Medium- to long-term prognostic impact of dipyridamole thallum-201 myocardial single-photon emission computed tomography in elderly patients.

Dipyridamole thallium-201 single-photon emission computed tomography (SPECT) has not been extensively evaluated for risk stratification and the medium- to long-term prognostic value in elderly cardiac patients who are unable to exercise. The present study group comprised 210 consecutive patients aged at least 70 years with known or suspected coronary artery disease (CAD). The SPECT findings were classified as a reversible, fixed, or combined (reversible and fixed) defect. Of the 210 patients, 201 (77+/-5 years, 85 male) were successfully followed for 49+/-26 months. Thirteen (7%) patients had cardiac events: cardiac death (n=10), non-fatal myocardial infarction (n=1), or coronary artery bypass grafting (n=2). Cardiac events occurred in 3 of 112 patients with normal SPECT and in 10 of 89 patients with an abnormal scan (0.7% /year vs 2.8% /year, p=0.01). Stepwise Cox regression analysis revealed that the significant predictors of cardiac events were combined defects (relative risk 7.3) and the number of defect areas (relative risk 4.4). The predictive value of dipyridamole thallium-201 SPECT is maintained over 4 years in mixed populations of elderly CAD patients who are unable to exercise.     

Coronary angiography is the best predictor of events in renal transplant candidates compared with noninvasive testing

Guidelines for the detection of coronary artery disease (CAD) and assess of risk in renal transplant candidates are based on the results of noninvasive testing, according to data originated in the nonuremic population. We evaluated prospectively the accuracy of 2 noninvasive tests and risk stratification in detecting CAD (>or=70% obstruction) and assessing cardiac risk by using coronary angiography (CA). One hundred twenty-six renal transplant candidates who were classified as at moderate (>or=50 years) or high (diabetes, extracardiac atherosclerosis, or clinical coronary artery disease) coronary risk underwent myocardial scintigraphy (SPECT), dobutamine stress echocardiography, and CA and were followed for 6 to 48 months. The prevalence of CAD was 42%. The sensitivities and negative predictive values for the 2 noninvasive tests and risk stratification were <75%. After 6 to 48 months, there were 18 cardiac events, 9 fatal. Risk stratification (P=0.007) and CA (P=0.0002) predicted the crude probability of surviving free of cardiac events. The probability of event-free survival at 6, 12, 24, 36, and 48 months were 98%, 98%, 94%, 94%, and 94% in patients with <70% stenosis on CA and 97%, 87%, 61%, 56%, and 54% in patients with >or=70% stenosis. Multivariate analysis showed that the sole predictor of cardiac events was critical coronary lesions (P=0.003). Coronary angiography may still be necessary for detecting CAD and determining cardiac risk in renal transplant candidates. The data suggest that current algorithms based on noninvasive testing in this population should be revised.     

Incremental prognostic value of myocardial perfusion 99m-technetium-sestamibi SPECT in the elderly

Coronary artery disease (CAD) is the main cause of death in elderly patients. Single-photon emission computed tomography (SPECT) with technetium-99m ((99m)Tc)-labeled agents is extremely useful for the diagnosis and risk stratification of CAD in the general population. However, its prognostic value for the elderly has not been established. This study examined disease outcome in 328 patients aged 74 or older, with suspected CAD who were submitted to either pharmacological (dipyridamole) or exercise stress SPECT with (99m)Tc-sestamibi, seven of whom were completely lost to follow-up. Endpoints were defined as hard (myocardial infarction or cardiac death) or total events (myocardial infarction, cardiac death or myocardial revascularization). Mean follow-up was 34+/-15 months. During this period 24 cardiac deaths, 11 myocardial infarctions and 21 cases of revascularization were observed. Perfusion defects were found in 27.1% of patients (12.8% reversible, 6.2% partially reversible and 8.1% fixed). Abnormal studies were predominant in men, patients with chest pain and those with ST-T abnormalities in the baseline electrocardiogram (ECG) or in the exercise treadmill test. An abnormal scan was significantly associated with cardiac events (P<0.0001). Multivariate analysis revealed that a abnormal scan was the most important independent predictor of hard or total cardiac events. Event rates increased according to myocardial perfusion scintigraphy (MPS): <1.0% of hard events per year in patients with normal MPS versus 14.3% per year in those with abnormal MPS. (99m)Tc-sestamibi SPECT was demonstrated to be a powerful tool for the prognostic evaluation of elderly patients with suspected CAD.     

Frequency and prognostic significance of silent coronary artery disease in patients with cerebral ischemia undergoing carotid endarterectomy.

To evaluate the prevalence and prognostic role of silent coronary artery disease (CAD) in patients with symptomatic high-grade carotid stenosis (70 to 99%) undergoing carotid endarterectomy, and with neither history nor symptoms of CAD, 106 patients (76 men, 30 women, mean age 58.7 years [range 42 to 71]) with recent cerebral ischemia were prospectively studied. Patients were stratified as to the presence (n = 27, 25%) or absence (n = 79, 75%) of silent CAD defined by concordant abnormal exercise electrocardiographic testing and thallium-201 myocardial scintigraphy. The male sex, the severity of the symptomatic carotid lesion (greater than 90%), and the coexistence of contralateral carotid disease identified patients with higher probability of coexisting CAD. The 106 patients underwent 121 operations (bilateral in 15). In the perioperative period, no deaths or cardiac events occurred, 1 patient suffered a recurrent stroke and 3 had a transient ischemic attack. During a mean follow-up period of 5.4 years, 9 patients died (1.7%/year): fatal myocardial infarction occurred in 5 (all in the silent CAD group), cancer in 3 and vertebrobasilar stroke in 1. Nonfatal events occurred in 9 patients: myocardial infarction in 1 (without silent CAD), unstable angina in 3 (with silent CAD), and cerebral ischemic attacks in 5. After 7 years, the Kaplan-Meier estimated survival free from coronary events was 51% in patients with silent CAD, and 98% in patients without CAD (p less than 0.01). In conclusion, among patients with symptomatic high-grade carotid stenosis undergoing carotid endarterectomy, even in absence of history or symptoms of CAD, a silent CAD is detectable in one fourth of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

99mTc-MIBI门电路SPECT对冠心病的诊断和心肌存活性评价的作用

为进一步评价99m锝-甲氧基异睛(99mTc-MIBI)门电路和非门电路单光子发射断层显像(SPECT)对冠心病的诊断价值及硝酸甘油介入诊断试验在心肌存活状态评价中的作用,对40例进行运动心肌灌注断层显象,并与冠状动脉(冠脉)造影比较.结果32例冠脉造影显示冠脉有意义狭窄.门电路断层显象对冠心病诊断总的敏感和特异性分别为93.8%和87.5%;非门电路断层显象分别为84.4%和87.5%,两相比较,无显著性差异(P＞0.05).对冠脉病变支数诊断敏感性门电路方法优于非门电路方法(分别为73.8%和62.3%,P＜0.05).特异性均为96.6%.20例进行含服硝酸甘油后静态心肌灌注断层显象,16例心肌梗死病人中有3例为部分可逆性心肌灌注缺损,4例慢性心肌缺血病人,全部有可逆性心肌灌注.表明硝酸甘油介入诊断试验有助于心肌灌注异常可逆性的评估;99mTc-MIBI门电路SPECT和硝酸甘油介入诊断试验是有效的对冠心病无创性诊断和心肌存活状态评价方法.     

Prognostic value of supine bicycle exercise stress echocardiography in patients with known or suspected coronary artery disease.

AIMS: To assess the prognostic significance of supine bicycle exercise stress echocardiography (ESE) for cardiac events, and the ESE additional role compared to other traditional clinical and echo variables, in patients with proven or suspected coronary artery disease (CAD). METHODS AND RESULTS: Clinical status and long-term outcome were assessed in 607 patients, for a mean period of 49.9 +/- 12.5 months. ESE was performed for the diagnosis of suspected CAD in 267 patients, and for the risk stratification in 340 patients. At baseline, the mean value of WMSI was 1.22 +/- 0.36, and the mean left ventricular ejection fraction was 58.2 +/- 10.9%. The ESE was positive for ischemia in 210 patients (34.9%), while the ECG was suggestive for ischemia in 157 patients. At peak effort, the mean WMSI was 1.38 +/- 0.46. Low work load was achieved by 158 patients (26.1%). During the follow-up period there were 222 events, including 48 cardiac deaths and 34 acute non-fatal myocardial infarction. By multivariable model, cigarette smoking, peak WMSI, positive ESE for ischemia and low work load were the only independent predictors of cardiac death. The cumulative 5-year mean survival rate according to ESE response was 95.9% in patients with negative ESE, and 81.7% in positive ESE (p < 0.00001). CONCLUSIONS: In patients with known or suspected CAD able to perform a physical stress, bicycle ESE is able to stratify patients at higher risk of cardiac events. The final report of an ESE performed for prognostic purpose should include both the assessment of induced dyssinergy and the evaluation of indexes of the extent and the severity of myocardial ischemia.     

Prognostic value of exercise echocardiography in patients with classic angina pectoris

The role of stress echocardiography in the prognostic evaluation of patients with angina pectoris is not well defined. This study included 437 patients (241 men and 196 women) with angina pectoris and a pretest probability of coronary artery disease (CAD) of > or = 0.7 who were referred for exercise echocardiography. No patient had a history of acute myocardial infarction or coronary revascularization. Mean age was 65 +/- 10 years. During a median follow-up of 2.7 years, hard cardiac events (cardiac death or nonfatal myocardial infarction) occurred in 19 patients and 53 patients underwent coronary revascularization. Event-free survival rates in patients with normal versus abnormal stress echocardiograms were 98% versus 83% at 1 year, 96% versus 75% at 3 years, and 87% versus 69% at 5 years, respectively. In a multivariate analysis of clinical, exercise stress, and echocardiographic parameters, independent predictors of hard cardiac events were Q waves on the electrocardiogram (chi-square 8.7, p = 0.003) and the presence of wall motion abnormalities during exercise in multivessel distribution (chi-square 5.3, p = 0.02). In an incremental model of clinical, exercise, and echocardiographic variables for the prediction of all cardiac events, the addition of echocardiographic data increased the chi-square of the model from 62 to 78 (p = 0.0003). Exercise echocardiography provides useful information in the risk stratification of patients with suspected CAD and a high pretest probability of CAD. Patients with normal exercise echocardiograms have a low event rate and therefore can be exempted from invasive procedures during the 3 years after a normal exercise echocardiogram.     

Value of gated SPECT myocardial perfusion imaging for individual cardiac risk assessment

Myocardial perfusion imaging enables not only accurate diagnosis of disease but also entails prognostic value. Myocardial perfusion SPECT contributes to assessment of future cardiac events independently of other clinical parameters. A normal stress myocardial perfusion scan is associated with a favorable prognosis independent of history, symptoms, and exercise electrocardiography test variables. Cardiac risk and benefit from invasive therapeutic strategies increase in relation to the severity of the abnormality of perfusion and function assessed by gated myocardial perfusion SPECT. Thus, stress myocardial perfusion imaging may serve as a gatekeeper for referral to coronary angiography enabling effective risk stratification in patients with suspected or documented coronary artery disease.     

Utility of Stress Single-Photon Emission Computed Tomography (SPECT) Perfusion Imaging in Predicting Outcome After Coronary Artery Bypass Grafting

Previous studies have examined the predictors of outcome in medically treated patients with coronary artery disease (CAD). There is limited information on predictors of outcome after coronary artery bypass grafting (CABG). This study examined the predictors of outcome of 255 patients with CAD, at a mean time of 5 years after CABG for angina pectoris. The 255 patients underwent coronary angiography and stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging after CABG. During a mean follow-up of 41 ± 28 months after stress testing, there were 34 hard events (24 cardiac deaths and 10 nonfatal myocardial infarctions). The hemodynamics during stress testing, and age and gender were not predictors of events. The SPECT variables of multivessel perfusion abnormality, perfusion deficit size, and increased lung thallium uptake were predictors of death and total events by uni- and multivariate survival analysis. There were 14 events in 45 patients (31%) with multivessel abnormality and increased lung thallium uptake, 14 events in 101 patients (14%) with either multivessel abnormality or increased lung uptake, and 6 events in 109 patients (6%) with neither of these 2 variables (p = 0.0001). The annual mortality and total event rates were 7.5% and 9.5% with both variables, 3.4% and 4.3% with either variable, and 0.6% and 1.7% with neither of the variables (p = 0.01). Thus, stress SPECT perfusion imaging is useful to stratify patients after CABG into low, intermediate, and high risk groups for future cardiac events.     

Increased all-cause and cardiac morbidity and mortality associated with the diagonal earlobe crease: a prospective cohort study

PURPOSE: To ascertain whether the diagonal earlobe crease (ELC) is associated prospectively with future death or cardiac events over 8 years of follow-up in two sets of patients: those with known coronary artery disease (CAD) and those without evidence for CAD. PATIENTS AND METHODS: We performed a prospective, observational study of 108 patients in four cohorts (each matched for age, sex, and race, but differing in the presence or absence of both a diagonal ELC and CAD in 1979 to 1982). Follow-up information was gathered by telephone interviews, and dates and causes of death were determined by reference to death certificates (n = 48), hospital records (n = 9), or attending physician statements (n = 1). RESULTS: During 8 to 10 years of follow-up, 58 of the patients had died. Patients with ELCs had poorer survival rates than those without creases, by stratified log-rank test (p = 0.006 for the cohorts thought not to have CAD, and p = 0.058 for those with CAD). Cardiac death rates (due to acute myocardial infarction, "sudden cardiac death," or heart failure) were also higher for patients with ELCs: 8.0 versus 0.9 cardiac deaths per 100 patient-years (p less than 0.001) in patients without CAD at entry, and 11.7 versus 3.7 cardiac deaths per 100 patient-years (p = 0.008) in patients with CAD in 1979 to 1982. Cardiac event rates (cardiac death, nonfatal myocardial infarction, or coronary artery bypass surgery) were also higher in those with ELCs: 10.4 versus 1.4 events per 100 patient-years (p less than 0.001) for those without known CAD, and 15.8 versus 5.7 events per 100 patient-years (p = 0.009) for those with CAD. CONCLUSION: These results suggest that a diagonal ELC is associated with increased all-cause and cardiac morbidity and mortality. Patients with ELCs may be at higher risk for coronary events, and might be especially cautioned to control or reduce other cardiac risk factors, even if currently without diagnostic evidence of CAD.     

Prediction of cardiac death in hemodialysis patients by myocardial fatty acid imaging.

OBJECTIVES: The aim was to evaluate the potential of single-photon emission computed tomography (SPECT) to predict cardiac death in chronic hemodialysis patients using the iodinated fatty acid analogue iodine-123 123I-beta-methyl iodophenyl-pentadecanoic acid (BMIPP). BACKGROUND: We previously reported that BMIPP SPECT could detect asymptomatic coronary artery disease with high sensitivity in hemodialysis patients. METHODS: We prospectively enrolled 375 asymptomatic hemodialysis patients who had undergone dual SPECT using 123I-BMIPP and 201thallium (Tl) chloride. Patients who had a clinical history of myocardial infarction and/or coronary revascularization were excluded from the study. Uptake on SPECT images was graded in 17 segments on a 5-point scale (0 normal, 4 absent) and assessed as summed BMIPP or Tl scores. RESULTS: During a 3.6 +/- 1.0-year follow-up, 57 patients who had undergone coronary revascularization within 60 days of SPECT were excluded from the analysis. Among the remaining 318 patients (male/female: 170/148; 64 +/- 12 years of age), 50 died of cardiac events (acute myocardial infarction 22, congestive heart failure 17, cardiac sudden death 11). Stepwise Cox hazard analysis associated cardiac death with age (> or =70 years) and with severely abnormal BMIPP SPECT images (BMIPP summed scores > or =12: hazard ratio 21.894; p < 0.0001). Kaplan-Meier analysis showed that the cardiac death-free survival rates at 3 years were 61% and 98% in patients with BMIPP summed scores of > or =12 and <12, respectively. CONCLUSIONS: Severely impaired myocardial fatty acid metabolism, which might mainly reflect repetitive myocardial ischemia, can identify a high-risk group of cardiac death among hemodialysis patients.     

Risk stratification of single or double vessel coronary artery disease and impaired left ventricular function using exercise radionuclide angiography

Patients with 3-vessel coronary artery disease (CAD) and normal left ventricular (LV) function have a worse prognosis if they manifest ischemia during exercise testing. The present study determines if exercise radionuclide angiography can aid in the risk stratification of patients with 1- or 2-vessel CAD and impaired LV function (ejection fraction less than 50%). Sixty-five consecutive patients with these findings were followed for a median duration of 24 months (range 12 to 49). Eleven of the 65 patients (17%) had severely ischemic exercise radionuclide angiograms, defined as: a decrease in ejection fraction with exercise; greater than or equal to 1.0 mm of ST-segment depression; and peak exercise workload less than or equal to 600 kg-m/min. During follow-up 11 patients had initial significant cardiac events: 4 cardiac deaths, 1 cardiac arrest, 4 myocardial infarctions and 2 bypass or angioplasty procedures for unstable angina greater than or equal to 3 months after the exercise study. Four of 11 patients (36%) with severely ischemic exercise radionuclide angiograms had events, compared to 7 of 54 patients (13%) without ischemic radionuclide angiograms. Event-free survival at 18 months was 73% for patients with severe exercise ischemia versus 92% for those without ischemia (p less than 0.05). Univariate analysis showed that severe ischemia on radionuclide angiography was the only variable of several tested that significantly predicted future cardiac events (chi-square = 8.16, p less than 0.005). Among patients with 1- or 2-vessel CAD and impaired resting LV function, severe ischemia on exercise radionuclide angiography identifies a subgroup at high risk for future cardiac events.     

Planar myocardial perfusion imaging for evaluation of patients with acute chest pain

BACKGROUND: Rest single-photon emission computed tomographic (SPECT) perfusion imaging identifies acute myocardial ischemia in patients with chest pain in the emergency department; however, the costs are high and radioisotopic services are usually not available 24 h a day. Planar imaging through a portable gamma camera may be useful in this setting. However, planar imaging might be associated with less predictive values in comparison with a gated SPECT imaging. We sought to evaluate rest planar myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia. METHODS: Patients within 6 h of chest pain onset and nondiagnostic electrocardiograms (ECGs) underwent planar myocardial perfusion imaging. Studies showing perfusion defects were considered suggestive of acute coronary syndromes. The results of planar scintigraphy were compared with the clinical diagnosis and outcomes. All patients were followed up and monitored for the occurrence of major cardiac events 120 days after hospital discharge. RESULTS: 71 patients underwent scintigraphy. Twenty-one (30%) patients had acute coronary syndromes, 15 (21%) had major cardiac events (8 had myocardial infarction and 7 underwent myocardial revascularization). Planar scintigraphy demonstrated perfusion defects in 21 patients, 16 (76%) patients with acute coronary syndromes, 12 (80%) patients who had major cardiac events and in 7 (88%) patients with myocardial infarction. The negative predictive value of planar scintigraphy was 90% for diagnosis of acute coronary syndromes and 94% for detecting major cardiac events. CONCLUSION: Early planar myocardial perfusion imaging allowed rapid and accurate risk stratification of emergency departments patients with possible myocardial ischemia and nondiagnostic ECGs.     

Review of coronary artery disease in patients with infrarenal abdominal aortic aneurysm.

In the process of establishing a less invasive assessment strategy for coronary artery disease (CAD) in patients with infrarenal abdominal aortic aneurysm (AAA), the incidence of CAD and the surgical and mid-term outcomes were reviewed. From January 1994 through September 2001, 94 elective surgical repairs of AAA were carried out. Preoperative coronary angiography showed 43 patients (45.7%) had CAD: 29 (67.4%) were asymptomatic, 23 had single-vessel disease (1VD), 12 had 2VD and 8 had 3VD. Of the 43 patients with CAD, 19 (44.2%) underwent coronary interventional therapy before aortic surgery (11 percutaneous transluminal coronary angioplasty (PTCA), 8 coronary artery bypass grafting). Eight asymptomatic patients underwent coronary interventional therapy. None of the patients died of cardiac causes or experienced a postoperative cardiac event. During the follow-up period, 10 late deaths occurred: 7 patients with CAD, and 3 cerebrovascular or cardiac deaths. There was no statistical difference in the survival rate between the groups with and without CAD. Two patients with CAD underwent PTCA during the follow-up period. The findings confirm the need for a less invasive assessment strategy of CAD that does not overlook asymptomatic myocardial ischemia, because the incidence of CAD in patients with AAA is high.     

Gated single-photon emission computed tomographic myocardial imaging: a new tool in clinical cardiology

BACKGROUND: Gated single-photon emission computed tomography (gated SPECT) myocardial perfusion imaging allows the analysis of left ventricular (LV) perfusion and function during the same acquisition. RESULTS: Gated SPECT provides additional information to myocardial perfusion, which improves test specificity in patients with known or suspected coronary artery disease and hence diminishes the amount of borderline diagnosis. Because gated SPECT provides reliable information on LV ejection fraction and LV volumes, it is also a valuable tool in risk stratification. In addition, from gated SPECT, images can be reconstructed from which wall motion can be assessed showing a good correlation with wall motion assessed by accepted imaging modalities as echocardiography, magnetic resonance imaging, and contrast angiography. In the future wall motion analysis from gated SPECT may also be used for revascularization stratification. CONCLUSIONS: Gated SPECT gives important additional information beyond myocardial perfusion imaging alone, which could have major clinical implications for optimal patient management.     

Prognostic significance of myocardial ischemia during dobutamine stress echocardiography in asymptomatic patients with diabetes mellitus and no prior history of coronary events

The prognostic significance of myocardial ischemia assessed by dobutamine stress echocardiography in asymptomatic patients with diabetes mellitus who have no previous coronary artery disease remains unclear. We assessed the value of dobutamine stress echocardiography for risk stratification in 161 asymptomatic patients with type 2 diabetes (mean 62 +/- 12 years of age; 96 men) who had no previous myocardial infarction or revascularization. End point during follow-up was hard cardiac events (cardiac death and nonfatal myocardial infarction). Ischemia was detected in 45 patients (28%). During a median follow-up of 5 years, 40 patients (25%) died (18 cardiac deaths) and 7 patients had nonfatal myocardial infarction (25 hard cardiac events). An abnormal dobutamine stress echocardiogram was associated with a higher mortality compared with a normal dobutamine stress echocardiogram (p = 0.03). In an incremental multivariate analysis model, clinical predictors of hard cardiac events were age and hypercholesterolemia. Ischemia was incremental to the clinical parameters. In conclusion, myocardial ischemia is an independent predictor of cardiac events in asymptomatic diabetic patients with no previous coronary artery disease.     

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.     

Usefulness of stress gated technetium-99m single photon emission computed tomographic myocardial perfusion imaging for the prediction of cardiac death in patients with moderate to severe left ventricular systolic dysfunction and suspected coronary artery disease

Although stress gated technetium-99m single-photon emission computed tomographic (SPECT) myocardial perfusion imaging (MPI) is useful in differentiating ischemic from nonischemic cardiomyopathy, its prognostic usefulness in this patient population is not well understood. Consecutive unique patients with suspected coronary artery disease who, for clinical indications, underwent technetium-99m rest and stress MPI demonstrating ejection fractions ≤40% by gated SPECT imaging were retrospectively identified. In addition to prescan variables, previously defined cutoffs for gated SPECT parameters using visual and standard 17-segment semiquantitative scoring were applied and related to the occurrence of cardiac death up to 5 years after MPI. Of the 475 patients fulfilling criteria for study inclusion, follow-up was complete in 444 (93%) over 3.7 ± 1.6 years. Of 393 patients without subsequent early (≤60 days) coronary revascularization, cardiac death occurred in 64 (16%). The summed stress score, an MPI measure of the extent and severity of coronary artery disease that also accounts for the ischemic burden, was the gated SPECT parameter most related to cardiac death with Kaplan-Meier 5-year cardiac death-free survival of 85.6% and 67.3% in patients with summed stress scores ≤8 and >8, respectively (p <0.001). In multivariate Cox regression analysis, a summed stress score >8 independently contributed to cardiac death (adjusted hazard ratio 2.20, 95% confidence interval 1.34 to 3.61), and its addition to the model significantly increased the global chi-square value over prescan variables (from 32.46 to 41.67, p = 0.002). In conclusion, stress MPI data from gated technetium-99m SPECT scans are useful for the prediction of cardiac death in patients with moderate to severe left ventricular systolic dysfunction in whom there is suspicion of underlying coronary artery disease.     

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

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

Clinical significance of inter-arm pressure difference and ankle-brachial pressure index in patients with suspected coronary artery disease

BACKGROUND: Although measuring blood pressure at the bilateral brachia is common in medical practice, its clinical significance in patients with suspected coronary artery disease (CAD) has not been fully clarified. METHODS: To define the significance of inter-arm systolic blood pressure difference in patients with suspected CAD, and to assess the relationship between inter-arm pressure difference and CAD, simultaneous brachial and ankle blood pressure measurements and stress myocardial single-photon emission computed tomography (SPECT) were performed in 386 consecutive patients with suspected CAD, excluding those with previous myocardial infarction or coronary revascularization. RESULTS: Subclavian artery stenosis, defined as > or = 15 mmHg inter-arm systolic blood pressure difference, was found in 27 patients (7%). Age (65 +/- 12 vs 65 +/- 11 years), male sex (21/27 vs 244/359), prevalence of hypertension(63% vs 56%), hypercholesterolemia (63% vs 62%), diabetes mellitus(33% vs 38%), cigarette smoking (44% vs 41%) and family history of CAD (15% vs 12%) were similar between patients with subclavian artery stenosis and those without. The incidence of decreased ankle-brachial pressure index (ABI) was higher (37% vs 12%, p = 0.001), and percentage ischemic myocardium as assessed by SPECT was greater (9.0 +/- 8.5% vs 5.6 +/- 6.6%, p < 0.05) in patients with subclavian artery stenosis than in those without. Furthermore, significant correlations were observed between inter-arm pressure difference and percentage ischemic myocardium (r = 0.13; p = 0.01), and ABI (r = -0.26, p < 0.0001). Among 386 patients, 283 underwent coronary angiography, and 63% of those who had inter-arm blood pressure difference had CAD. Furthermore, 83% of those CAD patients had multi-vessel CAD, which is regarded as a high-risk subset for subsequent cardiac events. CONCLUSIONS: Inter-arm pressure difference is often found in patients with suspected CAD, and is associated with significant CAD and peripheral artery disease. Thus, inter-arm pressure difference may be regarded as a simple marker for coronary and peripheral artery diseases.