ORIGINAL ARTICLES Assessment of Jeopardized Myocardium in Patients with One-vessel Disease

SUMMARY The size of the perfusion defect was assessed from a quantitative analysis of exercise thallium-201 images. Quantitative analysis was determined by measuring the area and the perimeter of the perfusion defect and expressing it as a percentage of the total left ventricular area or perimeter in three projections. Using this technique, we studied 50 patients with one-vessel disease of 50% or greater diameter narrowing. The planimetric and the perimetric methods correlated well (p < 0.001, r = 0.97). Of the 11 patients with less than 70% diameter narrowing, only one patient had abnormal exercise thallium-201 images. Of the remaining 39 patients with 70% or greater diameter narrowing, 35 circumflex disease. Mortality rates undoubtedly depend on left ventricular function: The worse the function, the poorer the prognosis. Therefore, the extent of jeopardized myocardium may have prognostic importance in patients with one-vessel disease; patients with more jeopardized myocardium may be at a higher risk of developing severe left ventricular dysfunction in the event of myocardium infarction. The purpose of this study was to assess the extent of jeopardized myocardium in patients with one-vessel disease by using quantitative analysis of exercise images, a simple technique that does not require computer manipulation, and to define the factors that affect the size of the defects in these patients. Materials and Methods We reviewed our records of exercise thallium-201 imaging and identified 50 patients with one-vessel disease who had undergone exercise perfusion imaging within 3 months of coronary angiography. There were 46 men and four women, ages 32-63 years (mean 52 years). Patients with associated cardiac diseases such as valvular heart disease or idiopathic hypertrophic subaortic stenosis and patients who had had previous bypass surgery were excluded. All patients were evaluated for symptoms of angina pectoris. No patient had unstable angina or historic or electrocardiographic evidence of myocardial infarction. Left-and right-heart catheterization, left ventriculography and coronary arteriography were per- formed with standard techniques. Each coronary vessel was visualized in multiple projections, including the sagittal oblique projection. Each patient had at least 50% diameter narrowing of one coronary artery. The lesion in the left anterior descending artery was classified as either proximal or distal to the first septal perforator and diagonal branches. In each patient with left circumflex artery disease, the lesion was before or involved the major posterolateral branch. In each patient with right coronary artery disease, the lesion was before the crux. The coronary circulation was rightdominant in patients with left circumflex or right coronary artery disease. The remaining vessels were either free of disease or had only slight luminal irregularities. Collaterals were considered present and significant if the collateral flow partially or completely opacified the diseased vessel beyond the site of occlusion or narrowing. The left ventriculograms, which were assessed qualitatively for wall-motion abnormalities, showed that none of these patients had akinetic or dyskinetic segments. The angiograms were reviewed by two experienced angiographers, and the consensus of both reviewers was used in the final interpretation. Exercise treadmill testing was performed according to the Bruce protocol. The end points of exercise were 2 2 mm of horizontal or downsloping ST depression (with or without angina), excessive fatigue or leg weakness, hypotension, frequent ventricular premature complexes, or attainment of at least 85% of the predicted maximal heart rate. Three electrocardiographic leads (V1, V, and aVF) were continuously monitored; lead V5 was used for interpretation. Blood pressure was obtained by the cuff method every 2 minutes. At peak exercise, 2 mCi of thallium-201 were injected intravenously and flushed with dextrose and water. The patient continued to exercise for 1 more minute. Within 10 minutes after injection, images were obtained in the anterior, left anterior oblique and left lateral projections by means of a commercially available scintillation camera (Baird Atomic System-77) equipped with a high-resolution, parallel-hole, 11/2-inch-thick collimator. Redistribution images were obtained 4 hours after exercise in the projections that showed the perfusion abnormalities. All patients in the study with initial abnormal images showed partia'L or complete redistribution in the delayed images. Our method for obtaining the exercise thallium-201 scintigrams has been described." 6 8 21-24 In brief, images were accumulated for a preset count (750,000 to 1,250,000 total counts), which required 8-12 minutes per projection. All images were corrected for background and for detector nonuniformity. Images were displayed on a television screen on a scale of 16 gray shades or 16 colors. The highest count displayed represents 100% on the scale and all other counts are digitally normalized to the maximum. Each of the 16 shades or colors represents a 6.25% increment in counts within the image. Depending on the visual in--spection of the background contribution, 20-30% background subtraction is used and the 16 colors are displayed over the remaining count range. In addition, the images were processed using an algorithm that weighs and spatially averages five adjacent data points in the matrix. The net result is a color-coded isocount contour display of the myocardial thallium-201 distribution. Polaroid pictures were obtained of the computer-smoothed images. We and others7' 25 have found that the color-coded display of the images improve the interpretation. Segments of the myocardium showing 25% decrease in counts (four-color shift) are considered abnormal. The borders of the defects are outlined by two independent observers and minor disagreements were settled by arbitration between the two observers. Quantitative analysis was done by two methods. In the first method, the size of the thallium-201 defect was determined by the method of Niess et al.26 with a computerized planimetry system (Hewlett-Packard 982A calculator and digitizer). This method expresses the size of thallium-201 perfusion defects as a percentage of total potential thallium uptake. The size of the defect was computed in each projection and expressed as a percentage of the total area of the myocardium, excluding the left ventricular cavity and the region of the valves. The average of the three projections was also determined ( In the second method, the perimeter of the defect was measured and expressed as a percentage of the total left ventricular perimeter in each projection ( Statistical analysis was performed using the t test or the analysis of variance when appropriate

Iodofiltic Acid I 123 (BMIPP) Fatty Acid Imaging Improves Initial Diagnosis in Emergency Department Patients With Suspected Acute Coronary Syndromes A Multicenter Trial

ObjectivesThe aim of this study was to assess the performance of β-methyl-p-[123I]-iodophenyl-pentadecanoic acid (BMIPP) single-photon emission computed tomography (SPECT) to detect acute coronary syndromes (ACS) in emergency department patients with chest pain.BackgroundEmergency department diagnosis of chest pain is problematic, often requiring prolonged observation and stress testing. BMIPP SPECT detects abnormalities in fatty acid metabolism resulting from myocardial ischemia, even many hours after symptom cessation.MethodsEmergency department patients with suspected ACS were enrolled at 50 centers. Patients received 5 mCi BMIPP within 30 h of symptom cessation. BMIPP SPECT images were interpreted semiquantitatively by 3 blinded readers. Initial clinical diagnosis was based on symptoms, initial electrocardiograms, and troponin, whereas the final diagnosis was based on all available data (including angiography and stress SPECT) but not BMIPP SPECT. Final diagnoses were adjudicated by a blinded committee as ACS, intermediate likelihood of ACS, or negative for ACS.ResultsA total of 507 patients were studied and efficacy was evaluated in 448 patients with sufficient data. The sensitivity of BMIPP by 3 blinded readers for a final diagnosis of ACS and intermediate likelihood of ACS was 71% (95% confidence interval [CI]: 64% to 79%), 74% (95% CI: 68% to 81%), and 69% (95% CI: 62% to 77%); the corresponding specificity of BMIPP was 67% (95% CI: 61% to 73%), 54% (95% CI: 48% to 60%), and 70% (95% CI: 64% to 76%). Compared with the initial diagnosis alone, BMIPP + initial diagnosis increased sensitivity from 43% to 81% (p < 0.001), negative predictive value from 62% to 83% (p < 0.001), and positive predictive value from 41% to 58% (p < 0.001), whereas specificity was unchanged (61% to 62%, p = NS).ConclusionsThe addition of BMIPP data to the initially available clinical information adds incremental value toward the early diagnosis of an ACS, potentially allowing determination of the presence or absence of ACS to be made earlier in the evaluation process. (Safety and Efficacy Iodofiltic Acid I 123 in the Treatment of Acute Coronary Syndrome [Zeus-ACS]; NCT00514501

The Accuracy of the Electrocardiogram during Exercise Stress Test Based on Heart Size

BACKGROUND: Multiple studies have shown that the exercise electrocardiogram (ECG) is less accurate for predicting ischemia, especially in women, and there is additional evidence to suggest that heart size may affect its diagnostic accuracy. HYPOTHESIS: The purpose of this investigation was to assess the diagnostic accuracy of the exercise ECG based on heart size. METHODS: We evaluated 1,011 consecutive patients who were referred for an exercise nuclear stress test. Patients were divided into two groups: small heart size defined as left ventricular end diastolic volume (LVEDV) <65 mL (Group A) and normal heart size defined as LVEDV ≥65 mL (Group B) and associations between ECG outcome (false positive vs. no false positive) and heart size (small vs. normal) were analyzed using the Chi square test for independence, with a Yates continuity correction. LVEDV calculations were performed via a computer-processing algorithm. SPECT myocardial perfusion imaging was used as the gold standard for the presence of coronary artery disease (CAD). RESULTS: Small heart size was found in 142 patients, 123 female and 19 male patients. There was a significant association between ECG outcome and heart size (χ(2) = 4.7, p = 0.03), where smaller hearts were associated with a significantly greater number of false positives. CONCLUSIONS: This study suggests a possible explanation for the poor diagnostic accuracy of exercise stress testing, especially in women, as the overwhelming majority of patients with small heart size were women

The 20 year evolution of dobutamine stress cardiovascular magnetic resonance

Over the past 20 years, investigators world-wide have developed and utilized dobutamine magnetic resonance stress testing procedures for the purpose of identifying ischemia, viability, and cardiac prognosis. This article traces these developments and reviews the data utilized to substantiate this relatively new noninvasive imaging procedure

Comparative Definitions for Moderate-Severe Ischemia in Stress Nuclear, Echocardiography, and Magnetic Resonance Imaging

The lack of standardized reporting of the magnitude of ischemia on noninvasive imaging contributes to variability in translating the severity of ischemia across stress imaging modalities. We identified the risk of coronary artery disease (CAD) death or myocardial infarction (MI) associated with ≥10% ischemic myocardium on stress nuclear imaging as the risk threshold for stress echocardiography and cardiac magnetic resonance. A narrative review revealed that ≥10% ischemic myocardium on stress nuclear imaging was associated with a median rate of CAD death or MI of 4.9%/year (interquartile range: 3.75% to 5.3%). For stress echocardiography, ≥3 newly dysfunctional segments portend a median rate of CAD death or MI of 4.5%/year (interquartile range: 3.8% to 5.9%). Although imprecisely delineated, moderate-severe ischemia on cardiac magnetic resonance may be indicated by ≥4 of 32 stress perfusion defects or ≥3 dobutamine-induced dysfunctional segments. Risk-based thresholds can define equivalent amounts of ischemia across the stress imaging modalities, which will help to translate a common understanding of patient risk on which to guide subsequent management decisions

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection