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7.13 Prognostic value of myocardial viability recognized by thallium scintigraphy in patients with previous myocardial infarction
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Abstracts Friday, May 4, 2001
Journal of Nuclear Cardiology January/February 2001
7.13 Prognostic value of myocardial viability recognized by scintigraphy in patients with previous myocardial infarction.
7.15 thallium
Z Petrasinovic, D Sobic-Saranovic I, M Ostojic, S Pavlovic 1, B Beleslin, J Marinkovic, M Nedeljkovic, A Djordjevic-Dikic, l Ncdeljkovic, N. Kozarevic 1. Cardiology Institute for Cardiovascular Diseases Belgrade Yugoslavia, INuclear cardiopuhnology Institute of Nuclear medicine, CCS Belgrade Yugoslavia.
F R I D A
The aim of the study was to assess the prognostic value of myocardial viability recognized by thallium-201(Tl)-scintigraphy in pts with previous (>3 months) myocardial infarction. Methods: Myocardial viability was assessed in 95 pts consisting of 55 pts (50 male; mean age 58=t=9years) by TI rest-redistributiun (after 4 hours) scintigraphy and in 40 pts (38 male; 56a=8 years) by TI stress-redistribution-reinjection scintigraphy (dipyridamolc: 0,54mmg/kg over 4 min; redistribution after 4 and 24 hours; reinjection after 24 hours). There was no significant difference between 2 groups concerning data on clinical, angiographical, and echocardiographical characteristics of the pts (p=os). All pts had angiographically documented significant CAD, with the mean ejection fraction of 43±10%. Dyssynergic segments were defined with TI activity of <50%, whereas myocardial viability was defined with increase in TI activity in those segments of >15%. Out of 95 pts, 36 were medically treated, and 59 were rcvascularized. All pts were followed up for 12 months, for adverse cardiac events (death and nonfatal myocardial reinfarction). Results: Tl-rest and stress scintigraphy was positive for myocardial viability in 65 pts (68 %) and negative in 30 pts (32 %). During follow-up there were 11 adverse cardiac events (12%; 7 deaths, 4 reinfarctions) including 8 out of 36 medically treated pts (22%) and 3 out of 59 revascularized pts (5%, p=0.02). By Kaplan-Meier analysis in the 36 medically treated patients, the 12 months survival was 90% in pts with myocardial viability and 60% in pts without myocardial viability (p=0.06). In the 59 revascularized patients, the 12 months survival was 98% in pts with myocardial viability and 87% without myocardial viability (13=0,06). Using the Cox proportional hazards model, myocardial viability was the best predictor of adverse cardiac events (HR 0,22, p= 0,04). Conclusions: In pts with previous MI and significant CAD the best survival and lowest incidence of adverse cardiac events was observed in revascularized viable pts, whereas the worse prognosis was found in non-viable either medically or surgically treated patients. Tl-scintigraphy recognized myocardial viability was the only single predictor of adverse cardiac events in this group of patients.
The effect of hormonal status on the exercise electrocardiogram. M.J. Henzlova, K.H. Zelniek, L.B. Croft, J.A. Diamond. Cardiovascular Institute Mount Sinai Medical Center New York United States of America. Exercise treadmill testing in women is percieved as less accurate due to a h i g h e r rate of false positive ST changes as compared to men. Hormonal status has been implicated as one of the causes of this phenomenon. Our objective was to assess the effect of hormonal status on the exercise stress ECG in women. We reviewed the results of 342 women (23-71 years old) who underwent in the past 12 months symptom-limited treadmill exercise stress testing with normal results of SPECT myocardial perfusion imaging. A positive exercise stress test (ECG +) was defined as > l m m horizontal or dowusloping ST segment depression in at least 3 contiguous beats in any lead during and/or after exercise. Women were grouped into pre-menopausal (N=37), post-menopausal on no hormonal replacement (N=231) and post-menopausal receiving hormone replacement (N-42). In 32 women baseline ECG was non-diagnostic. Hormone replacement therapy (HRT) was defined as any medication containing estrogen. Results: see table. Conclusion: The rate of false positive ECG responses to exercise is significantly higher in postmenopausal women on HRT when compared to pre-menopausal and post-menopausal women not on HRT. In post-menopausal women on HRT referred for stress testing for detection of CAD, myocardial perfusion imaging decreases the rate of false positive results.
Pre-menopausal Post-menopausal / noHRT Post-menopausal / HRT
ECG + 7(19%) 46(20%) 23(55%)
ECG 30 ! 85 19
Pre-menopausal vs. post-menopausal/no HRT, p>0.05, pre-menopausal vs. postmenopausal/HRT, p-0.01, post-menopausal/no HRT vs. post-menopausal/HRT, p<0.01. Exercise stress test results (N=310)
Y M A Y 4
7.14 Interpretive reproducibility of 99m-Tc-sestamibi myocardial perfusion SPECT in a consecutive group of male patients with stable angina pectoris before and after percutaneous transluminal angioplnsty. A Johansen, AL Gaster l, A Veje 2, T Haghfelt 1, p Thayssen 1, PF HoihmdCarlsen 2. Department of Nuclear Medicine Odense University Hospital, 1Department of Cardiology Odense University Hospital, 2Department of Nuclear Medicine Odanse University Hospital, Denmark. Inter- and intmobserver variability of 99m-Tc-sestamibi myocardial perfusion imaging (MPI) has rarely been investigated. The aim of this study was to evaluate the interpretive reproducibility with this technique. Materials: We report on 108 male patients with stable angina pectoris, referred consecutively to MPI before and after percutaneous transluminal angioplasty (PTCA).Methods: A twoday rest/stress 99m-Tc-sestamibi gated SPECT protocol was used. MPI was interpreted by two independent observers without knowledge of clinical data, using a semiquantitative visual 20-segment scoring model and kappa statistics with the following gradings of agreement: poor kappa (k) <- 0.40, moderate k 0.41-0.60, good k = 0.61-0.80, and excellent k >0.80. Results: lntraobserver agreement was good to excellent (k = 0.74-0.85) for both readers, while interobserver agreement was found to be good (k = 0.71-0.78) with regard to the overall interpretation of MPI as being normal, reversible or nonreversible. Exact agreement within and between observers was found in 82-92% of the cases when results were interpreted as normal, reversible or nonreversible, and 89-97% when interpreted as normal or abnormal. The observers had a good to excellent intraobserver agreement for all vascular territories (k 0.64-0.87). lnterobserver agreement was good in LAD and LCX territories (k = 0.66-0.79), and moderate to good in the RCA territory (k - 0.60-0.73). Exact agreement between and within observers was found in 82-97% of the vascular territories. Moderate to good intraobserver agreement was found for segmental score interpretation (k = 0.54-0.68), but with slightly lower interobserver agreement (k - 0.52-0.56), however, both inter- and intraobserver agreement were good judged by weighted kappa statistics. When comparing the interpretive reproducibility before and after PTCA, intra- and interobserver agreement was better after PTCA, probably reflecting an increase in normal scans after revascularisation. Conclusion: In a group of consecutive male patients with stable angina pectoris interpretive reproducibility (overall and individual vessel diagnosis) was good to excellent. However, segmental scoring reproducibility was only moderate to good. The semiquantitative visual analysis is a robust and a reproducible method of interpretation of MPI allowing comparison of results obtained before and after revascularisation.
7.16 TI-201 rest-redistribution imaging in coronary patients with LV dysfunction. Effects of sublingual nitroglycerine on redistribution TI-201 uptake. A. Antonopoulos, V. Voliotopoulos ], E. Gcorgiou I. Cardiology Branch "Ygeias Melathron" Clinic Athens Greece, 1Nuclear Laboratory Magnetic ResonanceIatropolis Center Halandri-Athens Greece. Background: T1-201 rest-redistribution imaging in patients with LV impairment is a procedure resulting in enhanced T1-201 uptake which is compatible with viable myoeardium. However, some segments showing reduced TI-201 uptake at redistribution images may consist viable, but hypoperfused, myocardium. It is hypothesized that the administration of nitroglycerine (NTG) before redistribution image acquisition would improve the tracer uptake in the redistribution hypoperfused segments. Patients and Methods: We studied 24 pts with chronic coronary artery disease and LV dysfunction and mean ejection fraction 34+/-6% with (mean age 56+/-7 years) who were referred to the Nuclear Laboratory for their functional evaluation. 22 pts had a previous Q wave myocardial infarction. The above pts were divided into two groups i.e. those who were undergone T1201 rest-redistribution imaging (11 pts, group 1) and those who were performed rest-NTG-redistribution imaging (13 pts, group 2). Thallium activity in each segment was graded using a semiquantitafive 4-point scale scoring system (0~absent uptake to 3~aormal). Fifteen minutes before redistribution images were acquired 0.3 mg of s.l. NTG was administered, and BP and HR monitoring was obtained in order to avoid hypotensive complication caused by NTG. Results: 480 myocardial segments were totally analysed of which 146 segments (30.4%) were hypoperfused at rest while 78 segments showed reverse redistribution (RR) and 66 exhibited permanent defects at redistribution imaging. Between the RR segments there were 23 (10.45%) segments with homogeneous distribution at rest in group 1 and 27 (10.38%) in group 2. The mean number of segments showing underperfusion at rest imaging was 1.94+/-0.89 while after redistribution this was 1.22+/-0.47 (p<0.02). The underperfusion score among pts of group 1 was 1.93+/-0.67 at redistribution images while among pts of group 2 was 1.47+/-0.21 (p<0.01). Among the RR segments improvement of the underperfusion score was observed in 27 out of 34 (79.4%) segments of group 2 while only in 23 out of 44 ( 5 2 % ) segments of group 1 (i.e. 1.42+/-0.28 vs 1.90+/-0.64, p<0.01). Conclusion: The above results indicate that in coronary patients with LV dysfunction s.1. NTG administration improve thallium-201 uptake in redistribution images and facilitate the detection of hypoperfused but viable myocardium.
Abstracts Friday, May 4, 2001
Journal of Nuclear Cardiology January/February 2001
7.13 Prognostic value of myocardial viability recognized by scintigraphy in patients with previous myocardial infarction.
7.15 thallium
Z Petrasinovic, D Sobic-Saranovic I, M Ostojic, S Pavlovic 1, B Beleslin, J Marinkovic, M Nedeljkovic, A Djordjevic-Dikic, l Ncdeljkovic, N. Kozarevic 1. Cardiology Institute for Cardiovascular Diseases Belgrade Yugoslavia, INuclear cardiopuhnology Institute of Nuclear medicine, CCS Belgrade Yugoslavia.
F R I D A
The aim of the study was to assess the prognostic value of myocardial viability recognized by thallium-201(Tl)-scintigraphy in pts with previous (>3 months) myocardial infarction. Methods: Myocardial viability was assessed in 95 pts consisting of 55 pts (50 male; mean age 58=t=9years) by TI rest-redistributiun (after 4 hours) scintigraphy and in 40 pts (38 male; 56a=8 years) by TI stress-redistribution-reinjection scintigraphy (dipyridamolc: 0,54mmg/kg over 4 min; redistribution after 4 and 24 hours; reinjection after 24 hours). There was no significant difference between 2 groups concerning data on clinical, angiographical, and echocardiographical characteristics of the pts (p=os). All pts had angiographically documented significant CAD, with the mean ejection fraction of 43±10%. Dyssynergic segments were defined with TI activity of <50%, whereas myocardial viability was defined with increase in TI activity in those segments of >15%. Out of 95 pts, 36 were medically treated, and 59 were rcvascularized. All pts were followed up for 12 months, for adverse cardiac events (death and nonfatal myocardial reinfarction). Results: Tl-rest and stress scintigraphy was positive for myocardial viability in 65 pts (68 %) and negative in 30 pts (32 %). During follow-up there were 11 adverse cardiac events (12%; 7 deaths, 4 reinfarctions) including 8 out of 36 medically treated pts (22%) and 3 out of 59 revascularized pts (5%, p=0.02). By Kaplan-Meier analysis in the 36 medically treated patients, the 12 months survival was 90% in pts with myocardial viability and 60% in pts without myocardial viability (p=0.06). In the 59 revascularized patients, the 12 months survival was 98% in pts with myocardial viability and 87% without myocardial viability (13=0,06). Using the Cox proportional hazards model, myocardial viability was the best predictor of adverse cardiac events (HR 0,22, p= 0,04). Conclusions: In pts with previous MI and significant CAD the best survival and lowest incidence of adverse cardiac events was observed in revascularized viable pts, whereas the worse prognosis was found in non-viable either medically or surgically treated patients. Tl-scintigraphy recognized myocardial viability was the only single predictor of adverse cardiac events in this group of patients.
The effect of hormonal status on the exercise electrocardiogram. M.J. Henzlova, K.H. Zelniek, L.B. Croft, J.A. Diamond. Cardiovascular Institute Mount Sinai Medical Center New York United States of America. Exercise treadmill testing in women is percieved as less accurate due to a h i g h e r rate of false positive ST changes as compared to men. Hormonal status has been implicated as one of the causes of this phenomenon. Our objective was to assess the effect of hormonal status on the exercise stress ECG in women. We reviewed the results of 342 women (23-71 years old) who underwent in the past 12 months symptom-limited treadmill exercise stress testing with normal results of SPECT myocardial perfusion imaging. A positive exercise stress test (ECG +) was defined as > l m m horizontal or dowusloping ST segment depression in at least 3 contiguous beats in any lead during and/or after exercise. Women were grouped into pre-menopausal (N=37), post-menopausal on no hormonal replacement (N=231) and post-menopausal receiving hormone replacement (N-42). In 32 women baseline ECG was non-diagnostic. Hormone replacement therapy (HRT) was defined as any medication containing estrogen. Results: see table. Conclusion: The rate of false positive ECG responses to exercise is significantly higher in postmenopausal women on HRT when compared to pre-menopausal and post-menopausal women not on HRT. In post-menopausal women on HRT referred for stress testing for detection of CAD, myocardial perfusion imaging decreases the rate of false positive results.
Pre-menopausal Post-menopausal / noHRT Post-menopausal / HRT
ECG + 7(19%) 46(20%) 23(55%)
ECG 30 ! 85 19
Pre-menopausal vs. post-menopausal/no HRT, p>0.05, pre-menopausal vs. postmenopausal/HRT, p-0.01, post-menopausal/no HRT vs. post-menopausal/HRT, p<0.01. Exercise stress test results (N=310)
Y M A Y 4
7.14 Interpretive reproducibility of 99m-Tc-sestamibi myocardial perfusion SPECT in a consecutive group of male patients with stable angina pectoris before and after percutaneous transluminal angioplnsty. A Johansen, AL Gaster l, A Veje 2, T Haghfelt 1, p Thayssen 1, PF HoihmdCarlsen 2. Department of Nuclear Medicine Odense University Hospital, 1Department of Cardiology Odense University Hospital, 2Department of Nuclear Medicine Odanse University Hospital, Denmark. Inter- and intmobserver variability of 99m-Tc-sestamibi myocardial perfusion imaging (MPI) has rarely been investigated. The aim of this study was to evaluate the interpretive reproducibility with this technique. Materials: We report on 108 male patients with stable angina pectoris, referred consecutively to MPI before and after percutaneous transluminal angioplasty (PTCA).Methods: A twoday rest/stress 99m-Tc-sestamibi gated SPECT protocol was used. MPI was interpreted by two independent observers without knowledge of clinical data, using a semiquantitative visual 20-segment scoring model and kappa statistics with the following gradings of agreement: poor kappa (k) <- 0.40, moderate k 0.41-0.60, good k = 0.61-0.80, and excellent k >0.80. Results: lntraobserver agreement was good to excellent (k = 0.74-0.85) for both readers, while interobserver agreement was found to be good (k = 0.71-0.78) with regard to the overall interpretation of MPI as being normal, reversible or nonreversible. Exact agreement within and between observers was found in 82-92% of the cases when results were interpreted as normal, reversible or nonreversible, and 89-97% when interpreted as normal or abnormal. The observers had a good to excellent intraobserver agreement for all vascular territories (k 0.64-0.87). lnterobserver agreement was good in LAD and LCX territories (k = 0.66-0.79), and moderate to good in the RCA territory (k - 0.60-0.73). Exact agreement between and within observers was found in 82-97% of the vascular territories. Moderate to good intraobserver agreement was found for segmental score interpretation (k = 0.54-0.68), but with slightly lower interobserver agreement (k - 0.52-0.56), however, both inter- and intraobserver agreement were good judged by weighted kappa statistics. When comparing the interpretive reproducibility before and after PTCA, intra- and interobserver agreement was better after PTCA, probably reflecting an increase in normal scans after revascularisation. Conclusion: In a group of consecutive male patients with stable angina pectoris interpretive reproducibility (overall and individual vessel diagnosis) was good to excellent. However, segmental scoring reproducibility was only moderate to good. The semiquantitative visual analysis is a robust and a reproducible method of interpretation of MPI allowing comparison of results obtained before and after revascularisation.
7.16 TI-201 rest-redistribution imaging in coronary patients with LV dysfunction. Effects of sublingual nitroglycerine on redistribution TI-201 uptake. A. Antonopoulos, V. Voliotopoulos ], E. Gcorgiou I. Cardiology Branch "Ygeias Melathron" Clinic Athens Greece, 1Nuclear Laboratory Magnetic ResonanceIatropolis Center Halandri-Athens Greece. Background: T1-201 rest-redistribution imaging in patients with LV impairment is a procedure resulting in enhanced T1-201 uptake which is compatible with viable myoeardium. However, some segments showing reduced TI-201 uptake at redistribution images may consist viable, but hypoperfused, myocardium. It is hypothesized that the administration of nitroglycerine (NTG) before redistribution image acquisition would improve the tracer uptake in the redistribution hypoperfused segments. Patients and Methods: We studied 24 pts with chronic coronary artery disease and LV dysfunction and mean ejection fraction 34+/-6% with (mean age 56+/-7 years) who were referred to the Nuclear Laboratory for their functional evaluation. 22 pts had a previous Q wave myocardial infarction. The above pts were divided into two groups i.e. those who were undergone T1201 rest-redistribution imaging (11 pts, group 1) and those who were performed rest-NTG-redistribution imaging (13 pts, group 2). Thallium activity in each segment was graded using a semiquantitafive 4-point scale scoring system (0~absent uptake to 3~aormal). Fifteen minutes before redistribution images were acquired 0.3 mg of s.l. NTG was administered, and BP and HR monitoring was obtained in order to avoid hypotensive complication caused by NTG. Results: 480 myocardial segments were totally analysed of which 146 segments (30.4%) were hypoperfused at rest while 78 segments showed reverse redistribution (RR) and 66 exhibited permanent defects at redistribution imaging. Between the RR segments there were 23 (10.45%) segments with homogeneous distribution at rest in group 1 and 27 (10.38%) in group 2. The mean number of segments showing underperfusion at rest imaging was 1.94+/-0.89 while after redistribution this was 1.22+/-0.47 (p<0.02). The underperfusion score among pts of group 1 was 1.93+/-0.67 at redistribution images while among pts of group 2 was 1.47+/-0.21 (p<0.01). Among the RR segments improvement of the underperfusion score was observed in 27 out of 34 (79.4%) segments of group 2 while only in 23 out of 44 ( 5 2 % ) segments of group 1 (i.e. 1.42+/-0.28 vs 1.90+/-0.64, p<0.01). Conclusion: The above results indicate that in coronary patients with LV dysfunction s.1. NTG administration improve thallium-201 uptake in redistribution images and facilitate the detection of hypoperfused but viable myocardium.