The detection of coronary artery disease: A comparison of exercise thallium imaging and exercise equilibrium radionuclide ventriculography

This study compared the accuracy of rest and exercise gated equilibrium technetium ventriculography with exercise thallium imaging in 50 consecutive male patients undergoing routine coronary angiography for the evaluation of chest pain. No patients were excluded on the basis of prior myocardial infarction, nature of angiographically defined coronary disease or symptoms. Antianginal therapy was continued in all patients. Eight patients had normal coronary arteries, 9 had single vessel, disease, 20 had double vessel disease and 13 had triple vessel disease. Sixteen patients had previously documented myocardial infarction. Using exercise radionuclide ventriculography, 34 patients with coronary disease were detected resulting in a sensitivity of 81%; 6 patients with normal coronary arteries had normal scans, a specificity of 75%, with a predictive accuracy of 80%. In comparison, thallium imaging detected 42 patients with coronary disease resulting in a sensitivity of 100%. Six patients with normal coronary arteries had normal thallium images resulting in a specificity of 75% and a predictive accuracy of 96%. These results suggest that exercise thallium imaging is a more accurate investigation than exercise equilibrium radio-nuclide ventriculography and is the investigation of choice in the noninvasive detection of coronary artey disease.     

Detection of coronary artery disease by exercise radionuclide ventriculography: using sector analysis

Exercise first-pass radionuclide ventriculography was performed on 65 patients with coronary artery disease (CAD) and 18 control subjects with normal coronary artery, Left ventricle (LV) was divided into 5 sectors in radial, and volume curves were generated for whole LV and each sector for estimating LVEF and time to end systole (TES). The differences of TES between whole LV and each sector were calculated and these 5 differences were averaged (Variation of TES). We defined this Variation of TES as an index of LV asynchrony, and used for detection of CAD. The overall sensitivity and specificity for identifying CAD were 63% and 83% (LVEF during exercise), 51% and 83% (delta LVEF). Variation of TES during exercise had a sensitivity and a specificity of 88% and 83%, and was more sensitive than both LVEF during exercise and delta LVEF (p less than 0.01). In conclusion, Variation of TES was a good marker of LV asynchrony and useful for the detection of CAD.     

Combined evaluation of first-pass radionuclide angiography and equilibrium radionuclide ventriculography in the diagnosis of coronary artery disease

The results of 203 patients who underwent firstpass radionuclide angiography (FP), as well as quantitative equilibrium radionuclide ventriculography (qERNV), were stored in a data base system and evaluated statistically. In patients with coronary artery disease (CAD) without previous myocardial infarction (MI), evaluation of global and regional ejection fraction (gEF, rEF) at rest revealed a poor sensitivity of 64% (Rest-qERNV) and 69% (Rest-FP), respectively. In patients with a history of one previous MI, the sensitivity of both methods was equivalent: FP 87% and qERNV 84%. In patients with several MIs, sensitivity was higher than 90%. Concerning localization of MI, remarkable differences between FP and qERNV were found. In posterior wall infarction, the FP sensitivity was 87% and qERNV only 67%, whereas in anterior wall infarction, the results were similar for both methods: 93% (FP) and 96% (qERNV), respectively. Since 30° RAO camera position achieves the best visualization of the anterior and posterior wall, FP is superior to qERNV in the evaluation of posterior wall asynergies. In addition, qERNV often fails to discriminate anterior and posterior wall motion abnormalities.     

Exercise radionuclide ventriculography: practical considerations and sensitivity of coronary artery disease detection.

Eighty-nine patients were evaluated for coronary artery disease (CAD) with exercise radionuclide ventriculography (ERV) and contrast coronary angiography. In 70 patients with documented lesions the ERV was abnormal in 65 for a sensitivity of 93%. In patients with normal coronary arteries, the ERV was abnormal in none for a specificity of 100%. Sensitivity of ERV for detecting CAD was affected by the level of exercise achieved. In patients with documented CAD who achieved adequate exercise (i.e., pressure rate product (PRP) greater than 250 or the development of angina or ST segment depression during exercise), the sensitivity was 98% (56 of 57 patients). In those with documented CAD who failed to achieve adequate exercise, the sensitivity was 69% (9 of 13 patients).     

Combined evaluation of first pass radionuclide angiography and equilibrium radionuclide ventriculography in the diagnosis of coronary artery disease

Results of 203 patients who underwent first pass radionuclide angiography (FP) and quantitative equilibrium radionuclide ventriculography (qERNV) were stored in a data base system and evaluated statistically. Eighty eight of these patients also underwent exercise equilibrium radionuclide ventriculography (E-qERNV). In patients with coronary artery disease (CAD) without previous myocardial infarction (MI), evaluation of global and regional ejection fraction (gEF, rEF) at rest revealed a poor sensitivity of 64%, the specificity was about 71% (qERNV). FP at rest revealed similar values of sensitivity (69%) and specificity (83%). Additional assessment of stress induced changes of gEF, significantly (P<0.05) improved sensitivity of qERNV in CAD patients without a history of previous MI to 84% (specificity 86%). In patients with one previous MI, however, similar values of sensitivity were found (RFP: 87%, R-qERNV: 84%, E-qERNV: 93%). In patients with several MI's, sensitivity was above 90% at rest and during exercise (R-FP: 96%, R-qERNV: 93%, E-qERNV: 100%).     

Combined evaluation of first pass radionuclide angiography and equilibrium radionuclide ventriculography in the diagnosis of coronary artery disease. II. Results during exercise

Results of 203 patients who underwent first pass radionuclide angiography (FP) and quantitative equilibrium radionuclide ventriculography (qERNV) were stored in a data base system and evaluated statistically. Eighty eight of these patients also underwent exercise equilibrium radionuclide ventriculography (E-qERNV). In patients with coronary artery disease (CAD) without previous myocardial infarction (MI), evaluation of global and regional ejection fraction (gEF, rEF) at rest revealed a poor sensitivity of 64%, the specificity was about 71% (qERNV). FP at rest revealed similar values of sensitivity (69%) and specificity (83%). Additional assessment of stress induced changes of gEF, significantly (P less than 0.05) improved sensitivity of qERNV in CAD patients without a history of previous MI to 84% (specificity 86%). In patients with one previous MI, however, similar values of sensitivity were found (R-FP: 87%, R-qERNV: 84%, E-qERNV: 93%). In patients with several MI's, sensitivity was above 90% at rest and during exercise (R-FP: 96%, R-qERNV: 93%, E-qERNV: 100%).     

Combined evaluation of first-pass radionuclide angiography and equilibrium radionuclide ventriculography in the diagnosis of coronary artery disease. I. Results at rest

The results of 203 patients who underwent first-pass radionuclide angiography (FP), as well as quantitative equilibrium radionuclide ventriculography (qERNV), were stored in a data base system and evaluated statistically. In patients with coronary artery disease (CAD) without previous myocardial infarction (MI), evaluation of global and regional ejection fraction (gEF, rEF) at rest revealed a poor sensitivity of 64% (Rest-qERNV) and 69% (Rest-FP), respectively. In patients with a history of one previous MI, the sensitivity of both methods was equivalent: FP 87% and qERNV 84%. In patients with several MIs, sensitivity was higher than 90%. Concerning localization of MI, remarkable differences between FP and qERNV were found. In posterior wall infarction, the FP sensitivity was 87% and qERNV only 67%, whereas in anterior wall infarction, the results were similar for both methods: 93% (FP) and 96% (qERNV), respectively. Since 30 degrees RAO camera position achieves the best visualization of the anterior and posterior wall, FP is superior to qERNV in the evaluation of posterior wall asynergies. In addition, qERNV often fails to discriminate anterior and posterior wall motion abnormalities.     

Quantitative equilibrium radionuclide ventriculography at rest in the evaluation of the severity of coronary disease

The results of examining 373 patients with a quantitative equilibrium radionuclide ventriculography were stored in a data bank and evaluated statistically. The following left ventricular parameters were evaluated: global and regional ejection fractions ( gEF , rEF1 - rEF5 ) and volume parameters (EDV, ESV, stroke volume, cardiac output, heart index). It appeared that in stages I and II of coronary heart disease evaluation of gEF , EDV and ESV under resting conditions does not sufficiently discriminate diseased patients from normals. Significant changes (p less than 0.025) of these parameters (vs. normal) were found only in CHD III and IV or in patients with a history of old myocardial infarction. The additional evaluation of the regional fraction yields, however, a significant increase (CHD I and II: +25%) of the sensitivity of the equilibrium radionuclide ventriculography in the diagnosis of coronary heart disease.     

Diagnosis of coronary artery disease using thallium imaging: tomographic versus planar imaging

Coronary artery disease was evaluated with tomographic and planar thallium imaging in 31 subjects who had undergone coronary angiography for assessment of chest pain syndrome. Coronary arteriography revealed significant coronary artery disease in 17; and 14 had normal coronary arteries. The sensitivity and specificity for planar imaging was 71% and 79%, and that for tomography, 94% and 79% respectively. The sensitivity and specificity figures for individual coronary artery lesion detection for planar imaging were 87/83 for LAD, 33/100 for LCX and 50/86 for RCA respectively, and for tomography the figures were 87/87 for LAD, 33/95 for LCX and 90/76 for RCA respectively. The use of coronary arteriography as a gold standard was considered by assessing its interobserver variability, which was 16%. The interobserver variability for thallium imaging was 8% and 3% respectively for tomographic and planar acquisitions.     

Comparison between dipyridamole and adenosine as pharmacologic coronary vasodilators in detection of coronary artery disease with thallium 201 imaging

Background

Both dipyridamole and adenosine are widely used as pharmacologic stressors with ²⁰¹Tl imaging for detection of coronary artery disease. The purpose of this study was to compare dipyridamole and adenosine ²⁰¹Tl imaging directly in patients with angiographically proved coronary artery disease.

Methods and Results

Fifty-four patients were submitted to two planar ²⁰¹Tl studies: one with dipyridamole and the other with adenosine. The interval between the two studies varied from 2 to 7 days and the order was assigned randomly. Three standard planar views were obtained 10 minutes and 4 hours after the injection of 3.0 mCi ²⁰¹Tl. Administration of dipyridamole was as follows: 0.142 mg/kg/min during 4 minutes, followed by a slight exercise and ²⁰¹Tl injection. The infusion of adenosine was as follows: 0.140 mg/kg/min during 6 minutes with injection of ²⁰¹Tl after the third minute of infusion. Patients were asked to give their preference considering the number type, severity, and duration of side effects on a scale from 0 (worst) to 5 (best). Reading was done by two experienced observers. The heart was divided into three segments per view. The change in systolic blood pressure was-12±11 mm Hg for adenosine and-5±10 mm Hg for dipyridamole (p<0.001), and the change in heart rate was 18±10 beats/min for adenosine and 8±7 beats/min for dipyridamole (p<0.001). With regions of interest, ischemic/normal wall ratios were determined: 0.78 ± 0.06 for adenosine and 0.83±0.08 for dipyridamole (p<0.001). Adenosine detected 295 normal, 170 ischemic, and 21 scar segments, whereas dipyridamole detected 326, 135, and 25 segments, respectively. Patients preferred adenosine (4.3±1.0 for adenosine vs 3.8±1.5 for dipyridamole; p<0.04) mainly because of the short duration of side effects.

Conclusion

This study shows that the use of adenosine with ²⁰¹Tl imaging may have some advantages over dipyridamole.     

Functional imaging of peripheral vascular disease: a comparison between exercise whole-body thallium perfusion imaging and contrast arteriography.

Whole-body thallium scintigraphy was used to study leg muscle perfusion in 12 healthy individuals and 31 patients with peripheral vascular disease. Subjects were scanned immediately after exercise and 4 hr later. Buttock, thigh and calf perfusion were measured in terms of fractional uptake relative to whole-body activity, percent change in fractional uptake over 4 hr and interextremity symmetry ratios. The results were compared to contrast arteriography on a region by region basis. The overall sensitivity and specificity of thallium scintigraphy were 80% and 73%, respectively. The results suggest that thallium scintigraphy may provide useful information about the hemodynamic significance of noncritical anatomic lesions.     

Improved detection of coronary artery disease by estimated myocardial thallium uptake

Myocardial thallium uptake has been assessed at the time of thallium scanning in a group of 50 male patients undergoing coronary arteriography and 10 young healthy volunteers. The net thallium dose injected was obtained by counting the dose prior to injection using the gamma camera and counting the syringe and IV cannula after injection. Significantly higher levels of myocardial thallium uptake were obtained in both the volunteers and patients with normal coronary anatomy (1.36% +/- 0.32%, n = 10 and 0.93% +/- 0.26%, n = 9, respectively) compared to patients with single, double or triple vessel coronary artery disease (0.63% +/- 0.19%, n = 11; 0.70% +/- 0.20%, n = 15; 0.67 +/- 0.18, n = 15, respectively). Exercise tests were positive in 46% of patients with coronary artery disease with an overall predictive accuracy of 56%. Thallium scans were positive in 68% of patients at a specificity of 89%. If the range of myocardial thallium uptake from the patients with normal coronary arteries is used to define a lower limit of normal, then the sensitivity of the thallium scan with thallium uptake is 90% with a predictive accuracy of 90% in the detection of significant coronary artery disease in this group of patients. Thus, estimation of total % thallium uptake is a simple index which yields useful diagnostic clinical information.     

Improved detection of coronary artery disease by estimated myocardial thallium uptake

Myocardial thallium uptake has been assessed at the time of thallium scanning in a group of 50 male patients undeergoing coronary arteriography and 10 young healthy volunteers. The net thallium dose injected was obtained by counting the dose prior to injection using the gamma camera and counting the syringe and IV cannula after injection. Significantly higher levels of myocardial thallium uptake were obtained in both the volunteers and patients with normal coronary anatomy (1.36%±0.32%, n=10 and 0.93%±0.26%, n=9, respectively) compared to patients with single, double or triple vessel coronary artery disease (0.63%±0.19%, n=11; 0.70%±0.20%, n=15; 0.67±0.18, n=15, respectively). Exercise tests were positive in 46% of patients with coronary artery disease with an overall predictive accuracy of 56%. Thallium scans were positive in 68% of patients at a specificity of 89%. If the range of myocardial thallium uptake from the patients with normal coronary arteries is used to define a lower limit of normal, then the sensitivity of the thallium scan with thallium uptake is 90% with a predictive accuracy of 90% in the detection of significant coronary artery disease in this group of patients. Thus, estimation of total % thallium uptake is a simple index which yields useful diagnostic clinical information.     

Assessment of left ventricular diastolic function: comparison of contrast ventriculography and equilibrium radionuclide angiography.

Twenty-two patients with coronary artery disease were studied first by radionuclide angiography (RNA) and then by contrast ventriculography. Cardiac medications were discontinued at least 72 hr before study. The patients were studied during atrial pacing at heart rates close to their spontaneous sinus rhythm. Contrast ventriculography was performed at 50 frames/sec in the 30 degrees right anterior oblique projection using 40 ml of a nonionic contrast medium (iopamidol) at a flow rate of 10-12 ml/sec. The contours of the left ventricular silhouette at contrast ventriculography were traced, frame by frame, on a graphic table with a digitizing penlight. Equilibrium 99mTc RNA was performed in the best septal 45 degrees left anterior oblique projection, acquiring 150,000 cts/frame, at 50 frames/sec and with a 5% gate tolerance. Time-activity curves from both end-diastolic and end-systolic ROIs were built and interpolated. Both RNA and contrast ventriculography volume curves were filtered with Fourier five harmonics. A close relationship was found between RNA and contrast ventriculography measurements of peak filling rate normalized to end-diastolic cps (r = 0.87, p less than 0.001) and stroke count (r = 0.87, p less than 0.001), ejection fraction (r = 0.94, p less than 0.001). Thus, in patients with coronary artery disease, LV filling can be accurately assessed using RNA.     

A comparison of planar and tomographic thallium scintigraphy in patients with coronary artery disease

Planar and tomographic scans from 57 patients are compared and related to coronary arteriographic results. Tomography identified inferior and septal defects not seen on planar imaging. Planar imaging better identified apical defects. Lesions of the left circumflex were poorly defined by both techniques.     

A comparison of planar and tomographic thallium scintigraphy in patients with coronary artery disease

Planar and tomographic scans from 57 patient are compared and related to coronary arteriographic results. Tomography identified inferior and septal defects not seen on planar imaging. Planar imaging better identified apical defects. Lesions of the left circumflex were poorly defined by both techniques.     

Gated thallium tomography--potential for improved accuracy in the detection of coronary artery disease

Gated thallium-201 myocardial tomography incorporating perfusion profile analysis was used alone, to assess left ventricular wall perfusion and left ventricular wall movement together in 29 consecutive patients, without prior infarction, who presented with chest pain. All patients had had coronary and left ventricular angiography. The proportion of false positive perfusion defects was reduced when an analysis of corresponding wall movement was made. This combined technique resulted in an improved specificity compared with standard 201Tl myocardial tomography. This approach shows the functional effect of reversible ischaemia on regional myocardial contractility and would appear to be particularly useful in the assessment of patients who present with atypical chest pain.     

Thallium-gated SPECT in patients with major myocardial infarction: effect of filtering and zooming in comparison with equilibrium radionuclide imaging and left ventriculography.

The effect of filtering and zooming on 201TI-gated SPECT was evaluated in patients with major myocardial infarction. METHODS: Rest thallium (TI)-gated SPECT was performed with a 90 degrees dual-head camera, 4 h after injection of 185 MBq 201TI in 32 patients (mean age 61 +/- 11 y) with large myocardial infarction (33% +/- 17% defect on bull's eye). End diastolic volume (EDV), end systolic volume (ESV) and left ventricular ejection fraction (LVEF) were calculated using a commercially available semiautomatic validated software. First, images were reconstructed using a 2.5 zoom, a Butterworth filter (order = 5) and six Nyquist cutoff frequencies: 0.13 (B5.13), 0.15 (B5.15), 0.20 (B5.20), 0.25 (B5.25), 0.30 (B5.30) and 0.35 (B5.35). Second, images were reconstructed using a zoom of 1 and a Butterworth filter (order = 5) (cutoff frequency 0.20 [B5.20Z1]) (total = 32 x 7 = 224 reconstructions). LVEF was calculated in all patients using equilibrium radionuclide angiocardiography (ERNA). EDV, ESV and LVEF were measured with contrast left ventriculography (LVG). RESULTS: LVEF was 39% +/- 2% (mean +/- SEM) for ERNA and 40% +/- 13% for LVG (P = 0.51). Gated SPECT with B5.20Z2.5 simultaneously offered a mean LVEF value (39% +/- 2%) similar to ERNA (39% +/- 2%) and LVG (40% +/- 3%), optimal correlations with both ERNA (r = 0.83) and LVG (r = 0.70) and minimal differences with both ERNA (-0.9% +/- 7.5% [mean +/- SD]) and LVG (1.1% +/- 10.5%). As a function of filter and zoom choice, correlation coefficients between ERNA or LVG LVEF, and gated SPECT ranged from 0.26 to 0.88; and correlation coefficients between LVG and gated SPECT volumes ranged from 0.87 to 0.94. There was a significant effect of filtering and zooming on EDV, ESV and LVEF (P < 0.0001). Low cutoff frequency (B5.13) overestimated LVEF (P < 0.0001 versus ERNA and LVG). Gated SPECT with 2.5 zoom and high cutoff frequencies (B5.15, B5.20, B5.25, B5.30 and B5.35) overestimated EDV and ESV (P < 0.04) compared with LVG. This volume overestimation with TI-gated SPECT in patients with large myocardial infarction was correlated to the infarct size. A zoom of 1 underestimated EDV, ESV and LVEF compared with a 2.5 zoom (P < 0.02). CONCLUSION: Accurate LVEF measurement is possible with TI-gated SPECT in patients with major myocardial infarction. However, filtering and zooming greatly influence EDV, ESV and LVEF measurements, and TI-gated SPECT overestimates left ventricular volumes, particularly when the infarct size increases.