Incremental value of left ventricular ejection fraction for detection of multivessel coronary artery disease in exercise (201)Tl gated myocardial perfusion imaging.

Assessment of reversible defects in exercise (201)Tl perfusion SPECT has low sensitivity and high specificity for detection of multivessel coronary artery disease (CAD). The goal of this study was to evaluate whether the left ventricular ejection fraction (LVEF) in exercise (201)Tl gated SPECT had incremental diagnostic value over perfusion data for detection of multivessel CAD. METHODS: One hundred eighty-two patients underwent exercise (201)Tl gated SPECT. Automated LV function analysis software was used for calculation of the postexercise and the rest LVEF. The best threshold between 0- to 1-vessel CAD and 2- to 3-vessel CAD was determined as the cutoff that on receiver-operating-characteristic analysis resulted in the best sensitivity for detection of multivessel CAD with an associated specificity of >90%. RESULTS: Only 18 (26.9%) of 67 patients with multivessel CAD had reversible defects in multiple territories. Sensitivities of the postexercise and the rest LVEF and the worsening of the LVEF by exercise did not differ from those of perfusion data alone. Sensitivities of the combination of perfusion data and the postexercise and rest LVEF did not differ from those of perfusion data alone, whereas the sensitivity of the combination of perfusion data and worsening of the LVEF (i.e., reversible defects in multiple territories or worsening of the LVEF >5.6% [or both]) was significantly greater than that of perfusion data alone (43.3% vs. 26.9%; P < 0.05), with an acceptable level of specificity (90.4%). CONCLUSION: The worsening of the LVEF by exercise has the potential to detect patients with multivessel CAD among those without multivessel patterns of reversible defects.     

定量门控201Tl心肌显像对冠心病患者的预后价值

目的 研究定量门控201Tl心肌显像对冠心病患者预后评估及冠心病治疗方案选择的价值.方法 对84例患者进行静息和运动负荷201Tl门控心肌灌注SPECT显像,并随访(32.92±16.77)个月.对心肌灌注图像进行评分(1～4分),计算总负荷评分(SSS)、总静息评分(SRS)和总差值分(SDS=SRS-SSS)、负荷左室射血分数(EF)值和静息EF值.结果 随访中9例发生心脏事件,年发生率为3.90%.SSS、SDS、SRS以及EF值均是心脏事件的独立预测因素(P＜0.005).Cox比例风险回归分析示SSS是心脏事件的最强预测因素.根据患者的负荷后EF值、SDS等可将患者分为低危、中危和高危组.结论 应用定量门控201Tl心肌显像可以对冠心病患者进行正确的预后评估,并可指导选择治疗方案.SSS是心脏事件的最强预测因素.     

定量门控心肌显像评价局部室壁运动

目的　探讨定量门控99Tcm 甲氧基异丁基异腈 (MIBI)、2 0 1 Tl和99Tcm tetrofosmin心肌显像评价局部室壁运动的可靠性。方法　对 30 1例左室功能受检者行门控99Tcm MIBI(n =15 8)、2 0 1 Tl(n =113)和99Tcm tetrofosmin(n=30 )心肌显像 ,采用QGSPECT程序评价左室总体和各区域局部室壁运动。并与二维超声心动图进行比较。结果　①左室总体局部室壁运动 :定量门控99Tcm MIBI心肌显像评价室壁运动与超声心动图的结果基本符合 (Kappa =0 6 3,P <0 0 1) ,定量门控2 0 1 Tl(Kappa =0 5 2 ,P <0 0 1)和99Tcm tetrofosmin(Kappa =0 5 4 ,P <0 0 1)心肌显像评价室壁运动与超声心动图的结果中等符合。②左室各区域局部室壁运动 :定量门控99Tcm MIBI和99Tcm tetrofosmin心肌显像能较准确评价左室前壁、前侧壁、后侧壁、下壁、前间壁、后间壁和后壁局部室壁运动 (Kappa =0 4 6～ 0 89,P <0 0 1) ;而定量门控2 0 1 Tl心肌显像只能较准确评价左室前壁、下壁和后壁局部室壁运动 (Kappa=0 6 5～ 0 72 ,P <0 0 1) ,其侧壁和间壁的可靠性低于前者 (Kappa =0 2 7～ 0 39)。结论　定量门控99Tcm MIBI、2 0 1 Tl和99Tcm tetro fosmin心肌显像能较准确评价局部室壁运动。     

腺苷激发与运动负荷心肌灌注断层显像在冠心病诊断中的比较研究

对常规心电图正常、无心肌梗塞史的冠心病患者进行腺苷激发与运动负荷２０１Ｔｌ心肌灌注断层显像。腺苷激发与运动负荷心肌灌注显像对冠心病诊断的敏感性分别为７９％与８１％，特异性分别为８０％与８１％，两组比较差异无显著性。两种方法对单支、双支、三支血管狭窄的敏感性分别为７４％与８９％，８０％与７１％，８２％与８８％，各组比较差异亦无显著性。冠心病患者腺苷试验引起副反应者占８９％。除２例因腺苷诱发严重心绞痛而终止试验外，其余症状均较轻微，于终止试验后迅速消失。因此，腺苷激发心肌灌注断层显像是安全有效的诊断冠心病的方法，其诊断价值与运动负荷心肌灌注断层显像相似，尤其适合于运动量不足和不能进行运动试验的患者。     

门控心肌灌注显像局部室壁运动异常判断冠状动脉狭窄程度的价值

目的 探讨99mTc-甲氧基异丁基异腈(99mTc-MIBI)门控心肌灌注显像出现的可逆性局部室壁运动异常(RWMA)在判断冠状动脉狭窄程度中的价值。方法 入选90例疑似冠心病患者,在门控心肌灌注显像的前后2周内进行冠状动脉造影检查。门控心肌SPECT检查应用9节段5分制进行室壁运动及增厚率评分。结果 心肌显像上可逆性RWMA判断≥75%的冠状动脉狭窄的灵敏度为64%,特异度为95%;用可逆性RWMA来区别严重冠状动脉狭窄(≥75%)和不严重的冠状动脉狭窄(<75%)有很高的阳性预测值(97%)。可逆性RWMA和濒危冠状动脉评分之间有良好的相关性。多因素分析显示,负荷室壁负荷总积分、室壁负荷差分值和心电图负荷试验阳性是濒危冠状动脉积分的独立危险因子。结论 根据99mTc-MIBI门控心肌灌注显像上可逆性RWMA判断严重冠状动脉狭窄具有高度的特异性和阳性预测值。潘生丁负荷后及可逆性RWMA增强了心肌灌注显像对冠状动脉狭窄程度的评估。     

腺苷和运动试验201Tl心肌灌注显像诊断女性冠心病价值比较

目的 对比腺苷试验和运动试验201Tl心肌灌注显像诊断女性冠心病的价值.方法 采用随机对照研究,观察138例女性冠心病疑似病例,按随机数字表法将其分为腺苷试验组和运动试验组,每组69例,分别进行201Tl心肌灌注显像,并在1周内行冠状动脉造影检查.负荷心肌灌注显像按心肌缺血严重程度与缺血范围分析,冠状动脉造影按主要血管狭窄程度(>50%为冠心病)分析.以冠状动脉造影结果 为"金标准",比较腺苷和运动试验对女性冠心病的诊断灵敏度、准确性、阴性预测值和假阳性率.2组间比较采用χ2检验或确切概率法.结果 腺苷试验方法 对女性冠心病诊断的灵敏度、阴性预测值、准确性分别为88.2%(45/51)、72.7%(16/22)和88.4%(61/69);运动试验组分别为91.7%(44/48)、66.7%(8/12)和81.2%(52/64),二者间差异无统计学意义(χ2=0.571,0.714,0.249,P>0.05).腺苷试验组假阳性率低于运动试验组[11.1%(2/18)与50.0%(8/16),P=0.023].结论 对于女性冠心病患者,腺苷试验心肌灌注显像与运动试验心肌灌注显像同样有效,且腺苷试验的诊断假阳性率低.

Abstract：

Objective To compare the diagnostic value of adenosine and exercise stress myocardial perfusion imaging (MPI) for detecting coronary heart disease (CHD) in women. Methods One hundred and thirty-eight patients with CHD were randomly divided into two groups: adenosine stress group (n = 69)and exercise stress group (n = 69). All patients underwent myocardial SPECT evaluation. Coronary angiography (CAG), referred as "gold standard" , was performed in each patient within 1 week before or after MPI. The diagnostic value of the two stress MPI was compared with χ2 test or Fisher's exact test. Results In adenosine stress group, the sensitivity, negative predictive value and accuracy were 88.2% (45/51),72.7% (16/22), 88.4% (61/69), respectively, which were not significantly different from those of the exercise stress group (91.7% (44/48), 66.7% (8/12), 81.2% (52/64); χ2 =0. 571, 0. 714, 0.249, P >0.05). However, the false positive rate of adenosine stress (11.1%, 2/18) was significantly lower than that of exercise stress (50.0%, 8/16), P = 0.023. Conclusions Adenosine and exercise stress MPI have similar value for CHD diagnosis in women, however, adenosine stress MPI may have an advantage of low false positive rate.     

Quantitative gated SPECT myocardial perfusion imaging with 201Tl: an assessment of the limitations

Gated SPECT (GSPECT) perfusion imaging has been increasing in popularity both with 99Tc(m) agents and 201Tl. However, both higher activities than administered in the UK and multi-headed cameras are often used. The aim of this study was to assess GSPECT imaging using lower activities of 201Tl with a single-headed camera. Seventy patients underwent stress and redistribution GSPECT imaging after a mean injected activity of 62 +/- 7 MBq 201Tl. These patients also underwent radionuclide ventriculography (RNVG) imaging. The Cedars Sinai Quantitative Gated SPECT (QGS) package was used to calculate left ventricular ejection fraction (LVEF) from the GSPECT studies. Comparison of ejection fractions calculated using GSPECT with those calculated using RNVG yielded a correlation coefficient of 0.70 for the stress studies and 0.71 for the redistribution studies. The width of the mean 95% prediction interval ranged from 22 to 74 percentage points for the stress studies and 22 to 86 percentage points for the redistribution studies. Ejection fractions calculated from stress and redistribution GSPECT studies showed a correlation of 0.80 with a mean 95% prediction interval of 42.6 +/- 0.4 percentage points. In conclusion, left ventricular ejection fractions calculated using the QGS algorithm from 201Tl GSPECT studies are inadequate for use in clinical practice.     

腺苷试验与运动试验201Tl心肌灌注显像对冠心病诊断价值的比较

目的比较腺苷试验与运动试验^201Tl心肌灌注显像对冠心病的诊断价值。方法将41例临床疑诊冠心病患者随机分为两组,一组进行腺苷试验^201Tl心肌灌注显像,一组进行运动试验^201Tl心肌灌注显像。两组试验对象均同期（2周内）行冠状动脉造影术。以冠状动脉狭窄≥50%作为冠心病诊断的“金标准”,比较两种负荷方法对冠心病的诊断价值。结果腺苷试验^201Tl心肌灌注显像对冠心病诊断的灵敏度、特异度、阳性预测率、阴性预测率、准确率分别为92.86%、57.14%、81.25%、80.0%、80.95%,运动试验^201Tl心肌灌注显像分别为100%、60.0%、71.43%、100%、80.0%,两种负荷方法对病变冠状动脉的检出率分别为66.67%和72.22%。结论两种负荷方法诊断冠心病的总体效能无显著差异。     

Comparison between exercise myocardial perfusion and wall motion using 201Tl and 191Irm simultaneously

By exploiting the ultrashort half-life 191Irm as tracer for left ventricular first-pass angiocardiography and 201Tl as myocardial perfusion agent, direct comparison between myocardial perfusion and regional wall motion was obtained during the same exercise stress test in patients with non-significant coronary artery disease, in patients with recent myocardial infarction, and in patients six weeks after successful percutaneous transluminal coronary angioplasty (PTCA). A good agreement between regional myocardial perfusion and regional wall motion was observed in patients with non-significant coronary artery disease and in most patients with recent myocardial infarction. In contrast, discrepancies occurred at maximal exercise in patients studied six weeks after successful PTCA: only 38% of the patients with no evidence of restenosis and with a completely normal myocardial perfusion scintigraphy had a normal regional wall motion at maximal exercise stress. According to these results, a normal uptake of 201Tl six weeks after PTCA would mean that the circulation has been successfully reestablished but without predicting the functional capacities of the myocardial cells which remain altered at least six weeks after the revascularization procedure in about two-thirds of the patients. We conclude that 191Irm in combination with 201Tl offers the opportunity of performing myocardial perfusion and wall motion studies simultaneously both at rest and during exercise.     

ATP负荷~(201)Tl心肌断层显像对冠心病的诊断价值

目的　评价ATP负荷2 0 1Tl心肌断层显像用于冠心病患者诊断的可行性和临床价值。方法　静脉注入ATP 0 .14mg·kg-1·min-1共 3min ,之后注射2 0 1Tl 148MBq ,10min和 3～ 4h后分别作心肌断层显像。结果　ATP负荷2 0 1Tl心肌断层显像诊断冠心病的灵敏度为 88% ,特异性为 90 %。ATP注入后引起的副作用轻微而短暂。结论　ATP负荷2 0 1Tl心肌断层显像用于诊断冠心病有较高的准确性     

Specific perfusion pattern in stress 201Tl myocardial scintigraphy of left main coronary artery disease

The usefulness of stress 201Tl myocardial scintigraphy for identifying left main coronary artery disease was evaluated with data from 23 patients with 50% or more narrowing of the left main coronary artery and 56 patients with 75% or more narrowing of the major coronary arteries but without left main coronary artery involvement (no left main coronary artery disease). Quantitative evaluation of stress perfusion scintigrams in all five patients with narrowing of the left main coronary artery of 90% or more showed a characteristic perfusion pattern (left main pattern) of extensive homogeneous defect over the whole anterolateral segment and simultaneous defects in all radii of the high anteroseptal and high posterolateral segments. On the other hand, such a perfusion pattern was noted in only 1 of 18 patients with less than 90% stenosis of the left main coronary artery and in only 1 of 56 patients with no left main coronary artery disease.     

Specific perfusion pattern in stress 201Tl myocardial scintigraphy of left main coronary artery disease

The usefulness of stress ²⁰¹Tl myocardial scintigraphy for identifying left main coronary artery disease was evaluated with data from 23 patients with 50% or more narrowing of the left main coronary artery and 56 patients with 75% or more narrowing of the major coronary arteries but without left main coronary artery involvement (no left main coronary artery disease). Quantitiative evaluation of stress perfusion scintigrams in all five patients with narrowing of the left main coronary artery of 99% or more showed a characteristic perfusion pattern (left main pattern) of extensive homogeneous defect over the whole anterolateral segment and simultaneous defects in all radii of the high anteroseptal and high posterolateral segments. On the other hand, such a perfusion pattern was noted in only 1 of 18 patients with less than 90% stenosis of the left main coronary artery and in only 1 of 56 patients with no left main coronary artery disease     

心肌灌注显像联合冠状动脉钙化积分诊断冠心病的价值及最新进展

心肌灌注显像（MPI）在冠心病的诊断、危险度分层及预后评价中扮演着越来越重要的角色,冠状动脉钙化积分（CACS）可协助对冠心病患者进行进一步的危险度分层,但两者有各自的局限性和不足。将两者联合应用可以相互弥补不足,为临床提供更多的信息。行SPECT/CT心肌灌注显像时,需进行衰减矫正CT（CTAC）扫描,若采用心电门控的呼气末屏气螺旋CT扫描,则在用于MPI衰减矫正的同时又可用于CACS测定,实现一站式检查,在减少患者辐射剂量的同时又可为临床提供更多的信息。笔者综述了CACS、MPI及两者联合应用的临床价值,并对一站式采集MPI与CACS的最新进展进行了综述。     

The additive value of gated SPET myocardial perfusion imaging in patients with known and suspected coronary artery disease

In myocardial perfusion scintigraphy, the clinical significance of fixed defects presents some difficulty. In this study, we evaluated whether additional information on left ventricular function assessed by quantitative gated single-photon emission computed tomography (gated SPET) would increase the diagnostic yield of the study in such patients. We studied 55 patients with a previous myocardial infarction and 20 patients without a previous myocardial infarction using gated SPET 99Tc(m)-tetrofosmin myocardial perfusion imaging. Each patient had to have a persistent perfusion defect consisting of at least three contiguous segments in the same vascular territory. The left ventricle was divided into 20 segments which were analysed for perfusion and wall thickening on a 4-point severity scale. Of the 55 patients with myocardial infarction, 19 (35%) patients showed preserved wall thickening in the region of the previous infarction with fixed perfusion abnormalities, which suggested residual myocardial viability. In the 20 patients without myocardial infarction, preserved wall thickening was seen in 10 (50%) patients with fixed perfusion defects, suggesting an attenuation artefact. Conversely, in 16 (29%) patients in the myocardial infarction group and two (10%) patients in the non-myocardial infarction group normal perfusion was associated with severely diminished wall thickening possibly due to stunning. We found an excellent correlation between wall thickening and left ventricular ejection fraction both for the patients with myocardial infarction and the patients without myocardial infarction (r = 0.86 and r = 0.82, respectively, both P<0.0001). A reasonable correlation between perfusion and left ventricular ejection fraction was found for the patients with myocardial infarction (r = 0.41, P = 0.002), and a non-significant correlation for the patients without myocardial infarction (r = 0.37, P = 0.1). Quantitative gated SPET myocardial imaging allows the detection of residual wall thickening in patients with a previous myocardial infarction who show severe fixed perfusion defects. In patients without myocardial infarction, gated SPET imaging allows differentiation between an attenuation artefact and a fixed perfusion defect due to coronary artery disease. In addition, gated SPET may show diminished ventricular function in normally perfused segments possibly due to myocardial stunning. The addition of gated SPET myocardial perfusion imaging increases diagnostic confidence and may have direct clinical implications for optimal patient management.     

Correct spatial normalization of myocardial perfusion SPECT improves detection of multivessel coronary artery disease

BACKGROUND: This study sought to improve the detection of multivessel coronary artery disease (CAD) with the use of rest and exercise single photon emission computed tomography (SPECT) perfusion scintigraphy by developing a processing scheme, which provides proper regional normalization of the images for interpretation. When SPECT perfusion images are interpreted, one area of myocardium serves as "normal." We hypothesized that if this "normal" region changes location from rest to stress, the stress images must be adjusted for proper interpretation. By taking into account the level of tracer activity in this "normal" area on the resting images, we could more accurately identify patients with multivessel CAD.Methods and results Dual-isotope rest (thallium 201) and exercise dobutamine or adenosine stress (technetium 99m sestamibi) perfusion SPECT studies were examined in 258 patients with 2- or 3-vessel CAD on coronary arteriography performed within 6 months of each other (mean interval, 19 days). If a shift in regional location of the "normal" segment from rest to stress was present, the images were (1) interpreted in the usual fashion for the number of vessels with ischemia (PRE-NORM) and (2) reinterpreted after quantitative normalization (ie, adjusting the display window until the intensity of the "normal" segment was matched at rest and stress [POST-NORM]). Interpretation was performed with blinding to arteriographic results. An angiographic stenosis was defined as luminal diameter stenosis greater than 50%. Three control groups comprising (1) single-vessel CAD (n = 119), (2) no significant angiographic CAD (n = 118), and (3) a normalcy group of low pre- and post-test probability of CAD (n = 44) were also studied to determine the incidence of false-positive results induced by the renormalization technique. A shift in the "normal" segment occurred in 81 studies of 258 patients (31%), 80 of which were read as abnormal PRE-NORM (sensitivity, 99%); however, for their 216 stenosed vessels, only 143 were detected PRE-NORM (vessel sensitivity, 66%; accuracy, 65%). The mean POST-NORM change in the display was 11%. POST-NORM, all 82 patients' studies were interpreted as abnormal (sensitivity, 100%), and 196 of 216 vascular territories were abnormal (vessel sensitivity, 91%; accuracy, 83%; both P <.0001 vs PRE-NORM). In the single-vessel disease, no significant disease, and normalcy groups, 19 of 119, 15 of 118, and 11 of 44 patients, respectively, demonstrated a shift in the peak pixel location. However, there were no significant changes in single-vessel sensitivity, angiographic specificity, or normalcy in these patients. CONCLUSIONS: With multivessel CAD, the "normal" region on SPECT often changes in location from rest to stress, potentially masking the extent and severity of multivessel ischemia. Renormalization of the images to match their resting level before image interpretation allows diagnosis of contralateral ischemia and strikingly improves the detection of multivessel CAD, without a substantive loss in specificity.