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Gated radionuclide angiocardiography in the noninvasive evaluation of a partially reversible alcoholic cardiomyopathy
Gated Radionuclide Angiocardiography in the Noninvasive Evaluation of a Partially Reversible Alcoholic Cardiomyopathy
Serial gated radionuclide angiocardiography was used to demonstrate partial reversal of alcoholic cardiomyopathy, following abstention from alcohol. Six months subsequent to total abstention, the resting ejection fraction, which is a sensitive index of left ventricular function, increased from 1g percent to 42 percent. Thirteen months following total abstention, the resting ejection fractii was preserved at 40 percent. During stress, the ejection fraction increased to 53 percent. The clinical implication of this case report is that gated radionuciii angiocardiography may be used to noninvasively evaluate accurately the subsequent course of reversible alcoholic cardiomyopathy.
MICHAEL L. SACHER, D.O. STEVEN J. SISKIND, M.D., F.A.C.C. BERNARD H. BOAL, M.D., F.A.C.P., F.A.C.C. Queens, New York
Some degree of improvement in the hearts of patients with alcoholic cardiomyopathy is documented following abstention from alcohol [ 1,2]. Previous case reports have focused upon cardiac catheterization and invasive argiocardiography to demonstrate the dynamic reversibility of this condition [2]. Generally, the degree of reversibility of this condition seldom is evaluated thoroughly, since serial noninvasive or invasive studies are rarely performed. We report a case of partially reversible alcoholic cardiomyopathy in which dramatic improvement was document@ noninvasively using gated radionuclide angiooardiography.
CASE REPORT
From the Section of Cardiology, Booth Memorial Medical Center, Queens, New York. Requests for reprints should be addressed to Dr. Michael L. Sacher, 99 Grand Avenue, Massapequa, York 11758. Manuscript accepted March
1985.
New 28,
A 51-year-old black man without hypertension or diabetes presented to the emergency room following a sudden onset of right upper back pain and dyspnea. The back pain was exacerbated with deep inspiration and coughing. Past medical history was significant only for consumption of one or two fifths of whiskey a day for 25 years and a 70 pack-year history of cigarette smoking. Physical examination revealed a blood pressure of 160/100 mm Hg, a pulse rate of 60 beats per minute, respirations of 20 per minute, and a temperature of 37*C. There were no peripheral stigmata of chronic alcoholism, and results of physical examination were otherwise unremarkable. Arterial blood gas values were normal. Chest roentgenography revealed cardiomegaly with normal pulmonary vascular markings. Electrocardiography revealed sinus rhythm with left atrial enlargement [3], voltage criteria for left ventricular hypertrophy [4], and frequent unifocal premature ventricular contractions. The patient was admitted to the respiratory intensive care unit where the diagnoses of pulmonary embolism and myocardial infarction were excluded. M-mode and two-dimensional echocardiography revealed four-chamber enlargement with reduced left ventricular function. Resting radionuclide angiocardiography showed biventricular enlargement with severe diffuse hypokinesis and an ejection fraction of 19 percent (Figure 1). A 24-hour Holter monitor revealed frequent unifocal premature ventricular contrac-
June 1986
The American Journal of Medicine
Volume 60
1205
ANGlOCARDIOGRAPHY
IN NONINVASIVE
EVALUATION
OF ALCOHOLIC
CARDIOMYOPATHY-SACHER
ET AL
tions with frequent complex ventricular ectopy including salvos of three and four consecutive premature beats. Antiarrhythmic therapy with procainamide was begun. Discharge was on the 10th hospital day with a diagnosis of alcoholic cardiomyopathy. Total abstention from alcoholic beverages was encouraged. After six months of total abstention from alcohol, noninvasive studies were repeated. Chest roentgenography revealed a normal cardiac silhouette. Resting radionuclide angiocardiography showed an enlarged left ventricle with anteroapical akinesis with otherwise normal wall motion and with an ejection fraction of 42 percent (Figure 2). A 24hour Holter monitor revealed frequent unifocal premature ventricular contractions with rare ventricular couplets but without other complex ventricular ectopy. Twelve months after continued abstention from alcohol, exercise radionuclide angiocardiography was performed. The resting study revealed a moderately enlarged left ventricle with mild diffuse hypokinesis with an ejection fraction of 40 percent. Twelve minutes and 100 watts of exercise were completed. At peak exercise, radionuclide angiocardiography revealed normal wall motion with an ejection fraction of 53 percent (Figure 3). M-mode and two-dimensional echocardiography showed an enlarged hypokinetic left ventricle with otherwise normal chamber measurements. The 24hour Holter monitor revealed frequent unifocat premature ventricular contractions, ventricular couplets, and salvos of three to four consecutive premature beats. The procainamide dosage was increased. To determine if a potentially correctable cause for the ventricular arrhythmia other than incomplete resolution of the alcoholic cardiomyopathy was present, cardiac catheterization and angiography were performed, demonstrating normal coronary arteries and mild diffuse left ventricular hypokinesis with an ejection fraction of 48 percent. After 15 months of total abstention from alcohol, the patient’ condition is clinically functional class I (New York Heart Association) [5]. The ventricular arrhythmia is being treated with procainamide.
Figure I. Initial gated radionuclide angiocardiogram at rest in the 30-degree left anterior oblique position at end diastole and end systole. There is biventricular enlargement with severe diffuse hypokinesis. The ejection fraction is 79
percent.
Figure 2. Gated radionuclide angiocardiogram at rest in the 3O-degree left anterior oblique position at end diastole and end systole, six months subsequent to Figure 1. An teroapical akinesis is present but overall there is marked improvement in left ventricular function. The ejection fra@ tion is 42 percent.
COMMENT’S
The diagnosis of alcoholic cardiomyopathy was firmly supported by the history of prolonged excessive alcohol consumption, by a lack of an identifiable cause for the clinical state other than alcohol abuse, by the presence of normal coronary arteries, and especially by the dramatic improvement following abstention from alcohol. In previous case reports, the course of reversible alcoholic cardiomyopathy has been followed noninvasively with chest roentgenography, electrocardiography, phonocardiography, and echocardiography [1,2,6]. Of these, none provides an accurate assessment of left ventricular function. When this cardiomyopathy was first described, noninvasive radionuclide angiooardiography was not available; therefore, cardiac catheterization and invasive angiography were used to evaluate the serial changes in left ventricular function. Gated radionuclide angiocardiography has been reported as being comparably sensitive to
Figure 3. Gated radionuclide angiocardiogram during peak exercise in the 3O-degree left anterior oblique position at end diastole and end systole, 13 months subsequent to Figure 1. There is normal global left ventricular wall motion. The ejection fraction is 53 percent.
1206
June
1966
The American
Journal
of Mediclne
Volume
60
ANGlOCARDiOGRAPHY
IN NONINVASIVE
invasive left ventriculography in the assessment of left ventricular function [7-IO]. To our knowledge, this is the first documentation of a case of alcoholic cardiomyopathy in which the improvement in left ventricular function was demonstrated using serial gated radionuclide angiocardiography. The important clinical implication from this report is that, once the diagnosis of alcoholic cardiomyopathy has been firmly established and abstention from or reduction in alcohol consumption has been implemented, then seri-
EVALUATION
OF ALCOHOLIC
CARDIOMYOPATHY-SACHER
ET AL
al gated radionuclide angiocardiography may be used to evaluate accurately the subsequent course of the disorder. ACKNOWLEDGMENT We thank William Valdner, R.T., Fred McCready, B.S., R.T., and Major Elmer Berry, B.S., C.N.M.T., for their technical support, and Caryn Poliseo for her secretarial help.
REFERENCES 1.
2.
3.
4.
5.
Demakis JG, Proskey A, Rahimtoola SH, et al: The natural course of alcoholic cardiomyopathy. Ann intern Med 1974; 60: 293-297. Schwartz L, Sample KA, Wigle ED: Severe alcoholic cardiomyopathy reversed with abstention from alcohol. Am J Cardiol 1975; 36: 963-966. The Criteria Committee of the New York Heart Association: The anatomic cardiac diagnosis. In: Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. Boston: Little, Brown, 1973; 91-93. The Criteria Committee of the New York Heart Association: The anatomic cardiac diagnosis. In: Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. Boston: Little, Brown, 1973; 80-86. The Criteria Committee of the New York Heart Association: Cardiac status and prognosis. In: Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. Boston: Little, Brown, 1973; 286.
6.
7.
8.
9.
10.
June
1966
Reeves WC, Nanda NC, Gramiak R: Echocardiography in chronic alcoholics following prolonged periods of abstinence. Am Heart J 1976; 95: 576-583. Zaret BL, Strauss HW, Hurley PJ, Natarajan TK, Pitt B: A noninvasive scintiphotographic method for detecting regional ventricular dysfunction in man. N Engl J Med 1971; 284: 1165-1170. Strauss HW, Zaret BL, Hurley PJ, Natarajan TK, Pitt B: A scintiphotographic method for measuring left ventricular ejection fraction in man without cardiac catheterization. Am J Cardiol 1971; 28: 575-580. Burow RD, Strauss HW, Singleton R: Analysis of left ventricular function from multiple gated acquisition cardiac blood pool imaging. Comparison to contrast angiography. Circulation 1977; 56: 1024-1028. Maddox DE, Wynne J, Uren R: Regional ejection fraction: a quantitative radionuclide index of regional left ventricular performance. Circulation 1979; 59: 1001-1009.
The American
Journal
of Medicine
Volume
60
1207
Serial gated radionuclide angiocardiography was used to demonstrate partial reversal of alcoholic cardiomyopathy, following abstention from alcohol. Six months subsequent to total abstention, the resting ejection fraction, which is a sensitive index of left ventricular function, increased from 1g percent to 42 percent. Thirteen months following total abstention, the resting ejection fractii was preserved at 40 percent. During stress, the ejection fraction increased to 53 percent. The clinical implication of this case report is that gated radionuciii angiocardiography may be used to noninvasively evaluate accurately the subsequent course of reversible alcoholic cardiomyopathy.
MICHAEL L. SACHER, D.O. STEVEN J. SISKIND, M.D., F.A.C.C. BERNARD H. BOAL, M.D., F.A.C.P., F.A.C.C. Queens, New York
Some degree of improvement in the hearts of patients with alcoholic cardiomyopathy is documented following abstention from alcohol [ 1,2]. Previous case reports have focused upon cardiac catheterization and invasive argiocardiography to demonstrate the dynamic reversibility of this condition [2]. Generally, the degree of reversibility of this condition seldom is evaluated thoroughly, since serial noninvasive or invasive studies are rarely performed. We report a case of partially reversible alcoholic cardiomyopathy in which dramatic improvement was document@ noninvasively using gated radionuclide angiooardiography.
CASE REPORT
From the Section of Cardiology, Booth Memorial Medical Center, Queens, New York. Requests for reprints should be addressed to Dr. Michael L. Sacher, 99 Grand Avenue, Massapequa, York 11758. Manuscript accepted March
1985.
New 28,
A 51-year-old black man without hypertension or diabetes presented to the emergency room following a sudden onset of right upper back pain and dyspnea. The back pain was exacerbated with deep inspiration and coughing. Past medical history was significant only for consumption of one or two fifths of whiskey a day for 25 years and a 70 pack-year history of cigarette smoking. Physical examination revealed a blood pressure of 160/100 mm Hg, a pulse rate of 60 beats per minute, respirations of 20 per minute, and a temperature of 37*C. There were no peripheral stigmata of chronic alcoholism, and results of physical examination were otherwise unremarkable. Arterial blood gas values were normal. Chest roentgenography revealed cardiomegaly with normal pulmonary vascular markings. Electrocardiography revealed sinus rhythm with left atrial enlargement [3], voltage criteria for left ventricular hypertrophy [4], and frequent unifocal premature ventricular contractions. The patient was admitted to the respiratory intensive care unit where the diagnoses of pulmonary embolism and myocardial infarction were excluded. M-mode and two-dimensional echocardiography revealed four-chamber enlargement with reduced left ventricular function. Resting radionuclide angiocardiography showed biventricular enlargement with severe diffuse hypokinesis and an ejection fraction of 19 percent (Figure 1). A 24-hour Holter monitor revealed frequent unifocal premature ventricular contrac-
June 1986
The American Journal of Medicine
Volume 60
1205
ANGlOCARDIOGRAPHY
IN NONINVASIVE
EVALUATION
OF ALCOHOLIC
CARDIOMYOPATHY-SACHER
ET AL
tions with frequent complex ventricular ectopy including salvos of three and four consecutive premature beats. Antiarrhythmic therapy with procainamide was begun. Discharge was on the 10th hospital day with a diagnosis of alcoholic cardiomyopathy. Total abstention from alcoholic beverages was encouraged. After six months of total abstention from alcohol, noninvasive studies were repeated. Chest roentgenography revealed a normal cardiac silhouette. Resting radionuclide angiocardiography showed an enlarged left ventricle with anteroapical akinesis with otherwise normal wall motion and with an ejection fraction of 42 percent (Figure 2). A 24hour Holter monitor revealed frequent unifocal premature ventricular contractions with rare ventricular couplets but without other complex ventricular ectopy. Twelve months after continued abstention from alcohol, exercise radionuclide angiocardiography was performed. The resting study revealed a moderately enlarged left ventricle with mild diffuse hypokinesis with an ejection fraction of 40 percent. Twelve minutes and 100 watts of exercise were completed. At peak exercise, radionuclide angiocardiography revealed normal wall motion with an ejection fraction of 53 percent (Figure 3). M-mode and two-dimensional echocardiography showed an enlarged hypokinetic left ventricle with otherwise normal chamber measurements. The 24hour Holter monitor revealed frequent unifocat premature ventricular contractions, ventricular couplets, and salvos of three to four consecutive premature beats. The procainamide dosage was increased. To determine if a potentially correctable cause for the ventricular arrhythmia other than incomplete resolution of the alcoholic cardiomyopathy was present, cardiac catheterization and angiography were performed, demonstrating normal coronary arteries and mild diffuse left ventricular hypokinesis with an ejection fraction of 48 percent. After 15 months of total abstention from alcohol, the patient’ condition is clinically functional class I (New York Heart Association) [5]. The ventricular arrhythmia is being treated with procainamide.
Figure I. Initial gated radionuclide angiocardiogram at rest in the 30-degree left anterior oblique position at end diastole and end systole. There is biventricular enlargement with severe diffuse hypokinesis. The ejection fraction is 79
percent.
Figure 2. Gated radionuclide angiocardiogram at rest in the 3O-degree left anterior oblique position at end diastole and end systole, six months subsequent to Figure 1. An teroapical akinesis is present but overall there is marked improvement in left ventricular function. The ejection fra@ tion is 42 percent.
COMMENT’S
The diagnosis of alcoholic cardiomyopathy was firmly supported by the history of prolonged excessive alcohol consumption, by a lack of an identifiable cause for the clinical state other than alcohol abuse, by the presence of normal coronary arteries, and especially by the dramatic improvement following abstention from alcohol. In previous case reports, the course of reversible alcoholic cardiomyopathy has been followed noninvasively with chest roentgenography, electrocardiography, phonocardiography, and echocardiography [1,2,6]. Of these, none provides an accurate assessment of left ventricular function. When this cardiomyopathy was first described, noninvasive radionuclide angiooardiography was not available; therefore, cardiac catheterization and invasive angiography were used to evaluate the serial changes in left ventricular function. Gated radionuclide angiocardiography has been reported as being comparably sensitive to
Figure 3. Gated radionuclide angiocardiogram during peak exercise in the 3O-degree left anterior oblique position at end diastole and end systole, 13 months subsequent to Figure 1. There is normal global left ventricular wall motion. The ejection fraction is 53 percent.
1206
June
1966
The American
Journal
of Mediclne
Volume
60
ANGlOCARDiOGRAPHY
IN NONINVASIVE
invasive left ventriculography in the assessment of left ventricular function [7-IO]. To our knowledge, this is the first documentation of a case of alcoholic cardiomyopathy in which the improvement in left ventricular function was demonstrated using serial gated radionuclide angiocardiography. The important clinical implication from this report is that, once the diagnosis of alcoholic cardiomyopathy has been firmly established and abstention from or reduction in alcohol consumption has been implemented, then seri-
EVALUATION
OF ALCOHOLIC
CARDIOMYOPATHY-SACHER
ET AL
al gated radionuclide angiocardiography may be used to evaluate accurately the subsequent course of the disorder. ACKNOWLEDGMENT We thank William Valdner, R.T., Fred McCready, B.S., R.T., and Major Elmer Berry, B.S., C.N.M.T., for their technical support, and Caryn Poliseo for her secretarial help.
REFERENCES 1.
2.
3.
4.
5.
Demakis JG, Proskey A, Rahimtoola SH, et al: The natural course of alcoholic cardiomyopathy. Ann intern Med 1974; 60: 293-297. Schwartz L, Sample KA, Wigle ED: Severe alcoholic cardiomyopathy reversed with abstention from alcohol. Am J Cardiol 1975; 36: 963-966. The Criteria Committee of the New York Heart Association: The anatomic cardiac diagnosis. In: Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. Boston: Little, Brown, 1973; 91-93. The Criteria Committee of the New York Heart Association: The anatomic cardiac diagnosis. In: Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. Boston: Little, Brown, 1973; 80-86. The Criteria Committee of the New York Heart Association: Cardiac status and prognosis. In: Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. Boston: Little, Brown, 1973; 286.
6.
7.
8.
9.
10.
June
1966
Reeves WC, Nanda NC, Gramiak R: Echocardiography in chronic alcoholics following prolonged periods of abstinence. Am Heart J 1976; 95: 576-583. Zaret BL, Strauss HW, Hurley PJ, Natarajan TK, Pitt B: A noninvasive scintiphotographic method for detecting regional ventricular dysfunction in man. N Engl J Med 1971; 284: 1165-1170. Strauss HW, Zaret BL, Hurley PJ, Natarajan TK, Pitt B: A scintiphotographic method for measuring left ventricular ejection fraction in man without cardiac catheterization. Am J Cardiol 1971; 28: 575-580. Burow RD, Strauss HW, Singleton R: Analysis of left ventricular function from multiple gated acquisition cardiac blood pool imaging. Comparison to contrast angiography. Circulation 1977; 56: 1024-1028. Maddox DE, Wynne J, Uren R: Regional ejection fraction: a quantitative radionuclide index of regional left ventricular performance. Circulation 1979; 59: 1001-1009.
The American
Journal
of Medicine
Volume
60
1207