Preoperative evaluation of patients with peripheral vascular disease

Coronary artery disease is the leading cause of death after revascularization procedures for abdominal aortic aneurysms and peripheral vascular disease. Late survival after vascular procedures is substantially reduced, largely by the high incidence of subsequent cardiac events. At the Lahey Clinic, it is not our practice to perform routine coronary angiography before elective revascularization. Thallium myocardial perfusion imaging should be performed in all patients before operation. Abnormal results on thallium exercise scanning showing multiple perfusion abnormalities or lung uptake at peak exercise identify patients who are candidates for preoperative cardiac catheterization. When severe correctable coronary artery disease is identified, these patients should be considered for coronary artery bypass surgery before vascular operation.     

腺苷负荷试验心肌灌注显像诊断冠心病的临床价值

目的　评价腺苷负荷试验心肌灌注显像诊断冠心病的准确性。方法　对 89例临床疑诊冠心病患者 ,分别静脉注射腺苷 ,剂量为 14 0 μg·kg-1·min-1,用药时间 6min(总剂量为 0 8mg/kg) ,注射过程中 ,行心电监测 ,观察患者的症状、血压和心率 ,于注射腺苷 3min末 ,静脉注射核素显像剂99mTc MIBI 92 5MBq ,1h后行心肌灌注断层显像 ,若显像异常 ,次日行静息心肌显像。所有患者行冠状动脉造影。结果　在 89例患者中 ,31例冠状动脉造影显示明显的冠状动脉狭窄病变 ,其中单支病变 10例 ,二支病变 11例 ,三支病变 10例。累及左前降支 2 8支 ,左回旋支 18支 ,右冠状动脉 16支 ,左主干 2支。腺苷负荷试验心肌灌注显像诊断冠心病的敏感性为 71%、特异性为 91%、阳性预测值81%、阴性预测值 84 %、准确性为 84 %。诊断单支、二支和三支冠状动脉病变患者的敏感性分别为5 0 %、73%、90 %。腺苷负荷试验心肌灌注显像判断血管病变的敏感性 77%、特异性 96 %、准确性 92 %。结论　腺苷负荷心肌灌注显像诊断冠心病敏感性及特异性均较高 ,具有重要的临床应用价值。     

Economics of myocardial perfusion imaging in Europe--the EMPIRE Study.

BACKGROUND: Physicians use myocardial perfusion imaging to a variable extent in patients presenting with possible coronary artery disease. There are few clinical data on the most cost-effective strategy although computer models predict that routine use of myocardial perfusion imaging is cost-effective. OBJECTIVES: To measure the cost-effectiveness of four diagnostic strategies in patients newly presenting with possible coronary artery disease, and to compare cost-effectiveness in centres that routinely use myocardial perfusion imaging with those that do not. METHODS: We have studied 396 patients presenting to eight hospitals for the diagnosis of coronary artery disease. The hospitals were regular users or non-users of myocardial perfusion imaging with one of each in four countries (France, Germany, Italy, United Kingdom). Information was gathered retrospectively on presentation, investigations, complications, and clinical management, and patients were followed-up for 2 years in order to assess outcome. Pre- and post-test probabilities of coronary artery disease were computed for diagnostic tests and each test was also assigned as diagnostic or part of management. Diagnostic strategies defined were: 1: Exercise electrocardiogram/coronary angiography, 2: exercise electrocardiogram/myocardial perfusion imaging/coronary angiography, 3: myocardial perfusion imaging/coronary angiography, 4: coronary angiography. Primary outcome measures were the cost and accuracy of diagnosis, the cost of subsequent management, and clinical outcome. Secondary measures included prognostic power, normal angiography rate, and rate of angiography not followed by revascularization. RESULTS: Mean diagnostic costs per patient were: strategy 1: 490 Pounds, 2: 409 Pounds, 3: 460 Pounds, 4: 1253 Pounds (P < 0.0001). Myocardial perfusion imaging users: 529 Pounds, non-users 667 Pounds (P = 0.006). Mean probability of the presence of coronary artery disease when the final clinical diagnosis was coronary artery disease present were, strategy 1: 0.85, 2: 0.82, 3: 0.97, 4: 1.0 (P < 0.0001), users 0.93, non-users 0.88 (P = 0.02), and when coronary artery disease was absent, 1: 0.26, 2: 0.22, 3: 0.16, 4: 0.0 (P < 0.0001), users 0.21, non-users 0.20 (P = ns). Total 2-year costs (coronary artery disease present/absent) were: strategy 1: 4453 Pounds/710 Pounds, 2: 3842 Pounds/478 Pounds, 3: 3768 Pounds/574 Pounds, 4: 5599 Pounds/1475 Pounds (P < 0.05/0.0001), users: 5563 Pounds/623 Pounds, non-users: 5428 Pounds/916 Pounds (P = ns/0.001). Prognostic power at diagnosis was higher (P < 0.0001) and normal coronary angiography rate lower (P = 0.07) in the scintigraphic centres and strategies. Numbers of soft and hard cardiac events over 2 years and final symptomatic status did not differ between strategy or centre. CONCLUSION: Investigative strategies using myocardial perfusion imaging are cheaper and equally effective when compared with strategies that do not use myocardial perfusion imaging, both for cost of diagnosis and for overall 2 year management costs. Two year patient outcome is the same.     

Interest in myocardial scintigraphy following the arterial switch procedure for transposition of the great vessels]

Coronary artery obstruction is the main late complication of the so-called arterial switch operation designed to repair transpositions of the great arteries in newborn infants by switching the great vessels and transferring the coronary ostia onto the posterior vessel. Our aim was to study the links between myocardial perfusion and coronary artery anatomy after the arterial switch operation. Forty-five patients (5.863 years) underwent a 201Tl myocardial SPECT and a selective coronary artery angiography. The latter was normal in 20 children: 13 had also a normal myocardial scan but 7 had myocardial perfusion defects including 2 with angina who had a very low coronary reserve at positron emission tomography. Twenty-five patients had severe coronary artery lesions: 5 with a normal myocardial scan and 20 with perfusion defects. Twelve out of these 20 underwent surgical revascularization and the SPECT images went back to normal in all within 6 months after surgery. Specificity and sensitivity of myocardial SPECT in detecting coronary artery lesions were 78% and 69% whereas positive and negative predictive values were 74 and 73%. We conclude that myocardial SPECT imaging is not the right way to detect late post arterial switch coronary artery lesions. It is helpful in decision making as to submit these children to surgical revascularization and in assessing its postoperative effectiveness.     

Assessment of myocardial perfusion with thallium-201 scintigraphy in exercise-induced left bundle branch block: diagnostic value and clinical significance.

Myocardial perfusion scintigraphy with thallium-201 was performed in 33 subjects (mean age 45 years, range 28-61) with exercise-induced, rate-dependent left bundle branch block (LBBB) in order to assess both the value of Thallium-201 myocardial imaging for the diagnosis of coronary artery disease (CAD) and the pathogenesis (ischaemic or not) of the conduction defect. Of the 33 patients evaluated, 16 had chest pain suggestive of CAD and 17 were asymptomatic. None had a history of prior myocardial infarction or clinical and echocardiographic signs of heart disease. LBBB appeared at a heart rate ranging from 70 to 160 b.min-1. Eighteen patients showed repolarization abnormalities (ST segment depression with deep inverted T waves) compatible with ischaemia, after QRS normalization. Thallium-201 myocardial uptake was normal in 12 subjects; in the remaining 21, reversible Thallium-201 defects were demonstrated in the septum (18 patients), septum and apex (2), and septum and infero-apical wall (1). No patient had irreversible defects and all had normal coronary angiography, with negative ergonovine tests for coronary artery spasm. The patients were followed up for a mean of 43 months (range 16-80). One patient died from sudden death, but no cardiac event occurred in the other patients. In conclusion, exercise Thallium-201 myocardial scintigraphy showed a high prevalence (64%) of reversible perfusion defects in a group of patients with exercise-induced LBBB without any evidence of CAD at angiography or coronary spasm at ergonovine test. Moreover, follow-up showed a relatively low rate of major cardiac events.     

Success, safety, and efficacy of implantation of diamond-like carbon-coated stents

The aim of this study was to evaluate safety and clinically defined efficacy of the implantation of a new stent coated with diamond-like carbon (DLC stent), in a group of patients who underwent percutaneous transluminal coronary revascularization procedures in two hemodynamic centers. This study was an observational prospective nonrandomized study that included 196 patients with a total of 236 significant de novo atheromatous coronary lesions, in which 245 DLC stents were implanted. The primary end point of this study was a composite of major cardiovascular events (death or acute myocardial infarction with or without Q) and need for target lesion revascularization (TLR) or target vessel revascularization (TVR) procedure during the first 48 hours and at 6 months after the DLC stent implantation. All patients had a myocardial perfusion imaging study with Tl(201) at 6 months after DLC stent implantation. Only patients with a myocardial perfusion imaging study indicative of myocardial ischemia were then submitted for a new coronary angiogram. No major cardiovascular event or emergency TVR occurred during hospitalization. At 6-month follow-up no major cardiovascular event occurred either, whereas the rate for TLR was 5.6% and that for TVR was 7.65%. This preliminary study provides enough clinical evidence that implantation of intracoronary bare metal stents coated with diamond-like carbon is associated with high success rates, safety, and efficacy, both in the hospital and at the 6-month follow-up after the interventional procedure.     

Outcome of patients with adenosine-induced ST-segment depression but with normal perfusion on tomographic imaging

Most patients with ST depression during adenosine infusion have reversible perfusion defects by single-photon emission computed tomographic (SPECT) perfusion images. Occasionally ST depression is observed in the setting of normal perfusion images. The outcome of such patients is controversial. We identified 65 patients who underwent gated SPECT perfusion imaging with adenosine as the stress agent. These patients were selected based on the following criteria: none had previous myocardial infarction or coronary revascularization, all were in sinus rhythm, and none had left bundle branch block. The 65 patients had normal SPECT images but ischemic ST response (>or=1 mm ST depression). There were 52 women and 13 men who were 66 +/- 13 years of age. History of diabetes mellitus was present in 16 patients (25%) and hypertension in 48 patients (74%). At a mean follow-up of 24 months, there were no cardiac deaths or myocardial infarctions, and there were 6 coronary revascularization procedures (2 coronary artery bypass graftings and 4 coronary stentings of 1-vessel coronary disease). One patient died of cancer. In conclusion, patients with no previous myocardial infarction or coronary revascularization who have normal SPECT images have a benign outcome despite the presence of ST depression (0% for death or myocardial infarction and 4.6%/year for coronary revascularization). Balanced ischemia could not be a common cause for discordant perfusion and ST response.     

冠状动脉造影正常的心肌梗塞患者核素心肌灌注显像

目的 :分析冠状动脉造影正常的心肌梗塞患者核素心肌灌注显像表现。　　方法 :回顾总结了 18例冠状动脉造影正常的心肌梗塞患者 99m锝 -甲氧基异丁基异腈 (99m Tc- MIBI)静息心肌断层显像。　　结果 :18例心肌梗塞患者心肌灌注显像均显示异常 ,12例有节段性缺损 ,6例未见缺损但可见心肌节段性稀疏。心肌灌注显像对心肌梗塞的定位与心电图 Q波比较 ,显示病变部位更明确。　　结论 :心肌灌注显像提供了冠状动脉造影正常的心肌梗塞患者心肌损伤部位及程度。     

Ischemic heart disease: value of MR techniques

Background. The cardiovascular applications of magnetic resonance (MR) techniques in coronary artery disease have increased considerably in recent years. Technical advantages of MR imaging are the excellent spatial resolution, the characterization of myocardial tissue, and the potential for three-dimensional imaging. These characteristics allow the accurate assessment of left ventricular mass and volume, the differentiation of infarcted from normal tissue, and the determination of systolic wall thickening and regional wall motion abnormalities. Methods. In addition to the conventionally used spin-echo and cine-echo techniques, newer techniques such as myocardial tagging, ultrafast MR imaging and MR coronary angiography have been developed. These newer techniques allow a more accurate assessment of ventricular function (tagging), myocardial perfusion (ultrafast imaging), and evaluation of stenosis severity (MR coronary angiography). Particularly early detection and flow assessment of stenosed coronary arteries and bypasses by MR angiography would constitute a major breakthrough in cardiovascular MR imaging. Apart from the MR imaging techniques, cardiac metabolism may be well assessed using MR spectroscopy. This provides unique information on the metabolic behaviour of the myocardium under conditions stress-induced ischemia. However, the definite niche of cardiac MR spectroscopy has still to be settled. Conclusion. Currently, MR techniques allow the evaluation of anatomy and function (accepted use), perfusion and viability (development phase), and coronary angiography (experimental phase). A particular strength of MR imaging is that one single MR test may encompass cardiac anatomy, perfusion, function, metabolism and coronary angiography. The replacement of multiple diagnostic tests with one MR test may have major effects on cardiovascular healthcare economics and would outweigh the cost inherent to the MR angiography procedure.     

Relationship between cardiac symptoms, myocardial perfusion defects and coronary angiography findings in systemic lupus erythematosus

Coronary angiography is generally regarded as the 'gold standard' test for diagnosing coronary artery disease (CAD). We sought to determine the relationship between cardiac symptoms and findings of coronary angiography and myocardial perfusion scintigraphy (MPS) in patients with systemic lupus erythematosus (SLE). Medical records of all SLE patients who underwent coronary angiography while attending our clinic over 24 years were reviewed, noting the indication for the test and its findings. Among patients who had MPS within 6 months prior to coronary angiography, a contingency table was used to rate the agreement between the two tests. Among the 35 patients who underwent coronary angiography, 31 had the test to investigate cardiac symptoms. Among the symptomatic patients, 17 (55%) had an abnormal angiogram with one or more plaques, while 14 (45%) had normal angiograms. All four asymptomatic patients had normal angiograms. Compared to those with normal angiograms, patients with abnormal angiograms had a higher mean number of cardiovascular risk factors per patient (1.6?±?1.4 vs. 0.6?±?1.0, p?=?0.02). Twenty-four patients had both angiography and MPS. Overall, the agreement between angiography and MPS was poor (κ?=?0, p?=?0.0008), with 14 (58.3%) patients having perfusion defects and normal angiograms. A proportion of SLE patients with cardiac symptoms do not have plaques on coronary angiography. Overall there is poor agreement between the findings of coronary angiography and MPS in SLE, suggesting mechanisms of ischemia other than plaques.     

Prognostic value of thallium-201 single-photon emission computed tomography for patients with multivessel coronary artery disease after revascularization (the Emory Angioplasty versus Surgery Trial [EAST])

The aim of this study was to investigate the relation between reversible thallium single-photon emission computed tomography (SPECT) myocardial perfusion defects at 1-year after revascularization and quantitative indexes in Emory Angioplasty versus Surgery Trial (EAST) and outcomes 3 years after revascularization in 336 patients. EAST was a randomized controlled trial assessing cardiac outcomes for angioplasty versus bypass surgery for patients with multivessel coronary artery disease. During this prospective trial, a substudy included the evaluation of the prognostic value of reversible defects on quantitative thallium SPECT. At 1-year after revascularization, 336 patients underwent SPECT thallium-201 stress myocardial perfusion and 3-hour delayed imaging. Subsequent events, percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery, myocardial infarction, and death, were recorded at 3 years. A stress-induced reversible thallium-201 defect was defined using a quantitative index of a reversibility score >30% and severity score >500. Reversible defects were observed more frequently in the percutaneous transluminal coronary angioplasty than in the coronary artery bypass graft surgery treatment groups (46% vs 27%, p <0.001). A total of 123 patients had stress-induced, reversible thallium defects and more events than patients with other perfusion results (freedom from all events was 81.3% vs 94% [p <0.001], and freedom from myocardial infarction and death 88.3% vs 95.5% [p = 0.031]). Quantitative thallium SPECT at 1 year after revascularization risk stratifies patients as to their likelihood of major cardiac outcomes.     

锝-氮-氮欧乙替心肌灌注显像对冠心病的诊断评价

目的评价锝-氮-氮欧乙替（^99mTc-N—NOET）心肌灌注显像检测冠心病的价值。方法对42例临床疑诊冠心病患者,行^99mTc-N-NOET运动负荷和再分布心肌灌注显像,所有患者行冠状动脉造影检查。结果在42例患者中,26例冠状动脉造影显示有冠状动脉狭窄病变,其中单支病变10例,二支病变7例,三支病变9例.^99mTc-N-NOET心肌显像检出心肌缺血或心肌梗死21例,未检出异常5例;16例冠状动脉造影正常患者,^99mTc-N-NOET心肌显像正常14例,异常2例.^99mTc-N-NOET心肌灌注显像诊断冠心病的敏感性为81％、特异性为88％、阳性预测值91％,阴性预测值74％,预测准确性为83％。诊断单支、二支和三支冠状动脉病变的敏感性分别为60％（6／10）、86％（6／7）、100％（9／9）。42例均无干扰心肌分辨的肺、肝重度摄取增高者。15min运动负荷显像肺脏摄取高,尤以冠状动脉狭窄患者增高明显。结论 ^99mTc-N-NOET心肌灌注显像检测冠心病敏感性、特异性较高,早期显像肺摄取增加与有意义的冠状动脉病变有关。     

腺苷负荷心肌灌注显像141例临床分析

目的:腺苷负荷心肌灌注显像(MPI)与冠状动脉造影(CAG)2种检查方法的结果对比分析。方法:对141例患者分别行腺苷负荷MPI及CAG检查,并使用校正的TIMI血流分级(CTFC)方法评价冠状动脉血流速度。对2种方法的检查结果进行比较分析。结果:腺苷负荷MPI阳性的99例患者中,经CAG检查确诊冠心病者52例,冠状动脉慢血流(CSF)者37例,冠状动脉正常者10例。腺苷负荷MPI对冠心病诊断的灵敏度和特异度为92.9%和44.7%;对CSF诊断的灵敏度和特异度为82.2%和75.0%。结论:腺苷负荷MPI阳性者中一部分为冠心病患者,一部分为CSF者,对于腺苷负荷MPI异常的患者需进一步行CAG检查以明确病情。     

Myocardial perfusion abnormalities in treated hypertensive patients without known coronary artery disease

OBJECTIVE: Myocardial perfusion abnormalities may occur in hypertensive patients in absence of significant coronary artery disease. However, it is not well established whether hypertensive patients without known coronary artery disease have a higher prevalence or extent of myocardial perfusion abnormalities compared with normotensive patients with similar clinical features. DESIGN: This study compares the prevalence and extent of rest and stress-induced myocardial perfusion abnormalities in patients with and without hypertension. METHODS: Dobutamine (up to 40 microg/kg per min) stress technetium-99m myocardial perfusion SPECT imaging was performed for evaluation of myocardial ischaemia in 350 patients (mean age = 60+/-13 years, 146 men) without known coronary artery disease. One hundred and forty-eight patients were hypertensive. Rest SPECT images were acquired 24 h after the test Abnormal perfusion was defined as the presence of reversible or fixed perfusion defects. RESULTS: No significant difference was detected between patients with and without hypertension regarding gender, prevalence of symptoms, risk factors, pretest probability of coronary artery disease (52+/-28 versus 53+/-29%), peak rate pressure product (21040+/-4755 versus 20774+/-4865) or number of patients achieving the target heart rate during stress (85 versus 86%). Hypertensive patients were significantly older (62+/-11 versus 58+/-13 years, P = 0.005) and were receiving beta-blockers more frequently (34 versus 18%, P = 0.0001). The prevalence of myocardial perfusion abnormalities was similar in patients with and without hypertension (28 versus 31% in patients with low, 38 versus 33% in patients with intermediate and 60 versus 58% in patients with high pretest probability of coronary artery disease, respectively). No significant difference was detected between the two groups regarding stress perfusion defect score (1.45+/-2.5 versus 1.50+/-2.6) or rest score (0.72+/-1.8 versus 0.68+/-1.6). CONCLUSION: Treated hypertensive patients without known coronary artery disease have a similar prevalence and severity of myocardial perfusion abnormalities at rest and at dobutamine stress compared with normotensive patients with similar clinical characteristics.     

Physiologic significance of chronic coronary aneurysms in patients with Kawasaki disease

Objectives. The aim of this study was to determine whether persistent coronary aneurysms in patients with Kawasaki disease are associated with altered myocardial perfusion and function.Background. Some patients with Kawasaki disease have died suddenly because of severe coronary artery stenosis; others have chronic coronary aneurysms.Methods. Eleven patients with chronic coronary aneurysms were enrolled in the study. The size of the aneurysms and the degree of associated stenosis were determined by angiography in nine patients and by echocardiography in two. All patients underwent simultaneous function and myocardial perfusion assessment during symptom-limited exercise by echocardiography and technetium-99m sestamibi imaging, respectively.Results. Of 33 vascular territories, 18 contained coronary aneurysms measuring 3.5 to 10 mm. Three aneurysms were associated with significant stenosis as detected by angiography. Of the 18 vascular territories, 13 were normal, and 5 manifested stress-induced perfusion defects; of the latter 5 areas, 4 had associated wall motion abnormalities. The three territories supplied by stenotic coronary arteries had both abnormal regional function and perfusion demonstrated during exercise.Conclusions. Patients with chronic coronary aneurysms may have associated stenosis, as detected by angiography, with a subjacent myocardium that is subject to abnormal perfusion and function. However, the majority of coronary aneurysms are associated with normal regional coronary flow reserve, as assessed by myocardial perfusion imaging, and even giant coronary aneurysms may be associated with normal coronary flow reserve and preserved regional myocardial function during stress.     

Risk stratification in uncomplicated type 2 diabetes: prospective evaluation of the combined use of coronary artery calcium imaging and selective myocardial perfusion scintigraphy.

AIMS: To determine the prevalence and clinical predictors of subclinical atherosclerosis and myocardial ischaemia in uncomplicated type 2 diabetes and assess their relationship to short-term outcome. METHODS AND RESULTS: Established risk factors and coronary artery calcium (CAC) scores were prospectively measured in 510 asymptomatic type 2 diabetic subjects (mean age 53+/-8 years, 61% males) without prior cardiovascular disease. Myocardial perfusion scintigraphy (MPS) was performed in all subjects with CAC > 100 Agatston units (AU) (n=127), and a random sample of the remaining patients with CAC < or = 100 AU (n=53). Significant CAC (> 10 AU) was found in 46.3%. Twenty events occurred (two coronary deaths, nine non-fatal myocardial infarctions, three acute coronary syndromes, three non-haemorrhagic strokes, and three late revascularisations) during a median follow-up of 2.2 years (25th-75th percentile = 1.9-2.5 years). The age, systolic blood pressure, the duration of diabetes, United Kingdom Prospective Diabetes Study risk score, CAC score, and extent of myocardial perfusion abnormality were significant predictors of time to cardiovascular events in a univariable Cox proportional hazard model. No cardiac events or perfusion abnormalities occurred in subjects with CAC < or = 10 AU up until 2 years of follow-up. CAC and MPS findings were synergistic for the prediction of short-term cardiovascular events. CONCLUSION: Subclinical atherosclerosis, measured by CAC imaging, is superior to the established cardiovascular risk factors for predicting silent myocardial ischaemia and short-term outcome. Further studies evaluating the impact of CAC imaging on clinical outcomes and its cost effectiveness are warranted.     

Transient myocardial perfusion abnormalities during cold provocation test in patients with arterial hyperreactivity.

The effect of peripheral cold provocation on myocardial perfusion was evaluated utilizing thallium-201 perfusion imaging in 13 selected patients with arterial hyperreactivity (Raynaud's phenomenon: n = 8; migraine: n = 6) and angiographically documented coronary artery spasm. Eleven out of 13 subjects with coronary arterial spasm--but none of a group of patients with obstructive coronary artery disease--had transient myocardial perfusion defects during cold provocation. The localization of transient perfusion abnormalities during myocardial scintigraphy correlated with the myocardial areas distal to the spontaneous or ergonovine-induced coronary arterial spasm detected by angiography. Transient reduction of tracer uptake during cold provocation and normalization of myocardial perfusion by redistribution imaging was paralleled by areas of hypokinesia observed during the test by contrast ventriculography (n = 8). The described findings in the coronary system during peripheral cold pressor test occurred independently of the presence of Raynaud's phenomenon, and without achieving the ischemic threshold.     

Single photon emission computed tomography dual isotope myocardial perfusion imaging in women with systemic lupus erythematosus. I. Prevalence and distribution of abnormalities

OBJECTIVE: To determine the prevalence of myocardial perfusion abnormalities in women with systemic lupus erythematosus (SLE) using single photon emission computed tomography (SPECT) dual isotope myocardial perfusion imaging (DIMPI). METHODS: Consecutive female patients registered at the University of Toronto Lupus Clinic were offered DIMPI evaluation and all who accepted were studied. Patients underwent SPECT DIMPI using dipyridamole stress. Resting and stress images were acquired using thallium-201 (201TI) and technetium 99m-sestamibi (99mTc sestamibi), respectively. We recorded segmental perfusion abnormalities, severity and reversibility of any abnormality, and number of vessel territories involved. Ejection fraction was also measured. RESULTS: One hundred thirty patients were studied. Mean (SD) age and disease duration at study were 45.1 (11.1) years and 14.6 (9.4) years, respectively. Thirteen patients (10%) had a history of angina pectoris or myocardial infarction. Overall, 52 (40%) patients had an abnormality of myocardial perfusion, including 11 (85%) with a history of angina or myocardial infarction. In those with no history of coronary artery disease, 41 (35%) had an abnormality detected. The perfusion defect was reversible in 47 (90%). In 37 (71%) cases perfusion defects were seen in the region of a single vessel territory. Eighteen (13.8%) patients had an ejection fraction (EF) < 50%. CONCLUSION: Using SPECT DIMPI, 40% of all women with SLE and 35% of women with SLE with no history of coronary artery disease had abnormalities of myocardial perfusion, suggesting a high prevalence of early coronary artery disease. The early detection of disease will facilitate study of atherosclerotic risk factors; such women can also be targeted for a focused program of risk factor management.     

Progressive deterioration of left ventricular function in a patient with a normal coronary angiogram

Cardiac ischemia with a normal coronary angiogram can be caused by coronary microvascular dysfunction.A favorable prognosis,with excellent long-term clinical outcome,without major acute coronary events,has been consistently reported in these patients.We report a patient with a normal coronary angiogram and 3 episodes of myocardial infarctions,where the formation of a ventricular aneurysm and progressive deterioration of left ventricular function was documented,and hypoperfusion of the myocardium was confirmed by cardiovascular magnetic resonance imaging,This case suggests that myocardial ischemia caused by coronary microvascular dysfunction could have a poor prognosis.Whether this case represents a special clinical condition which is between the cardiac syndrome X and coronary artery disease remains to be investigated.     

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。