腺苷超声与核素心肌显像推测心绞痛相关狭窄血管的比较

目的 比较腺苷超声心动图与腺苷核素心肌灌注显像诊断冠心病及推测稳定型心绞痛患者相关狭窄血管的价值。方法 51例临床诊断为稳定型心绞痛的住院患者同期进行腺苷超声心动图与腺苷核素心肌灌注显像检查,超声心动图示室壁运动障碍,心肌显像检测核素分布稀疏或缺损,并在2周内行冠状动脉造影对照。结果 51例患者接受冠状动脉造影,诊断冠心病42例,9例排除冠心病,诊断狭窄血管74支。超声心动图阳性者33例,心肌显像阳性者39例。超声心动图诊断狭窄血管敏感性62%,特异性86%,准确性75%。核素心肌显像诊断狭窄血管敏感性80%,特异性89%,准确性84%。二者诊断符合率84%。结论 研究结果显示,与腺苷超声心动图诊断稳定型心绞痛患者狭窄血管相比较,腺苷心肌灌注显像具有更高的敏感性,尤其识别多支病变及中重度狭窄血管更敏感。     

心肌灌注显像在女性冠心病诊断中价值

目的评价心肌灌注显像对女性冠心病患者的诊断价值。方法 344例有胸痛、胸闷症状女性患者,行静息+药物负荷心肌灌注显像检测,并与冠状动脉造影结果进行对比分析。结果冠状动脉狭窄178例患者中心肌灌注显示异常者130例;冠状动脉造影无异常或不规则166例中心肌灌注显像异常50例,无异常116例;以冠状动脉造影结果为标准,心肌灌注显像对女性冠心病诊断的敏感度、特异度、阳性预测值、阴性预测值分别为73.0%,69.9%,72.2%,70.7%。结论心肌灌注显像对女性冠心病患者的诊断及是否进一步行冠状动脉造影的筛选有一定价值。     

Fusion imaging: Combined visualization of 3D reconstructed coronary artery tree and 3D myocardial scintigraphic image in coronary artery disease

Background: In patients with coronary artery disease, coronary angiography is performed for assessment of epicardial coronary artery stenoses. In addition, myocardial scintigraphy is commonly used to evaluate regional myocardial perfusion. These two-dimensional (2D) imaging modalities are typically reviewed through a subjective, visual observation by a physician. Even though on the analysis of 2D display scintigraphic myocardial perfusion segments are arbitrarily assigned to three major coronary artery systems, the standard myocardial distribution territories of the coronary tree correspond only in 50–60% of patients. On the other hand, the mental integration of both 2D images of coronary angiography and myocardial scintigraphy does not allow an accurate assignment of particular myocardial perfusion regions to the corresponding vessels. To achieve an objective assignment of each vessel segment of the coronary artery tree to the corresponding myocardial regions, we have developed a 3D ‘fusion image’ technique and applied it to patients with coronary artery disease. The morphological data (coronary angiography) and perfusion data (myocardial scintigraphy) are displayed in a 3D format, and these two 3D data sets are merged into one 3D image. Results: Seventy-eight patients with coronary artery disease were studied with this new 3D fusion technique. Of 162 significant coronary lesions, 120 (74%) showed good coincidence with regional myocardial perfusion abnormality on 3D fusion image. No regional myocardial perfusion abnormality was found in 44 (26%) lesions. Furthermore, the 3D fusion image revealed 24 ischemic myocardial regions that could not be related to angiographically significant coronary artery lesions. Conclusion: The results of this study demonstrate that our newly developed 3D fusion technique is useful for an accurate assignment of coronary vessel segments to the corresponding myocardial perfusion regions, and suggest that it may be helpful to improve the interpretative and decision-making process in the treatment of patients with coronary artery disease.

     

不同狭窄程度下冠状动脉微循环阻力对心肌缺血的诊断价值

目的基于血流动力学原理,构建冠状动脉个性化三维模型,研究不同狭窄程度下冠状动脉微循环阻力对心肌缺血的诊断价值。方法回顾性选取2018年1~10月于首都医科大学附属北京友谊医院接受冠状动脉增强扫描(CTA)和核素心肌灌注显像(MPI)检查的44例患者,其中男性31例,女性13例,共分析133支血管。借助电路分析方法计算冠状动脉微循环阻力。以心肌灌注显像作为诊断心肌缺血的"金标准",比较不同狭窄程度下,微循环阻力对心肌缺血的诊断价值。采用SPSS 20. 0及Medcalc 18. 0软件进行分析,以心肌灌注显像作为诊断心肌缺血的金标准,比较微循环阻力在缺血组(n=67)及非缺血组(n=66)的差异;分别计算不同狭窄程度下,微循环阻力对心肌缺血的诊断阈值。结果微循环阻力对25%~70%冠状动脉狭窄时,诊断价值最高。当冠状动脉狭窄25%~70%时,微循环阻力对诊断心肌缺血敏感性为87%~94%,特异性为71%~91%。当冠状动脉狭窄为25%~50%时,微循环阻力对心肌缺血的诊断阈值为183. 3;冠状动脉狭窄为50%~70%时,微循环阻力对心肌缺血的诊断阈值为137. 9。结论通过构建冠状动脉个性化三维模型、计算冠状动脉微循环阻力,分析不同狭窄程度下微循环阻力对心肌缺血的诊断价值。当冠状动脉存在25%~70%狭窄时,微循环阻力对心肌缺血的诊断阈值可为临床精准诊断提供一定意义的理论依据。     

二维应变超声心动图结合实时心肌超声造影评价冠状动脉不同狭窄程度对心肌灌注和心功能的影响

目的 应用二维应变超声心动图(2D-Strain)结合实时心肌超声造影(MCE)评价静息状态下冠状动脉(冠脉)不同程度狭窄患者局部心肌血流灌注和应变的变化及两者之间的关系.方法 对25例冠心病患者及15例健康志愿者行MCE和2D-Strain检查.血供异常的心肌节段按供血冠狭窄程度分为轻度狭窄组(50%～75%)、中度狭窄组(76%～89%)和重度狭窄组(≥90%).从MCE再灌注允盈曲线获得A值和β值分析心肌灌注;应用2D-Strain测量心肌纵向收缩期峰值应变(SL)分析心功能.结果 在异常冠脉供血区,随着冠脉狭窄程度的加重;各组的A值与对照组相比呈递减趋势,但差异无统计意义(P>0.05);而中度狭窄组和重度狭窄组的β值和SL值均显著低于对照组(β值:0.75±0.67和0.67±0.53对0.97±0.65;SL值:11.60±5.89和9.58±6.51对19.46±6.17,均P<0.05).β值与SL值有相关性(r=0.65,P<0.05).结论 MCE的再灌注参数β值和2D-Strain测量的SL值均可发现静息状态下>75%的冠脉狭窄引起的心肌缺血,且两者具有较好的相关性.     

腺苷负荷心肌超声造影评价冠状动脉狭窄程度的研究

目的 探讨腺苷负荷心肌超声造影(myocardial contrast echocardiography,MCE)对不同程度狭窄冠状动脉供血心肌灌注的评价作用.方法 24例冠心病患者总计384个心肌节段按照相应的供血冠 状动脉狭窄程度分为 A组(无狭窄)、B组(狭窄5O%～75%)、C组(狭窄76%～89%)及D组(狭窄≥90%).运用参数量化技术对静息及腺苷负荷MCE心肌灌注参数(A、β和A×β)进行定量分析,随后对四组各参数值变化幅度绘制ROC曲线并获得最佳截点和灵敏性、特异性.结果 静息状态,A、β和A×β值在A、B、C和D组中均逐渐降低,而A、B两组间差异无统计学意义(均P＞0.05);腺苷负荷状态,A、B两组增加,C、D两组减少,ROC曲线分析显示,参数A×β的变化幅度诊断冠状动脉狭窄的曲线下面积最大,灵敏性和特异性分别为:B组 81.3%和94.9%,C组82.6%和84.5%,D组71.9%和86.3%.结论 腺苷负荷 MCE 可用于估测冠状动脉的不同程度狭窄.     

Scintigraphic diagnosis of coronary artery disease: myocardial bull's-eye images contain the important information

The bull's-eye image, also called polar map image, has been developed as an important display for the visual and quantitative analysis of myocardial perfusion scintigrams. Quantitative analysis can be performed for example by comparing areas in the bull's-eye image with normal limits or by processing it using artificial neural networks. The usefulness of such methods is highly dependent on the information content of the bull's-eye image. The purpose of this study was to investigate whether there is more diagnostically important information in a set consisting of the myocardial bull's-eye image plus tomographic slice image than in the bull's-eye image alone. A population of 135 patients who had undergone both myocardial scintigraphy and coronary angiography, with no more than 3 months elapsing between the two examinations, was studied retrospectively. Four experienced observers independently classified visually all scintigrams regarding the presence/absence of coronary artery disease in two vascular territories using a four-grade scale. The observers classified the scintigrams once viewing bull's-eye images only, and once viewing tomographic slices and bull's-eye images. Coronary angiography was used as gold standard. The classifications were evaluated using the areas under the receiver operating characteristics (ROC) curves. The classifications based on bull's-eye images only were slightly more accurate than those based on tomographic slices and bull's-eye images in one of the two vascular territories (ROC areas of 0·66 vs. 0·64). The opposite relationship was found in the other vascular territory (0·78 vs. 0·81). None of the differences was statistically significant. In conclusion, the diagnostically important information for the diagnosis of coronary artery disease by myocardial perfusion scintigraphy is present in the bull's-eye image.     

Non-invasive diagnosis of in stent stenosis by stress 99m technetium tetrofosmin myocardial perfusion imaging

Background The aim of this study was to assess the accuracy of stress 99m technetium tetrofosmin myocardial perfusion imaging for the diagnosis of in stent stenosis (ISS).Methods We studied 72 patients who underwent exercise or dobutamine stress 99m technetium tetrofosmin imaging, 0.9±0.5 years after percutaneous coronary interventions in which stents were deployed. Coronary angiography was performed within 3 months of the stress test. ISS was defined as ≥50% stenosis in a coronary segment with previous stenting. Significant coronary artery disease (CAD) was defined as ≥50% stenosis within or outside the stented coronary segment.Results The stent was deployed in 1 coronary artery in 52 patients, and in 2 coronary arteries in 20 patients (a total of 92 detected in 42 (58%) patients (51 stents). Reversible perfusion abnormalities were present in 34 of patients with ISS (sensitivity=81%, CI 70–94). Regional sensitivity for diagnosis of stenosis per stent was 76% (CI 65–88), specificity was 83% (CI 71–94) and accuracy was 79% (CI 69–85). Reversible perfusion abnormalities were detected in ≥2 vascular distributions in 15 of 22 patients with multi-vessel CAD and in 5 of 50 patients without (sensitivity for identifying multivessel CAD=68%, CI 50–89; specificity=90%, CI 82–98; and accuracy=83%, CI 75–90).Conclusion Stress 99m technetium tetrofosmin myocardial perfusion imaging is a useful non-invasive technique for the diagnosis of in stent stenosis and extent of CAD in patients with previous percutanenous coronary artery interventions.     

ASCI 2010 contrast media guideline for cardiac imaging: a report of the Asian Society of Cardiovascular Imaging cardiac computed tomography and cardiac magnetic resonance imaging guideline working group

To evaluate the accuracy of myocardial perfusion SPECT (MPI) in the detection and allocation of vessel specific perfusion defects (PD) using standard distribution territories in a routine clinical procedure of patients with multivessel disease (MVD). Combined quantitative coronary angiography and fractional flow reserve (QCA/FFR) measurements were used as invasive reference standard. 216 vessels in 72 MVD patients (67 ± 10 years, 28 female) were investigated using MPI and QCA. FFR of 93 vessels with intermediate stenoses was determined. MPI detected significant stenoses according to QCA/FFR findings with a sensitivity of 85%. However, vessel-based evaluation using standard myocardial distribution territories delivered a sensitivity of only 62% (28 MPI+ out of 45 (QCA/FFR)+ findings), with specificity, PPV and NPV of 90, 62 and 90%. 7/17 false positive and 7/17 false negative findings (41%) could be attributed to incorrect allocation of reversible PD to their respective coronary arteries. 6/17 (35%) perfusion territories were classified as false negative when additional fixed PD were present. MPI had reasonable sensitivity for the detection of significant coronary artery disease in patients with multivessel disease. However, sensitivity decreased markedly, when the significance of each individual stenosis was evaluated using standard myocardial supplying territories. In this setting, 41% of false negative and false positive MPI findings resulted from incorrect allocation of reversible perfusion defects to their determining supplying vessel.     

64层螺旋CT血管成像与心肌灌注显像探测功能相关冠状动脉病变

目的 比较64层螺旋CT血管成像(CTA)和心肌灌注显像(MPI)对功能相关冠状动脉狭窄性病变的诊断价值.方法 回顾性分析20例确诊和11例拟诊冠状动脉病变(CAD)患者的64层CTA和MPI图像.按照目测直径法判断CTA图像上冠状动脉狭窄程度:≥50%或＜50%;相应MPI图像上的心肌缺血分为可逆性和固定性灌注异常区.结果 31例患者的124条冠状动脉中,23条CTA图像上狭窄≥50% ,其中7条(30.43%)狭窄血管的供血心肌在MPI上呈现灌注异常区;101条狭窄＜50%及正常,其中10条(9.90%)血管的供血心肌在MPI图像上呈现灌注异常区.冠状动脉狭窄程度与其供应心肌节段发生缺血的风险概率之间差异有统计学意义(χ2=6.667,P=0.01),而冠状动脉不同狭窄部位与其供应心肌节段发生缺血的风险概率之间差异无统计学意义(χ2=6.839,P=0.065).64层螺旋CTA在探测MPI图像上缺血心肌节段所对应的狭窄≥50%冠状动脉的敏感度、特异性、阴性预测值、阳性预测值分别为41.18%、85.05%、90.01%和30.43%.结论 64层螺旋CTA能清晰显示冠状动脉的重要形态学信息,但其探测功能相关狭窄≥50%冠状动脉的阳性预测值较低,而MPI则是评价CAD导致心脏功能改变的重要检查方法.     

腺苷负荷心肌灌注显像对冠心病的诊断价值

【目的】评价腺苷负荷试验心肌灌注显像对冠心病的诊断价值及腺苷负荷试验的安全性。【方法】收集2011年2月至2013年2月在本院疑诊冠心病患者75例,均行腺苷负荷^99m Tc-甲氧基异丁基异腈（MIBI）心肌灌注断层显像,腺苷按体重0．14 mg/（kg ·min）通过输液泵静脉双通路给药,并对心肌灌注断层显像图作定性分析,所有患者1～3 d后行冠状动脉造影检查。【结果】75例患者中冠脉造影正常32例;1支以上狭窄≥50％者43例,其中单支病变14例,双支病变16例,三支病变13例;共检出病变血管85支,累及左前降支（L AD ）38支,左回旋支（LCX）28支,右冠状动脉（RCA）21支,左主干（LM）2支。腺苷负荷心肌灌注显像诊断冠心病的灵敏度为88．3％（38/43）,特异性为87．5％（28/32）,准确性为88．0％（66/75）,阳性预测值为90．5％（38/42）,阴性预测值为84．8％（28/33）。对病变冠脉诊断灵敏度为75．9％（63/83）,特异性93．7％（133/142）,准确性87．1％（196/225）,阳性预测值为94．0％（63/67）,阴性预测值为84．2％（133/158）。对单支、双支、3支血管病变诊断的灵敏度分别为50％（7/14）、62．5％（10/16）和92．3％（12/13）。对各病变血管检测灵敏度为：LAD 86．1％（31/36）,LCX 55．6％（15/27）,RC A 85％（17/20）。腺苷不良反应总发生率为80％（60/75）。【结论】腺苷负荷试验心肌灌注显像诊断冠心病敏感性及特异性均较高,并且不良反应轻微,是协助诊断冠心病安全有效的方法。     

Combining cardiac magnetic resonance and computed tomography coronary calcium scoring: added value for the assessment of morphological coronary disease?

To investigate prospectively, in patients with suspicion of coronary artery disease (CAD), the added value of coronary calcium scoring (CS) as adjunct to cardiac magnetic resonance (CMR) for the diagnosis of morphological coronary stenosis in comparison to catheter angiography (CA). Sixty consecutive patients (8 women; 64 ± 10 years) referred to CA underwent CMR (1.5 T) including perfusion and late gadolinium-enhancement imaging as well as CS with computed tomography. Diagnostic performance was evaluated for CMR and CS separately, and for both methods combined, with CA as reference standard. Best CS threshold combined with a specificity >90% to predict significant stenosis in patients without abnormalities on CMR was determined from receiver operator characteristics (ROC) analysis. Abnormal CMR results were considered to indicate significant stenosis regardless of CS; CS above threshold reclassified patients to have CAD regardless of CMR. CA identified 104/960 (11%) coronary segments with coronary artery stenosis >50% in 36/60 (60%) patients. ROC revealed an area-under-the-curve of 0.83 (95%CI: 0.68-0.99) with the best CS threshold of 495 Agatston score (sensitivity 50%). CMR depicted 128/960 (13%) myocardial segments with abnormalities in 31/60 (52%) patients. Sensitivity, specificity, negative (NPV) and positive predictive value (PPV) of CMR were 78, 88, 72 and 90%. When adding CS to CMR, sensitivity and NPV increased to 89 and 83%, while specificity and PPV slightly decreased to 83 and 89%. Accuracy of the combined approach (87%) was significantly (P < 0.05) higher than that of CMR (82%) alone. Adding CS to CMR improves the accuracy for the detection of morphological CAD.     

Exercise thallium-201 scintigraphy in the localization of myocardial ischaemia

Summary. We performed a retrospective study in order to study the ability of thallium-201 exercise scintigraphy to detect and to localize coronary artery perfusion defects (in comparison with a recent coronary angiogram). We studied 81 patients (67 males); their average age was 52.3 years (men 50.5 and women 54.1 years). They performed a pulse-conducted cycle exercise test, and 2 min before end of exercise 75 MBq of thallium-201 was infused intravenously, and tomographic images were reconstructed by using a Siemens-Rota SPECT gamma camera immediately and 4 h after exercise. The thallium-201 uptake defects were attributed to different coronary arteries, and the results were compared with a coronary angiogram made afterwards in 48 patients. The groups of one-, two- and three-vessel disease were 27, 21, and 21 patients, and only 12 patients did not have significant (over 50%) stenoses. The latter had the highest ejection fraction and working capacity. Sensitivity of thallium-201 exercise scintigraphy was 65%, whereas that of exercise ECG was 41% in patients with a low ejection fraction, while in the whole material the sensitivity of thallium-201 scintigraphy was 91% and that of exercise ECG was 54%. A stenosis in the right coronary artery was best localized by the thallium-201 scintigram (86% correctly); a stenosis in the left anterior descending artery was localized correctly in 75% of the cases, but a stenosis in left circumflex artery was localized correctly only in 44%. We conclude that exercise thallium-201 scintigraphy is a useful method not only in detecting but also in localizing coronary artery disease.     

Incremental value of dual-energy CT to coronary CT angiography for the detection of significant coronary stenosis: comparison with quantitative coronary angiography and single photon emission computed tomography

To determine the value of dual-energy CT (DECT) and combined information of perfusion and angiography in diagnosing coronary artery disease (CAD), with single photon emission computed tomography (SPECT) and quantitative coronary angiography (QCA) as a reference standard. Thirty-four patients were enrolled in this study. DECT was used as a contrast-enhanced retrospectively ECG-gated scan protocol during the rest state and tubes were set at 140/100 kV. DECT angiography (DE-CTA) and DECT perfusion (DE-CTP) were calculated from two kV images. DE-CTP results were compared with SPECT and DE-CTA with QCA, respectively. The combined DE-CTP with DE-CTA data were compared to QCA in diagnosis of obstructive CAD (stenosis ≥ 50%). DECT showed diagnostic image quality in 31 patients. Using SPECT as a reference, DE-CTP had sensitivity of 68%, specificity of 93%, and sensitivity of 81%, and specificity of 92% for identifying any type of perfusion deficits on the segment- and territory-based analysis, respectively. Using QCA as a reference standard, DE-CTA showed sensitivity of 82%, specificity of 91% and accuracy of 86% for detecting ≥50% coronary stenosis on the vessel-based analysis, whereas the combination of DE-CTA and DE-CTP gave sensitivity of 90%, specificity of 86% and accuracy of 88% for detecting ≥50% coronary stenosis, respectively. Combination of DE-CTP and DE-CTA may improve diagnostic performance compared to CTA alone for the diagnosis of significant coronary stenosis.     

腺苷负荷心肌核素显像在冠心病诊断与介入治疗中的作用

目的探讨腺苷负荷心肌核素显像在冠心病诊断及介入治疗中的作用。方法冠心病的可疑患者,行腺苷负荷心肌核素显像,部分患者进行冠脉造影和介入治疗,介入治疗前后进行腺苷负荷心肌核素显像检查对比。腺苷负荷心肌核素显像采用单光子发射断层显像图像采集系统,腺苷总量为840μg/kg静脉泵入,3 min后静脉推注99mTc-MBI925 MBq,90 min后进行心肌断层显像,如果发现心肌显像异常,次日再行静息心肌显像。结果134例冠心病患者,年龄21~85(63.3±14.8)岁,男90例,女44例,进行腺苷负荷心肌核素显像,109例提示有心肌缺血现象,25例正常,诊断阳性率达81.3%。12例患者经过冠状动脉造影,有冠脉狭窄的患者行PCI,前后复查腺苷心肌核素显像,介入后心肌核素血流灌注较介入前明显改善(P<0.01)。结论腺苷负荷心肌核素显像在冠心病的诊断中起着重要的作用,其敏感性与特异性较高,同时在冠心病介入治疗前后疗效评价方面有一定的临床意义。     

国产腺苷的安全性评价及其负荷心肌灌注显像诊断冠心病的价值

目的：评价国产腺苷临床应用安全性及腺苷负荷心肌灌注显像对冠心病的诊断价值。方法：对51例临床疑诊冠心病患者,分别静脉注射腺苷,注射3 min末,静脉注射核素显像剂99Tcm-MIBI 925 MBq,1～1.5 h行心肌灌注断层显像,分析患者在腺苷注入后的血流动力学改变、副作用发生情况。经半年以上随访排除或确诊冠心病,评价腺苷负荷心肌灌注显像对冠心病的诊断价值。结果：腺苷输注后,86.3%（44/51）患者出现各种副作用,停药后均很快缓解。腺苷负荷试验心肌灌注显像诊断冠心病的敏感性90.9%,特异性71.4%,准确性88.2%,阳性预测值95.2%,阴性预测值55.6%。结论：国产腺苷可安全地应用于负荷心肌灌注显像。腺苷负荷心肌灌注显像诊断冠心病敏感性较高,具有重要的临床应用价值。     

Noninvasive diagnosis of coronary artery disease in patients with diabetes by dobutamine stress real-time myocardial contrast perfusion imaging

OBJECTIVE: The aim of this study was to assess the accuracy of real-time myocardial contrast perfusion imaging (MCPI) during dobutamine stress in the diagnosis and localization of coronary artery disease (CAD) in patients with diabetes. Myocardial contrast echocardiography is a new technique that allows evaluation of myocardial perfusion. Its utility in diabetic patients has not been defined. RESEARCH DESIGN AND METHODS: Dobutamine-atropine stress test was performed in conjunction with MCPI using Optison or Definity at rest and at peak stress in 128 patients with diabetes and suspected CAD who underwent coronary angiography within 1 month. CAD was defined as > or =50% stenosis in one or more coronary artery. MCPI was considered diagnostic of CAD in the presence of reversible perfusion abnormalities. The normalcy rate of MCPI was additionally determined in 18 asymptomatic nondiabetic patients with low probability. RESULTS: CAD was detected in 101 (79%) patients by angiography. Reversible perfusion abnormalities were detected in 90 patients with and 13 patients without CAD. The overall sensitivity of MCPI was 89% (95% CI 83-95), specificity 52% (33-71), and accuracy 81% (75-88). Reversible abnormalities were detected in two or more vascular distributions in 44 of 56 patients with multivessel CAD and in 8 of 63 patients without (sensitivity 68%, specificity 87%, positive predictive value 84%, and accuracy 79%). Regional sensitivity was 75% (65-85) for left anterior descending CAD, 71% (60-83) for left circumflex, and 67% (55-78) for right CAD. MCPI was normal in 16 of the 18 patients with low clinical probability of CAD (normalcy rate 89%). CONCLUSIONS: MCPI is a useful noninvasive technique for the diagnosis and localization of CAD in diabetic patients. The extent of perfusion abnormalities can identify patients with multivessel CAD with a moderate sensitivity and high specificity.     

Adenosine stress first pass perfusion for the detection of coronary artery disease in patients with aortic stenosis: a feasibility study

Purpose: Detection of coronary artery disease (CAD) with magnetic resonance imaging (MRI) using adenosine stress first pass perfusion in patients with aortic stenosis in comparison with invasive angiography. Twenty-three consecutive patients (15 male, mean age 68 ± 12 years) with relevant aortic stenosis (aortic valve area 0.90 ± 0.41 cm2) were examined by MRI (1.5 T, Philips Intera CV™). Contrast-enhanced first pass perfusion was performed with adenosine stress (140 μg/kg/min) and under rest conditions. The results were compared with invasive coronary angiography with regard to the presence of a relevant coronary artery stenosis (>70%). Three of 23 patients (13%) had contraindications for adenosine administration (one patient with atrioventricular block, two patients with mild claustrophobia). In the remaining 20 patients, adenosine stress perfusion could be performed without any complications. CAD was correctly detected in eight patients and correctly ruled out in 10 of 12 patients. False-positive results were seen in two patients with severe myocardial hypertrophy. Sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 80%, 83%, and 100%, respectively. Adenosine stress perfusion can be performed without complications even in patients with high grade aortic stenosis. MRI is helpful to detect and rule out significant CAD in these patients. Severe myocardial hypertrophy may lead to false-positive results. Our initial results indicate that due to a high negative predictive value pre-operative invasive coronary angiography might probably be waived in patients without perfusion defects in stress MRI.     

Exercise echocardiography and single photon emission computed tomography in patients with left anterior descending coronary artery stenosis

To compare the diagnostic value of exercise echocardiography and perfusion single photon emission computed tomography (SPECT) in the detection of the presence and the severity of coronary artery disease, we studied 21 patients with isolated stenosis of different degree of the left anterior descending artery. Both echocardiography and SPECT were performed in conjunction with the same symptom-limited bicycle exercise test. Positivity of the test was based on the presence of exercise-induced wall motion abnormalities and transient perfusion defects, respectively. For both tests, an ‘ischemic’ score was derived, as index of extent and severity of myocardial ischemia. Coronary arteriography was evaluated by caliper. The agreement between exercise echocardiography and SPECT for the presence of coronary artery disease was 90%; the discordance was due to two patients with positive echocardiography and negative SPECT. A good correlation between ischemic wall motion and perfusion score indices was found (r=0.78, p<0.0001. Moreover, the percent diameter stenosis was well correlated with both ischemic indices (r= 0.75, p<0.0001; r=67, p<0.001, respectively). In patients with a positive test, the mean value of ischemic wall motion score index was higher in patients with a diameter stenosis ≥ 70% than in patients with a diameter stenosis <70% (0.59 ± 0.19 vs 0.29 ± 0.12, p < 0.01); a similar trend was found for ischemic perfusion score index (0.51 ± 0.35 vs 0.27± 0.12, ns). The results of this study indicate that in patients with single vessel disease of left anterior descending artery exercise echocardiography and SPECT give the same information on the presence, the extent and the severity of myocardial ischemia.     

Diagnosis of vasospastic angina by hyperventilation and cold-pressor stress echocardiography: comparison to I-MIBG myocardial scintigraphy.

OBJECTIVES: We assessed the usefulness of hyperventilation and cold-pressor stress echocardiography in the diagnosis of vasospastic angina compared with that of iodine-123 metaiodobenzylguanidine (123I-MIBG) myocardial scintigraphy. BACKGROUND: Various noninvasive methods have been used to detect vasospastic angina, but they are not very sensitive in the diagnosis of vasospastic angina. 123I-MIBG images and stress echocardiography have recently been proposed as a useful tool for detecting vasospastic angina. METHOD: Thirty patients (21 males and 9 females, mean age: 52 +/- 14 years) who complained of rest angina were enrolled for this study. The hyperventilation and cold-pressor stress echocardiography test consisted of hyperventilation for 6 minutes, followed by cold water pressor for 2 minutes under continuous electrocardiographic and echocardiographic monitoring. Left ventricular regional wall motion by echocardiogram was analyzed by using the 16-segment model, and wall motion ranging from normokinesis to dyskinesis was evaluated visually in each segment. Single-photon emission computed tomography images of 123I-MIBG myocardial scintigraphy were divided into 26 segments. Defect scores were established using the 4 grades. The echocardiographic criteria for coronary spasm was worsening wall motion and the scintigraphic criteria was defect score more than moderately reduced. Acetylcholine was selectively injected into the right coronary artery (20 microg and 50 microg) and left coronary artery (20 microg, 50 microg, and 100 microg). RESULTS: Of 30 patients, 20 patients had coronary spasm on coronary angiography with an intracoronary injection of acetylcholine, whereas 10 patients showed no spasm. Multivessel spasms were observed in 15 patients. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of hyperventilation and cold-pressor stress echocardiography for diagnosing in patients with vasospastic angina were 90%, 90%, 95%, 82%, and 90%, respectively. However, those of 123I-MIBG myocardial scintigraphy for diagnosing in patients with vasospastic angina were 90%, 40%, 75%, 67%, and 73%, respectively. The specificity of hyperventilation and cold-pressor stress echocardiography was significantly higher than that of 123I-MIBG myocardial scintigraphy (P <.05). CONCLUSION: The specificity of hyperventilation and cold-pressor stress echocardiography in diagnosing coronary spasm were higher than that shown by 201I-MIBG myocardial scintigraphy.