for our software [Cedars-Sinai Medical Center]). All participants underwent mental stress testing with a public speaking task. Rest/stress myocardial perfusion single photon emission computed tomography was performed via conventional methodology. Images were visually compared for number and severity of perfusion defects by use of a scoring method from 0 to 4. A summed difference score was calculated as the difference between summed stress and rest scores. A score of greater than 3 was considered abnormal. MSIMI developed in 19% of patients with normal LVEF and 31% of those with reduced LVEF. There is no statistically significant difference between the two groups (P=.11). Conclusions  CAD patients with left ventricular dysfunction are equally susceptible to MSIMI as those with normal LVEF. This study was supported by grants HL 070265 and HL 072059 from the National Heart. Lung, and Blood Institute. This material is also the result of work supported by resources and with the use of facilities at the Department of Veterans. Affairs Medical Center, Gainesville, Fla.