Patient motion during myocardial perfusion SPECT can produce images that show artifactual perfusion defects. The relationship between the degree of motion and the extent of artifactual perfusion ...defects is not clear for either single- or double-head detectors. Using both single- and double-head detectors and quantitative perfusion SPECT (QPS) software, we studied the pattern and extent of defects induced by simulated motion and validated a new automatic motion-correction program for myocardial perfusion SPECT.
Vertical motion was simulated by upward shifting of the raw projection datasets in a returning pattern (bounce) and in a nonreturning pattern at 3 different phases of the SPECT acquisition (early, middle, and late), whereas upward creep was simulated by uniform shifting throughout the acquisition. Lateral motion was similarly simulated by left shifting of the raw projection datasets in a returning pattern and in a nonreturning pattern. Simulations were performed using single- and double-head detectors, and simulated motion was applied to projection images from 8 patients who had normal 99mTc-sestamibi SPECT findings. Additionally, images from 130 patients with actual clinical motion were assessed before and after motion correction. The extent of perfusion defects was assessed by QPS, and a 20-segment, 5-point scoring system was used to assess the effect of motion on the presence and extent of perfusion defects.
Of 12 bounce simulations, the bouncing motion failed to produce significant (>3%) perfusion defects with either the single- or the double-head detector. With the single-head detector, early shifting created the largest defect, whereas with the double-head detector, shifting during the middle of the acquisition created the largest defect. With regard to upward creep, defects were of larger extent with the double- than the single-head detector. With the single-head detector, 8 of 20 simulated motion patterns yielded significant perfusion defects of the left ventricle, 7 (88%) of which were significantly improved after motion correction. With the double-head detector, 12 of 20 patterns yielded significant defects, all of which improved significantly after correction. Of 2,600 segments in the 130 patients with actual clinical motion, only 1.3% (30/2,259) of segments that were considered normal (score = 0 or 1) changed to abnormal (score = 2-4) after motion correction, whereas 27% (92/341) of abnormal segments were reclassified as normal after motion correction.
Artifactual perfusion defects created by simulated motion are a function of the time, degree, and type of motion and the number of camera detectors. Application of an automatic motion-correction algorithm effectively decreases motion artifacts on myocardial perfusion SPECT images.
OBJECTIVE:
To develop a hierarchical approach to cardiac risk stratification after treadmill testing.
PATIENTS:
Clinical and treadmill test data were used to identify a patient population that may be ...candidates for further risk stratification with stress tomographic myocardial perfusion imaging. A prospective series of 3,620 medically treated patients (42% female, mean age 63 years) with a 2.5% mortality was identified (follow‐up 2.5 ± SD 1.5 years).
MEASUREMENTS AND MAIN RESULTS:
A Cox proportional hazards model was used to estimate a patient’s likelihood of cardiac death. Kaplan‐Meier survival curves were used to estimate time to cardiac death by nuclear test results. Annual rates of cardiac death were 0.4% (n = 921), 1% (n = 2,498), and 1% (n = 201) for patients with low, intermediate, and high Duke treadmill scores (DTS). For patients with an intermediate DTS, multivariate estimators of cardiac death included the number of ischemic vascular territories (relative risk per defect 1.4, p = .01), the number of infarcted vascular territories (relative risk per defect 2.4, p = .00001), and the DTS (relative risk per unit 0.97, p = .00001), following adjustment for a patient’s pretest risk of coronary disease. For patients with an intermediate DTS, the presence of no, one or two, and three vascular territories with defects was associated with annual rates of cardiac death of 0.5%, 1.4%, and 2.5%, respectively (p < .0001). Kaplan‐Meier survival curves exhibited a statistically worsening survival for patients with defects by 1 year after treadmill exercise.
CONCLUSIONS:
For symptomatic patients with an intermediate treadmill test score, the exercise myocardial perfusion scan may be used to stratify their risk of cardiac death over 3 years of follow‐up. Patient management may be efficiently guided by further outcome assessment, with an exercise nuclear scan for patients whose treadmill test score is intermediate.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
To date, there are no data on the feasibility and accuracy of bedside pacing stress echocardiography in patients admitted to the hospital with new-onset chest pain or unstable angina. We evaluated ...the feasibility of pacing stress echocardiography and examined its correlation with myocardial perfusion stress scintigraphy (rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion single-photon emission computerized tomography) performed within 24 hours of the pacing stress echocardiography test. We studied 70 consecutive patients after acute myocardial infarction had been excluded. The bedside pacing stress echocardiography test was performed with 10Fr transesophageal pacing catheters. We found pacing stress echocardiography to be feasible and safe (3% minor adverse event rate) at the patients’ bedside. Target heart rate of >85% of the age-predicted heart rate was achieved in 96% of patients, and the mean rate-pressure product was 22,644 ± 4,520 beats/min/mm Hg. The mean duration of the bedside pacing stress echocardiography test including technical preparations and image interpretation was 41 ± 7 minutes. Pacing stress echocardiography and myocardial perfusion stress scintigraphy correlated well for identification or exclusion of inducible myocardial ischemia in 63 of 70 patients (90%) (κ 0.81, p <0.001). The extent of inducible myocardial ischemia by vascular territories correlated with myocardial perfusion stress scintigraphy in 52 of 70 patients (74%) (κ 0.6, p <0.001). We conclude that bedside pacing stress echocardiography is feasible and safe, and highly correlates with myocardial perfusion stress scintigraphy for identifying inducible myocardial ischemia in patients with new onset of chest pain or unstable angina.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background. Little is known about changes of myocardial perfusion in patients undergoing coronary revascularization or medical therapy. The purpose of this observational study was to assess the ...long-term effects of revascularization or conservative therapy on serial quantitative myocardial perfusion single photon emission computed tomography (SPECT). Methods and Results. The study population consisted of 421 patients who underwent serial rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion SPECT with at least a 1-year interval between the 2 studies and who had abnormal quantitative scan results on the first stress SPECT. The mean interval between scans was 32.7 ± 15.9 months. Patients were divided into 3 groups according to stress defect extent: group 1 had small stress defects (4%-10%, n = 145), group 2 had intermediate stress defects (>10%-20%, n = 144), and group 3 had extensive stress defects (>20%, n = 132) at baseline. Forty patients in group 1, 44 in group 2, and 54 in group 3 underwent coronary revascularization between 2 SPECT studies; the others had conservative therapy. In group 3 patients with revascularization, stress defect extent and reversible defect extent were remarkably reduced (14.5% ± 13.6% and 13.1% ± 12.5%, respectively; both P < .0001), with greater improvement in those patients reporting increased use of cardiac medications; resting defect extent was slightly reduced (1.9% ± 6.4%, P < .05). In group 3 patients with conservative therapy, a small reduction in stress defect extent was noted (2.3% ± 8.3%, P < .05). In group 2, there were modest, similar reductions in reversible defect extent in both the patients with revascularization (2.7% ± 7.7%, P < .05) and those with conservative therapy (1.8% ± 7.3%, P < .05), as well as a small but significant reduction in stress defect extent in those with conservative therapy (2.1% ± 8.2%, P < .05). In group 1 patients, no significant changes in stress, rest, or reversible defect extent were found with either therapy. Conclusions. The findings of this study show that improvement in quantitative myocardial perfusion abnormalities over time occurs in some patients with either revascularization or conservative therapy and suggest that, in patients with extensive defects, greater improvement may be seen in those who undergo revascularization. (J Nucl Cardiol 2001;8:428-37.)
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background. The impact of long-acting nitrates on the extent and severity of stress-induced myocardial ischemia is not well described, especially after long-term treatment.
Methods. Forty patients ...with chronic stable angina and reversible ischemia on an exercise stress myocardial perfusion single photon emission computed tomography (ex-SPECT) were prospectively studied in a 6-week period. At baseline, rest thallium-201/exercise stress technetium 99m sestamibi SPECT was performed, followed by treatment with extended-release isosorbide 5-mononitrate (5-ISMN, Imdur). Follow-up ex-SPECT was performed 5 days and 6 weeks after the initiation of therapy with extended-release 5-ISMN. The exercise treadmill testing (ETT) protocol and exercise duration of the follow-up studies were the same as that of the baseline ETT. Defect extent and severity were analyzed both by means of an automated quantitative method, with CEqual software, and visually, with a 20-segment scoring system (which was also used to derive a summed stress score SSS).
Results. In the 6-week study period, significant reductions occurred in both the extent and the severity of exercise-induced ischemia by means of quantitative SPECT (13.8%
P < .0003 and 12.7%
P < .0003, respectively). There was no significant change in these variables between stages 2 (day 5) and 3 (6 weeks), indicating no development of tolerance to the nitrate effect. Similar reductions were noted by means of the visual analysis (SSS reduction of 13.0%
P < .002) in the entire study period.
Conclusions. Patients with chronic-stable-angina treated with a long-acting nitrate demonstrate improvement in myocardial perfusion defect extent and severity in an extended period by means of both visual and quantitative analysis of sequential exercise testing to the same rate-pressure product end point. (J Nucl Cardiol 2000;7:342–53.)
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Electron-beam computed tomography (EBCT) and nuclear cardiology techniques are both valuable in the noninvasive assessment of patients with suspected coronary artery disease. The techniques, however, ...are different in the information they provide about the patient. EBCT provides anatomic information on coronary atherosclerosis, whereas myocardial perfusion single-photon emission computed tomography assesses the physiologic significance of coronary stenosis. Because of these differences, the techniques are highly complementary.
In considering the complementary nature of these methods, it is important to clarify the issues being raised. An important question in the consideration of a patient with known or suspected coronary artery disease is, What is the risk in an individual patient of developing clinical coronary artery disease? The answer to this question will determine who needs aggressive medical management. A second question in a suspected coronary artery disease patient is, What is the risk of cardiac death? As will be discussed, this risk, in general, determines the need to consider coronary revascularization. In the former question, EBCT testing and clinical assessment alone is usually sufficient, and in some cases nuclear testing can be of additional value. In answering the second question, on the basis of currently available data, the EBCT and nuclear cardiology studies appear to be operating in a complementary fashion.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
The study compared the prognostic significance of myocardial perfusion single-photon emission computed tomography (SPECT) (MPS) in patients early and late after coronary artery bypass graft surgery ...(CABG).
The long-term effectiveness of CABG is limited by graft stenosis. The greatest incidence of graft occlusion occurs between five and eight years after surgery. However, little is known regarding the appropriate time to stress patients post-CABG with respect to risk stratification.
We identified 1,765 patients, who underwent MPS 7.1 +/- 5.0 years post-CABG. All patients underwent rest T1-201/stress Tc-99m sestamibi MPS and were followed up > or =1 year after testing. Patients with early CABG or PTCA (<60 days after MPS) were censored. The prognostic population consisted of 1,544 patients. A semiquantitative visual analysis employing a 20-segment model was used to define summed stress score (SSS), summed rest score (SRS), summed difference score (SDS), and the number of nonreversible segments (NRS).
During follow-up, 53 cardiac deaths (CD) occurred. There was a significant increase in annual CD rates as a function of SSS. A multivariate analysis identified age, ischemia (SDS), and infarct size (NRS) as independent predictors of CD. Nuclear variables added incremental value to prescan information. The annual CD rate was relatively low (1.3%) in patients < or =5 years post-CABG. In this subgroup only age and infarct size (NRS) were predictive of CD.
MPS is strongly predictive of subsequent CD in post-CABG patients and adds incremental value over clinical and treadmill test information. Our data suggest that symptomatic patients < or =5 years and all patients >5 years post-CABG may benefit from testing.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
DNA-based immunization is a contemporary strategy for developing vaccines to prevent infectious diseases in animals and humans. Translating the efficacy of DNA immunization demonstrated in murine ...models to the animal species that represent the actual populations to be protected remains a significant challenge. We tested two hypotheses directed at enhancing DNA vaccine efficacy in outbred animals. The first hypothesis, that DNA-encoding fetal liver tyrosine kinase 3 ligand (Flt3L) and GM-CSF increases dendritic cell (DC) recruitment to the immunization site, was tested by intradermal inoculation of calves with plasmid DNA encoding Flt3L and GM-CSF followed by quantitation of CD1(+) DC. Peak DC recruitment was detected at 10-15 days postinoculation and was significantly greater (p < 0.05) in calves in the treatment group as compared with control calves inoculated identically, but without Flt3L and GM-CSF. The second hypothesis, that DNA encoding Flt3L and GM-CSF enhances immunity to a DNA vector-expressed Ag, was tested by analyzing the CD4(+) T lymphocyte response to Anaplasma marginale major surface protein 1a (MSP1a). Calves immunized with DNA-expressing MSP1a developed strong CD4(+) T cell responses against A. marginale, MSP1a, and specific MHC class II DR-restricted MSP1a epitopes. Administration of DNA-encoding Flt3L and GM-CSF before MSP1a DNA vaccination significantly increased the population of Ag-specific effector/memory cells in PBMC and significantly enhanced MSP1a-specific CD4(+) T cell proliferation and IFN-gamma secretion as compared with MHC class II DR-matched calves vaccinated identically but without Flt3L and GM-CSF. These results support use of these growth factors in DNA vaccination and specifically indicate their applicability for vaccine testing in outbred animals.
The efficacy of antianginal agents in the treatment of patients with chronic stable angina has traditionally been evaluated by performance measures, such as the exercise treadmill test (ETT). ...Although reliable and reproducible, ETT is not a sensitive measure of changes in myocardial ischemia. The effects of antianginal agents on coronary blood flow and myocardial perfusion have been less frequently studied. Angiographic studies have demonstrated that nitrates may operate by preferentially directing blood flow to ischemic regions of the myocardium. These investigations have been limited, however, by the invasive nature of the evaluation. Measurements of regional myocardial perfusion may also be made with noninvasive tests. Both quantitative single-photon emission computed tomography (SPECT) and positron emission tomography (PET) have been employed, but few studies have used these techniques to assess the effects of antianginal drugs (in general) and nitrates (in particular) on changes in reversible myocardial perfusion defects. Studies that have evaluated the direct effects of nitrate treatment on coronary blood flow and myocardial perfusion defects in patients with chronic stable angina are reviewed, and preliminary data from a study of the effects of long-term nitrate treatment on myocardial perfusion are discussed.
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IJS, IMTLJ, KILJ, KISLJ, NUK, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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