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rest gated-spect imaging in asymptomatic diabetics with suspected coronary artery disease
Journal of Nuclear Cardiology Volume 11, Number 4;S21-S38
tation BMCs Experimental data suggest that Bone Marrow Derived Stem Cells ( BMCs) which may contribute to the healing of myocardial infarction and therefore to sympathetic innervation. We analyzed the results of 4 patients undergoing I-123-MIBG myocardial scintigraphy (SPECT) pre and post cell transplantation. Methods and Results: 4 patients with chronic heart failure, mean LVEF 29⫾5 %, with history of anterior myocardial infraction, were transplanted with autologous BMSCs via a balloon catheter placed into the infarctrelated (LAD) artery. The amount of BMSCs were about 15.6⫾8.5⫻106. We studied the patients a few days pre- and 3 months post transplantation, using I-123-MIBG myocardial scintigraphy. All pts underwent myocardial tomography using I-123-MIBG 4 hours post injection. We compared the two studies for each patient and calculated the counts from short axis slices. Images were assessed by quantitative measures of the activity in the area with decreased activity compared to normal segments for both studies, which were expressed as the ratio postopoerative activity/preoperarive activity. Two Regions of interest (ROI) were selected for each image. The first for the normal and the second for abnormal segment of myocardium. The ratio, r, of counts per pixel of normal ROI to counts per pixel of abnormal ROI was calculated. The average value of r was 1.72⫾0.2 and 1.29⫾0.2, p value of 0.078, for pre and post transplantation studies correspondingly. Conclusion: We observe that the r ratio decreases significantly after BMSCs transplantation. This fact of the improvement in counts suggests that this ratio can be used as a critirio for BMSCs- which might be associated with myocardial regeneration and revascularization and consequently with improvement in myocardial sympathetic innervation. 65.35 STRESS/REST GATED-SPECT IMAGING IN ASYMPTOMATIC DIABETICS WITH SUSPECTED CORONARY ARTERY DISEASE M Mazzanti, M Marini, G Cianci, GP Perna Lancisi Heart Hospital, Ancona, Italy It’s known that that in the routine use of diagnostic imaging, the stratification of asymptomatic diabetics patients (pts) is not widely accepted. The aim of present study was to evaluate the use of gated stress/rest myocardial perfusion imaging (gMPI) in asymptomatic diabetic population at increased risk of CAD. Methods: From January 2003, 214 diabetic (163 males, age 61⫾6 ys) without history of CAD performed gMPI. The cardiovascular risk score (CVRS) was calculated following Italian Health Ministry charts and it was always ⱖ20% (that is multiple risk factors). To perform gated-SPECT study we adopted a dual-day stress/rest protocol. Both post-exercise and resting images were gated and acquired 20 –30 minutes after injection of technetium 99m-tetrofosmin at peak of exercise using a dual-head camera. Perfusion quantitation (SSS, SRS, SDS), and left ventricular global ejection fraction (LVEF) were automatically calculated by using Autoquant™ software package. Results: 115 pts (54%) had abnormal gMPI for perfusion parameters with a SSS ⱖ8, and in 12 of these pts the post-stress LVEF was abnormal (LVEF ⬍ 45%). About the left ventricular function, was normal in all remaning 202 pts, moreover were not differences about RAS between normal and abnormal gMPI. 77 pts (67%) because of an abnormal MPI with a SSS ⬎ 13 were referred to angiography and 67 pts (87%) showed significant CAD. 51/67 (76%) demonstrated left descending artery stenosis ⬎ 70% and/or significant 3-vessel disease (⬎ 70% stenosis). All pts with abnormal LVEF revealed 3-vessel disease. Thus the rate of revascularization of this cohoort of asymptomatic diabetic subjects without a standard indication for stress testing who had abnormal MPI was 24%. Conclusions: In a population of asymptomatic diabetic males, the incidence of abnormal gMPI was substantial and clinical assessment alone did not result predictive of abnormal MPI. The potential routine use of screening test with gMPI may provide additional value in asymptomatic diabetics at increased CVRS with a good cost/effective profile. 65.36 RISK STRATIFICATION OF FUTURE CARDIAC EVENTS USING 123 I-BMIPP SPECT IN PATIENTS WITH KNOWN OR SUSPECTED CORONARY ARTERY DISEASE M Nanasato, T Chikamori, H Fujita, M Toba, T Nishimura Cardiac fatty acid metabolism SPECT imaging study group, JAPAN
Abstracts Saturday, October 2, 2004
S31
Background: It remains unknown whether metabolically impaired myocardium is related to future cardiac events. The aim of this multi-center study is to assess the prognostic value of BMIPP in patients with known or suspected coronary artery disease (CAD). Methods: BMIPP-SPECT was performed to 270 patients with known or suspected CAD. Patients with previous MI or those who underwent coronary revascularization before and after 2 months of SPECT had been excluded. BMIPP uptake was graded on a 20-segment, five-point scoring model. In addition, clinical risk score was developed based on documented CAD, typical angina, NYHA classification and the necessity of hospital admission at the time of BMIPP SPECT. They were followed up with a primary end point of cardiac death, non-fatal MI, congestive heart failure, intervention, and unstable angina. Results: During 3.6⫾1.2 years, 33 patients had cardiac events: cardiac death in 7, nonfatal MI in 3, CHF in 10, PCI in 4, CABG in 5, and unstable angina in 4. Using clinical risk score, event rate was 3% in low-risk, 14% in intermediate-risk, and 27% in high-risk groups (P⬍0.05, respectively). Furthermore, patients with BMIPP defect score ⬍5 in the low-risk group had event rate of only 1%, whereas those with defect score ⱖ5 in the high-risk group had event rate of 39%. Conclusion: These results suggest that BMIPP-SPECT is useful for risk stratification of future cardiac events in patients with known or suspected CAD. Table. The event rate of the patients Clinical risk score BMIPP score
Low
Intermediate
high
⬍5 5 or more
1/74 (1.3%) 2/21 (9.5%)
6/72 (8.3%) 11/54 (20.3%)
2/21 (9.5%) 11/28 (39.2%)
P ⬍ 0.05 for trend.
65.37 RELATIONSHIP BETWEEN MYOCARDIAL PERFUSION SCINTIGRAPHY AND BRACHIAL ARTERY ENDOTHELIAL FUNCTION IN SYSTEMIC LUPUS ERYTHEMATOSUS M Nikpour1, M Urowitz1, D Gladman1, D Ibanez1, P Harvey2, J Floras2, J Rouleau2, R Iwanochko2 1 University of Toronto Lupus Clinic and 2Division of Cardiology, Toronto Western Hospital, Toronto, Canada Background: Up to 35% of patients with SLE have abnormalities on myocardial perfusion imaging (MPI).It is postulated that endothelial dysfunction (EdF) is a precursor to atherosclerosis and may contribute to abnormalities on MPI. Aim: To determine the relationship between EdF measured using brachial artery Doppler ultrasound and MPI in patients with SLE. Method: This was a prospective study of 76 women with SLE, without clinical CAD. Assessment of EdF using brachial artery Doppler ultrasound was performed in all patients. Endothelium-dependent (ed) and independent (eid) flow mediated dilatation (FMD) was measured in response to postischemic reactive hyperemia and sublingual GTN respectively. All patients also underwent rest-stress MPI using SPECT 99mTc sestamibi using dipyridamole stress. MPI was interpreted using a 20 segment model. Summed stress score (SSS) were computed. Results: 40(52.6%) patients had both normal FMD and MPI. 7(9.2%) patients had both abnormal FMD and MPI. 8(10.5%) patients had abnormal FMD alone while 21(27.6%) patients had abnormal MPI alone. 36(47.4%) had an abnormality in either or both investigations. There was no agreement between FMD and MPI (Kappa⫽9.2%, correlation coefficient ⫽ ⫺0.01, NS). However in an analysis of continuous variables, there was a statistically significant but weak negative correlation between eid and MPI (correlation coefficient ⫽ ⫺0.35, p⫽0.002). Conclusion: In this study there was no agreement between FMD and MPI. Abnormal FMD with normal MPI is in keeping with the hypothesis that endothelial dysfunction is a precursor to myocardial ischemia, whereas normal FMD with abnormal MPI may reflect external influences such as treatment with statins at the time of study. Our findings indicate that brachial FMD and myocardial scintigraphy are complementary investigations in assessing the cardiovascular health of patients with SLE and should not be used interchangeably. When used in combination, brachial FMD and
tation BMCs Experimental data suggest that Bone Marrow Derived Stem Cells ( BMCs) which may contribute to the healing of myocardial infarction and therefore to sympathetic innervation. We analyzed the results of 4 patients undergoing I-123-MIBG myocardial scintigraphy (SPECT) pre and post cell transplantation. Methods and Results: 4 patients with chronic heart failure, mean LVEF 29⫾5 %, with history of anterior myocardial infraction, were transplanted with autologous BMSCs via a balloon catheter placed into the infarctrelated (LAD) artery. The amount of BMSCs were about 15.6⫾8.5⫻106. We studied the patients a few days pre- and 3 months post transplantation, using I-123-MIBG myocardial scintigraphy. All pts underwent myocardial tomography using I-123-MIBG 4 hours post injection. We compared the two studies for each patient and calculated the counts from short axis slices. Images were assessed by quantitative measures of the activity in the area with decreased activity compared to normal segments for both studies, which were expressed as the ratio postopoerative activity/preoperarive activity. Two Regions of interest (ROI) were selected for each image. The first for the normal and the second for abnormal segment of myocardium. The ratio, r, of counts per pixel of normal ROI to counts per pixel of abnormal ROI was calculated. The average value of r was 1.72⫾0.2 and 1.29⫾0.2, p value of 0.078, for pre and post transplantation studies correspondingly. Conclusion: We observe that the r ratio decreases significantly after BMSCs transplantation. This fact of the improvement in counts suggests that this ratio can be used as a critirio for BMSCs- which might be associated with myocardial regeneration and revascularization and consequently with improvement in myocardial sympathetic innervation. 65.35 STRESS/REST GATED-SPECT IMAGING IN ASYMPTOMATIC DIABETICS WITH SUSPECTED CORONARY ARTERY DISEASE M Mazzanti, M Marini, G Cianci, GP Perna Lancisi Heart Hospital, Ancona, Italy It’s known that that in the routine use of diagnostic imaging, the stratification of asymptomatic diabetics patients (pts) is not widely accepted. The aim of present study was to evaluate the use of gated stress/rest myocardial perfusion imaging (gMPI) in asymptomatic diabetic population at increased risk of CAD. Methods: From January 2003, 214 diabetic (163 males, age 61⫾6 ys) without history of CAD performed gMPI. The cardiovascular risk score (CVRS) was calculated following Italian Health Ministry charts and it was always ⱖ20% (that is multiple risk factors). To perform gated-SPECT study we adopted a dual-day stress/rest protocol. Both post-exercise and resting images were gated and acquired 20 –30 minutes after injection of technetium 99m-tetrofosmin at peak of exercise using a dual-head camera. Perfusion quantitation (SSS, SRS, SDS), and left ventricular global ejection fraction (LVEF) were automatically calculated by using Autoquant™ software package. Results: 115 pts (54%) had abnormal gMPI for perfusion parameters with a SSS ⱖ8, and in 12 of these pts the post-stress LVEF was abnormal (LVEF ⬍ 45%). About the left ventricular function, was normal in all remaning 202 pts, moreover were not differences about RAS between normal and abnormal gMPI. 77 pts (67%) because of an abnormal MPI with a SSS ⬎ 13 were referred to angiography and 67 pts (87%) showed significant CAD. 51/67 (76%) demonstrated left descending artery stenosis ⬎ 70% and/or significant 3-vessel disease (⬎ 70% stenosis). All pts with abnormal LVEF revealed 3-vessel disease. Thus the rate of revascularization of this cohoort of asymptomatic diabetic subjects without a standard indication for stress testing who had abnormal MPI was 24%. Conclusions: In a population of asymptomatic diabetic males, the incidence of abnormal gMPI was substantial and clinical assessment alone did not result predictive of abnormal MPI. The potential routine use of screening test with gMPI may provide additional value in asymptomatic diabetics at increased CVRS with a good cost/effective profile. 65.36 RISK STRATIFICATION OF FUTURE CARDIAC EVENTS USING 123 I-BMIPP SPECT IN PATIENTS WITH KNOWN OR SUSPECTED CORONARY ARTERY DISEASE M Nanasato, T Chikamori, H Fujita, M Toba, T Nishimura Cardiac fatty acid metabolism SPECT imaging study group, JAPAN
Abstracts Saturday, October 2, 2004
S31
Background: It remains unknown whether metabolically impaired myocardium is related to future cardiac events. The aim of this multi-center study is to assess the prognostic value of BMIPP in patients with known or suspected coronary artery disease (CAD). Methods: BMIPP-SPECT was performed to 270 patients with known or suspected CAD. Patients with previous MI or those who underwent coronary revascularization before and after 2 months of SPECT had been excluded. BMIPP uptake was graded on a 20-segment, five-point scoring model. In addition, clinical risk score was developed based on documented CAD, typical angina, NYHA classification and the necessity of hospital admission at the time of BMIPP SPECT. They were followed up with a primary end point of cardiac death, non-fatal MI, congestive heart failure, intervention, and unstable angina. Results: During 3.6⫾1.2 years, 33 patients had cardiac events: cardiac death in 7, nonfatal MI in 3, CHF in 10, PCI in 4, CABG in 5, and unstable angina in 4. Using clinical risk score, event rate was 3% in low-risk, 14% in intermediate-risk, and 27% in high-risk groups (P⬍0.05, respectively). Furthermore, patients with BMIPP defect score ⬍5 in the low-risk group had event rate of only 1%, whereas those with defect score ⱖ5 in the high-risk group had event rate of 39%. Conclusion: These results suggest that BMIPP-SPECT is useful for risk stratification of future cardiac events in patients with known or suspected CAD. Table. The event rate of the patients Clinical risk score BMIPP score
Low
Intermediate
high
⬍5 5 or more
1/74 (1.3%) 2/21 (9.5%)
6/72 (8.3%) 11/54 (20.3%)
2/21 (9.5%) 11/28 (39.2%)
P ⬍ 0.05 for trend.
65.37 RELATIONSHIP BETWEEN MYOCARDIAL PERFUSION SCINTIGRAPHY AND BRACHIAL ARTERY ENDOTHELIAL FUNCTION IN SYSTEMIC LUPUS ERYTHEMATOSUS M Nikpour1, M Urowitz1, D Gladman1, D Ibanez1, P Harvey2, J Floras2, J Rouleau2, R Iwanochko2 1 University of Toronto Lupus Clinic and 2Division of Cardiology, Toronto Western Hospital, Toronto, Canada Background: Up to 35% of patients with SLE have abnormalities on myocardial perfusion imaging (MPI).It is postulated that endothelial dysfunction (EdF) is a precursor to atherosclerosis and may contribute to abnormalities on MPI. Aim: To determine the relationship between EdF measured using brachial artery Doppler ultrasound and MPI in patients with SLE. Method: This was a prospective study of 76 women with SLE, without clinical CAD. Assessment of EdF using brachial artery Doppler ultrasound was performed in all patients. Endothelium-dependent (ed) and independent (eid) flow mediated dilatation (FMD) was measured in response to postischemic reactive hyperemia and sublingual GTN respectively. All patients also underwent rest-stress MPI using SPECT 99mTc sestamibi using dipyridamole stress. MPI was interpreted using a 20 segment model. Summed stress score (SSS) were computed. Results: 40(52.6%) patients had both normal FMD and MPI. 7(9.2%) patients had both abnormal FMD and MPI. 8(10.5%) patients had abnormal FMD alone while 21(27.6%) patients had abnormal MPI alone. 36(47.4%) had an abnormality in either or both investigations. There was no agreement between FMD and MPI (Kappa⫽9.2%, correlation coefficient ⫽ ⫺0.01, NS). However in an analysis of continuous variables, there was a statistically significant but weak negative correlation between eid and MPI (correlation coefficient ⫽ ⫺0.35, p⫽0.002). Conclusion: In this study there was no agreement between FMD and MPI. Abnormal FMD with normal MPI is in keeping with the hypothesis that endothelial dysfunction is a precursor to myocardial ischemia, whereas normal FMD with abnormal MPI may reflect external influences such as treatment with statins at the time of study. Our findings indicate that brachial FMD and myocardial scintigraphy are complementary investigations in assessing the cardiovascular health of patients with SLE and should not be used interchangeably. When used in combination, brachial FMD and