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Prognosis after normal tetrofosmin study in patients with proven CAD
Journal of Nuclear Cardiology Volume 6, N u m b e r 1, Part 2
Abstracts Wednesday morning, April 21, 1999
$93
43.58
43.60
THE PROGNOSTIC VALUE OF NORMAL STRESS Te-99m SESTAMIBI SPECT P Soman, A Banfield, N Lahiri, A Lahiri . Northwick Park Hospital, Harrow, UK
EXERCISE 99mTECHNETIUM TETROFOSMIN TOMOGRAPHY FOR CARDIAC RISK STRATIFICATION OF PATIENTS WITH SUSPECTED OR K N O W N C O R O N A R Y ARTERY DISEASE A.R. Galassi, S. Azzarelli, G. Rodi, A. La Manna, S. Musumeci*, A. Drago, G. Giuffrida. Institute of Cardiology, University of Catania, Italy.
To determine the prognostic value of normal Tc-99m sestamibi (MIBI) SPECT imaging, we examined the incidence of cardiac death and non-fatal myocardial infarction (MI) in 473 patients including 201 (42%) women, aged 56+12 years, who had a normal stress MIBI scan. Eighty nine percent were referrred for s3anptons and/or abnormal exercise electrocardiography (ECG) suggestive of coronau' artery disease (CAD), 5% for screening as3anptomatic patients at high coronary risk and 6% with known CAD. A two- day stress rest protocol was used with graded dynamic exercise in 90% (mean workload 9.1+3 METS; peak heart rate 934-13% of target) and dipyridamole in 10%. ST segment depression > 1 rain on the exercise ECG was observed in 278 (60%) of patients. During 30a:16 (6-56) months of follow up, 2 cardiac deaths (mmualised mortality rate 0.2%, 95% CI 0.02-0.7%) and no MI occurred, suggesting that patients with an intermediate probability of CAD and a normal stress MIBI SPECT have a benign prognosis, despite abnormal exercise ECG, and irrespective of gender.
43.59 PROGNOSIS AF1T_R NORMAL TETROFOSMIN STUDY IN PATIENTS WITH PROVEN CAD J.J.J.Borm, J.E.Roeters van Lennep, H.Roeters van Lennep, A.H.Zwinderman, E.E.van der Wall, E.KJ. Pauwels. Department of Nuclear Medicine, Academic Hospital Leiden, The Netherlands The long term prognosis for ischemic events after a normal myocardial perfusion study and proven CAD is not well known. We performed a follow-up study to assess the long term prognosis.Between August 1995 and March 1998 542 studies in 528 patients (in a series of 1306 consecutive studies in 1252 patients), showed normal myocardial uptake of 99mTc-tetrofosmin both after exercise or pharmacological stress and at rest. In this group 165 angiographic studies were performed. In 113 patients (68%) CAD was demonstrated. Follow-up data showed 9 fatalities, 5 of proven non-cardiac origin, one of proven cardiac origin, an average of 351 days [median 216, range 48 - 953] after a normal perfusion study, resulting in at most 4 attributable deaths. Four (3 attributable) deaths were seen in the 113 patients with proven CAD, an average of 608 days [median 553, range 375 - 953] after the normal tetrofosmin study. Three of these patients had triple-vessel disease and one single-vessel disease. These results indicated that a normal tetrofosmin study, even in the presence of proven CAD, is associated with a good one-year prognosis. This finding may have implications for the management of this patient group.
99mTc-Tetrofosmin is a radioisotope which has been shown to be an accurate alternative to 20lthallium for the detection of coronary artery disease. However its prognostic value is less well determined. To this end, 181 consecutive patients (mean age 58+9 years) with suspected or known coronary artery disease who underwent exercise SPECT 99mTc-Tetrofosmin scintigraphy were evaluated to determine prognostic indicators of adverse events. Follow-up, defined as time from scanning until a soft event (revascularization procedures), hard event (myocardial infarction and cardiac death) or patient response averaged 41+ 17 months. Patients were excluded if a revascularization procedure was performed within 6 months. Over the entire follow-up 23 soft events (12.7%) and 10 hard events (3.9% myocardial infarction rate and 1.7% cardiac death rate) occurred. There were 76 patients with normal scan (42%) and 105 with abnormal scans (58%). Patients with normal scans were at low risk, and rates of outcomes increased significantly with worsening scan abnormalities. Of the 10 patients with hard events 9 had an abnormal scan. Among 14 clinical, exercise and scintigraphic variables the stepwise discriminant analysis selected significant for prediction (p<0.001) three variables composed hierarchically by the combined fixed and reversible scintigraphic defect, sex and peak exercise time. Thus, exercise SPECT 99mTcTetrofosmin scintigraphy is a useful noninvasive test to stratify patients with suspected or known coronary artery disease.
43.61 SAFETY OF DOBUTAMINE STRESS IN MYOCARDIAL PERFUSION SPECT, EVALUATED BY SERIAL DETERMINATION OF ENZYMATIC MARKERS OF CELL INJURY J. Calqueiro, V. Gil, A. Ventosa, L. Bronze, J. M. Figueira, E. M. Goraes, L. Oliveira, R. Seabra-Gomes. Hospital de Santa Cruz, Carnaxide, PORTUGAL To evaluate the safety of high-dose dobutamine stress in myocardial perfusion scintigraphy, as assessed by serial determination of enzymatic markers of myocardial cell injury, we studied 19 patients (pt), 12 men, 66±9 y.o., who underwent myocardial SPECT with pharmacologic stress for suspected or confirmed CAD. Angina was present in 10 pt, past myocardial infarction in 10 and previous revascularization (2 PTCA, 8 CABG) in 10. Stress was performed using increasing doses of dobulamine until reaching 40gg/kg/min or 85% of maximal predicted heart rate. Angina occurred in 3 pt and ST depression in 1 pt. one episode of sustained VT, 1 of non-sustained VT and 2 of comple~ ' ?B also occurred. SPECT thallinm-201 was performed. Reversible perfusion defects (PD) were present in 13 pts, and normal perfusion or only fixed PD in 6 pts. Blood samples were obtained at baseline, and 4 and 24 hours after dobutamme infusion, to allow measurement oftroponin I, myoglobin and CK-MB mass (quimiolummescence, Access, Sanofi-Pastear), CK and CK-MB (kinetic method). Results were as follows (mean±SD): Troponin I Myoglobin CK-MB mass CK CK-MB (~g/t) (~g/b (~g/l) O:/b 0:/1) reference Baseline 4 hours 24 hours p
<0,1 0,02K-0,02 0,06"0,16 0,02±0,03 ns
<90 19,4~:11,3 23,6+13,8 22,54-13,0 ns
<8 M<130W<100 2,10-~,75 68,3±46,0 2,41=1:0,78 55,1:~34,1 2,36-4:0,88 54,9-'x.26,9 ns ns
<16 10.3±1,00 10,0±0,00 10,5=~1,21 r~
In conclusion, pharmacologic stress with high-dose dobutamine is a safe method, even when evaluated by serial deterrmnation of enzymatic markers of myocardial cell injury.
Abstracts Wednesday morning, April 21, 1999
$93
43.58
43.60
THE PROGNOSTIC VALUE OF NORMAL STRESS Te-99m SESTAMIBI SPECT P Soman, A Banfield, N Lahiri, A Lahiri . Northwick Park Hospital, Harrow, UK
EXERCISE 99mTECHNETIUM TETROFOSMIN TOMOGRAPHY FOR CARDIAC RISK STRATIFICATION OF PATIENTS WITH SUSPECTED OR K N O W N C O R O N A R Y ARTERY DISEASE A.R. Galassi, S. Azzarelli, G. Rodi, A. La Manna, S. Musumeci*, A. Drago, G. Giuffrida. Institute of Cardiology, University of Catania, Italy.
To determine the prognostic value of normal Tc-99m sestamibi (MIBI) SPECT imaging, we examined the incidence of cardiac death and non-fatal myocardial infarction (MI) in 473 patients including 201 (42%) women, aged 56+12 years, who had a normal stress MIBI scan. Eighty nine percent were referrred for s3anptons and/or abnormal exercise electrocardiography (ECG) suggestive of coronau' artery disease (CAD), 5% for screening as3anptomatic patients at high coronary risk and 6% with known CAD. A two- day stress rest protocol was used with graded dynamic exercise in 90% (mean workload 9.1+3 METS; peak heart rate 934-13% of target) and dipyridamole in 10%. ST segment depression > 1 rain on the exercise ECG was observed in 278 (60%) of patients. During 30a:16 (6-56) months of follow up, 2 cardiac deaths (mmualised mortality rate 0.2%, 95% CI 0.02-0.7%) and no MI occurred, suggesting that patients with an intermediate probability of CAD and a normal stress MIBI SPECT have a benign prognosis, despite abnormal exercise ECG, and irrespective of gender.
43.59 PROGNOSIS AF1T_R NORMAL TETROFOSMIN STUDY IN PATIENTS WITH PROVEN CAD J.J.J.Borm, J.E.Roeters van Lennep, H.Roeters van Lennep, A.H.Zwinderman, E.E.van der Wall, E.KJ. Pauwels. Department of Nuclear Medicine, Academic Hospital Leiden, The Netherlands The long term prognosis for ischemic events after a normal myocardial perfusion study and proven CAD is not well known. We performed a follow-up study to assess the long term prognosis.Between August 1995 and March 1998 542 studies in 528 patients (in a series of 1306 consecutive studies in 1252 patients), showed normal myocardial uptake of 99mTc-tetrofosmin both after exercise or pharmacological stress and at rest. In this group 165 angiographic studies were performed. In 113 patients (68%) CAD was demonstrated. Follow-up data showed 9 fatalities, 5 of proven non-cardiac origin, one of proven cardiac origin, an average of 351 days [median 216, range 48 - 953] after a normal perfusion study, resulting in at most 4 attributable deaths. Four (3 attributable) deaths were seen in the 113 patients with proven CAD, an average of 608 days [median 553, range 375 - 953] after the normal tetrofosmin study. Three of these patients had triple-vessel disease and one single-vessel disease. These results indicated that a normal tetrofosmin study, even in the presence of proven CAD, is associated with a good one-year prognosis. This finding may have implications for the management of this patient group.
99mTc-Tetrofosmin is a radioisotope which has been shown to be an accurate alternative to 20lthallium for the detection of coronary artery disease. However its prognostic value is less well determined. To this end, 181 consecutive patients (mean age 58+9 years) with suspected or known coronary artery disease who underwent exercise SPECT 99mTc-Tetrofosmin scintigraphy were evaluated to determine prognostic indicators of adverse events. Follow-up, defined as time from scanning until a soft event (revascularization procedures), hard event (myocardial infarction and cardiac death) or patient response averaged 41+ 17 months. Patients were excluded if a revascularization procedure was performed within 6 months. Over the entire follow-up 23 soft events (12.7%) and 10 hard events (3.9% myocardial infarction rate and 1.7% cardiac death rate) occurred. There were 76 patients with normal scan (42%) and 105 with abnormal scans (58%). Patients with normal scans were at low risk, and rates of outcomes increased significantly with worsening scan abnormalities. Of the 10 patients with hard events 9 had an abnormal scan. Among 14 clinical, exercise and scintigraphic variables the stepwise discriminant analysis selected significant for prediction (p<0.001) three variables composed hierarchically by the combined fixed and reversible scintigraphic defect, sex and peak exercise time. Thus, exercise SPECT 99mTcTetrofosmin scintigraphy is a useful noninvasive test to stratify patients with suspected or known coronary artery disease.
43.61 SAFETY OF DOBUTAMINE STRESS IN MYOCARDIAL PERFUSION SPECT, EVALUATED BY SERIAL DETERMINATION OF ENZYMATIC MARKERS OF CELL INJURY J. Calqueiro, V. Gil, A. Ventosa, L. Bronze, J. M. Figueira, E. M. Goraes, L. Oliveira, R. Seabra-Gomes. Hospital de Santa Cruz, Carnaxide, PORTUGAL To evaluate the safety of high-dose dobutamine stress in myocardial perfusion scintigraphy, as assessed by serial determination of enzymatic markers of myocardial cell injury, we studied 19 patients (pt), 12 men, 66±9 y.o., who underwent myocardial SPECT with pharmacologic stress for suspected or confirmed CAD. Angina was present in 10 pt, past myocardial infarction in 10 and previous revascularization (2 PTCA, 8 CABG) in 10. Stress was performed using increasing doses of dobulamine until reaching 40gg/kg/min or 85% of maximal predicted heart rate. Angina occurred in 3 pt and ST depression in 1 pt. one episode of sustained VT, 1 of non-sustained VT and 2 of comple~ ' ?B also occurred. SPECT thallinm-201 was performed. Reversible perfusion defects (PD) were present in 13 pts, and normal perfusion or only fixed PD in 6 pts. Blood samples were obtained at baseline, and 4 and 24 hours after dobutamme infusion, to allow measurement oftroponin I, myoglobin and CK-MB mass (quimiolummescence, Access, Sanofi-Pastear), CK and CK-MB (kinetic method). Results were as follows (mean±SD): Troponin I Myoglobin CK-MB mass CK CK-MB (~g/t) (~g/b (~g/l) O:/b 0:/1) reference Baseline 4 hours 24 hours p
<0,1 0,02K-0,02 0,06"0,16 0,02±0,03 ns
<90 19,4~:11,3 23,6+13,8 22,54-13,0 ns
<8 M<130W<100 2,10-~,75 68,3±46,0 2,41=1:0,78 55,1:~34,1 2,36-4:0,88 54,9-'x.26,9 ns ns
<16 10.3±1,00 10,0±0,00 10,5=~1,21 r~
In conclusion, pharmacologic stress with high-dose dobutamine is a safe method, even when evaluated by serial deterrmnation of enzymatic markers of myocardial cell injury.