Technetium-99m Sestamibi Single-photon Emission Research Articles

Diagnostic Accuracy of Four-Dimensional Computed Tomography in Preoperative Localization of Primary Hyperparathyroidism After Negative or Inconclusive Sestamibi: A Systematic Review and Meta-analysis

Objective The aim of the study is to assess the diagnostic accuracy of 4-dimensional computed tomography (4D-CT) scans for patients with primary hyperparathyroidism (pHPT) after negative or inconclusive Technetium-99m sestamibi single-photon emission computed tomography scan. Methods A literature search of several databases was conducted from inception to August 2023. Eligible studies reported adult patients (>18 years old) who underwent 4D-CT after negative or inconclusive sestamibi results. The pooled proportions were analyzed using a random-effects model. This review was registered in PROSPERO (CRD42023446285). Results From 208 initial studies screened, 10 met the eligibility criteria, with a total of 335 patients with a diagnosis of pHPT who underwent 4D-CT scans and subsequent surgical exploration. Nine of the studies reported a pooled sensitivity of localization of 71% (0.71; 95% confidence interval [CI]: 0.610, 0.811, I 2 = 72%). The pooled specificity of localization across 5 studies was calculated at 47% (0.47; 95% CI: −0.111, 1.059, I 2 = 99%). Seven of the included studies reported a pooled positive predictive value of 81% (0.81; 95% CI: 0.708, 0.917, I 2 = 70%), and 6 of the studies reported a negative predictive value of 28% (0.28; 95% CI: −0.114, 0.683, I 2 = 98%). Conclusions For pHPT patients with inconclusive sestamibi scans, 4D-CT demonstrates promising results with good diagnostic accuracy for the localization of pHPT. Additional studies evaluating larger groups of patients may provide further support for the use of 4D-CT in this population.

Relationship Between Infarct Artery, Myocardial Injury, and Outcomes After Primary Percutaneous Coronary Intervention in ST-Segment-Elevation Myocardial Infarction.

The extent to which infarct artery impacts the extent of myocardial injury and outcomes in patients with ST-segment-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention is uncertain. We performed a pooled analysis using individual patient data from 7 randomized STEMI trials in which myocardial injury within 30 days after primary percutaneous coronary intervention was assessed in 1774 patients by cardiac magnetic resonance (n=1318) or technetium-99m sestamibi single-photon emission computed tomography (n=456). Clinical follow-up was performed at a median duration of 351 days (interquartile range, 184-368 days). Infarct size and outcomes were assessed in anterior (infarct vessel=left anterior descending) versus nonanterior (non-left anterior descending) STEMI. Median infarct size (percentage left ventricular myocardial mass) was larger in patients with anterior compared with nonanterior STEMI (19.7% [interquartile range, 9.4%-31.7%] versus 12.6% [interquartile range, 5.1%-20.5%]; P<0.001). Patients with anterior compared with nonanterior STEMI were at higher risk for 1-year all-cause mortality (6.2% versus 3.6%; adjusted hazard ratio [HR], 1.66 [95% CI, 1.02-2.69]; P=0.04) and heart failure hospitalization (4.4% versus 2.6%; adjusted HR, 1.96 [95% CI, 1.15-3.36]; P=0.01). Infarct size was a predictor of subsequent all-cause mortality or heart failure hospitalization in anterior STEMI (adjusted HR per 1% increase, 1.05 [95% CI, 1.03-1.07]; P<0.001), but not in nonanterior STEMI (adjusted HR, 1.02 [95% CI, 0.99-1.05]; P=0.19). The P value for this interaction was 0.04. Anterior STEMI was associated with substantially greater myonecrosis after primary percutaneous coronary intervention compared with nonanterior STEMI, contributing in large part to the worse prognosis in patients with anterior infarction.

Addressing the challenges of missed parathyroid glands in ultrasonography for secondary hyperparathyroidism: a retrospective observational study.

Preoperative localization plays an important role in secondary hyperparathyroidism (SHPT) surgery. The advantages of neck ultrasound (US) include high availability and low cost. However, the reported sensitivity of US is 54%-76%, and the reason for missed parathyroid glands (PGs) on US has been rarely addressed. Fifty-four patients who were diagnosed with renal SHPT from September 2020 to March 2022 were included in this retrospective study. Preoperative localization included surgeon-oriented US and technetium 99m-sestamibi single-photon emission CT (SPECT)/CT. A total of 212 PGs were pathologically confirmed, resulting in a success rate of 96.2% (52 of 54). Using echo, 193 PGs (91.0%) were accurately localized, while 19 glands (9.0%) were not identified, including those in ectopic positions (n = 12, at thymus or intrathyroid or others), of small size (<1 cm, n = 6), or overlapping with an ipsilateral PG (n = 1). US accurately detected 4 PGs in 36 (66.7%) patients, while SPECT/CT localized 4 glands in 19 patients (35.2%). Although the number of US-detectable PGs was not associated with success rate, it showed a significant negative correlation with surgical time (rs = -0.459, P = 0.002). US detected 4 glands in 66% of SHPT patients with a sensitivity of 90% for localization. Ectopic position and small size were the most common reasons for the failure to detect PG on US. Complete preoperative echo localization might shorten operating time.

Analysis of the successful clinical treatment of 140 patients with parathyroid adenoma: A retrospective study.

BACKGROUNDParathyroid adenoma (PA) sometimes recurs after surgery, how to improve the surgical success rate of PA is the key to the treatment of this disease.AIMTo investigate the clinical features, diagnosis, and surgical treatment of patients with PA.METHODSPatients who were pathologically confirmed with PA and had undergone surgery for the first time between January 2010 and December 2017 at the Beijing Shijitan Hospital affiliated to Capital Medical University were included in the study. The clinical features, localization diagnosis, and surgical treatment of these patients were analyzed.RESULTSOf the 140 patients, 32 were male and 108 were female; 132 cases had one adenoma, and 8 had two adenomas. In addition, 114 cases had clinical symptoms, among which 51, 28, 23, 8, and 4 had urinary system, skeletal system, digestive system, neuromuscular system, and neuropsychiatric symptoms, respectively, while 26 cases had no obvious symptoms. The median level of preoperative parathyroid hormone (PTH) was 201.0 pg/mL. The positive detection rate of technetium-99m sestamibi (Tc-99m MIBI) single-photon emission computed tomography/computed tomography (SPECT/CT), ultrasound examination, and the combined use of Tc-99m MIBI SPECT/CT and ultrasound examination was 92.9%, 85.5%, and 96.4%, respectively. Open surgery was performed in all patients, and PTH was monitored during surgery. The success rate of surgery was 98.6%. After surgery, 21 cases developed hypocalcemia, 1 case developed temporary hoarseness, and 19 cases had transient hypoparathyroidism but there was no permanent hypoparathyroidism, postoperative hemorrhage, or hematoma in the surgical area.CONCLUSIONFor patients with clinically unexplained skeletal system, urinary system, and neuropsychiatric symptoms, the possibility of PA should be considered. Imaging examinations such as ultrasound and Tc-99m MIBI SPECT/CT could be integrated before surgery to obtain accurate localization diagnosis. Precise preoperative localization, intraoperative PTH monitoring, and delicate surgery to protect the integrity of the PA capsule ensure a minimally invasive and successful surgery.

Clinical Outcomes in Patients With ST-Segment Elevation MI and No Standard Modifiable Cardiovascular Risk Factors.

The author recently reported ∼50% excess early mortality in patients with first-presentation ST-segment elevation myocardial infarction (STEMI) without standard modifiable cardiovascular risk factors (SMuRFs); the cause of this is not clear. The aim of this study was to examine differences in infarct characteristics and clinical outcomes in patients with versus without SMuRFs (dyslipidemia, hypertension, diabetes mellitus, and smoking). Individual-level data were pooled from 10 randomized percutaneous intervention (PCI) trials in which infarct size was measured within 1month by either cardiac magnetic resonance or technetium-99m sestamibi single-photon emission computed tomography imaging. First-presentation STEMI was classified into 2 groups according to the presence or absence of at least 1 SMuRF. Among 2,862 patients, 524 (18.3%) were SMuRF-less. After adjusting for study effect, SMuRF-less patients had more frequent poor pre-PCI flow Thrombolysis In Myocardial Infarction 0/1 compared with patients with at least 1SMuRF (72.0% vs 64.1%; OR: 1.35; 95%CI: 1.08-1.70). There were no independent associations between the presence or absence of SMuRFs at baseline and infarct size (estimate =-0.35; 95%CI:-1.93 to 1.23), left ventricular ejection fraction (estimate =-0.06; 95%CI:-1.33 to 1.20), or mortality at 30days (HR: 0.46; 95%CI: 0.19-1.07) and 1 year (HR:0.74; 95%CI: 0.43-1.29). First-presentation STEMI patients with no identifiable baseline SMuRFs had a higher risk of Thrombolysis In Myocardial Infarction flow grade 0/1 pre-PCI. However, after adjustment, there were no significant associations between SMuRF-less status and infarct size, left ventricle ejection fraction, or mortality.

A Novel Mouse Model of Radiation-Induced Cardiac Injury Reveals Biological and Radiological Biomarkers of Cardiac Dysfunction with Potential Clinical Relevance.

Radiation-induced cardiotoxicity is a significant concern in thoracic oncology patients. However, the basis for this disease pathology is not well characterized. We developed a novel mouse model of radiation-induced cardiotoxicity to investigate pathophysiologic mechanisms and identify clinically targetable biomarkers of cardiac injury. Single radiation doses of 20, 40, or 60 Gy were delivered to the cardiac apex of female C57BL/6 mice ages 9-11 weeks, with or without adjacent lung tissue, using conformal radiotherapy. Cardiac tissue was harvested up to 24 weeks post-radiotherapy for histologic analysis. Echocardiography and Technetium-99m sestamibi single photon emission computed tomography (SPECT) at 8 and 16 weeks post-radiotherapy were implemented to evaluate myocardial function and perfusion. Mouse cardiac tissue and mouse and human plasma were harvested for biochemical studies. Histopathologically, radiotherapy resulted in perivascular fibrosis 8 and 24 (P < 0.05) weeks post-radiotherapy. Apical perfusion deficits on SPECT and systolic and diastolic dysfunction on echocardiography 8 and 16 weeks post-radiotherapy were also observed (P < 0.05). Irradiated cardiac tissue and plasma showed significant increases in placental growth factor (PlGF), IL6, and TNFα compared with nonradiated matched controls, with greater increases in cardiac cytokine levels when radiotherapy involved lung. Human plasma showed increased PlGF (P = 0.021) and TNFα (P = 0.036) levels after thoracic radiotherapy. PlGF levels demonstrated a strong correlation (r = 0.89, P = 0.0001) with mean heart dose. We developed and characterized a pathophysiologically relevant mouse model of radiation-induced cardiotoxicity involving in situ irradiation of the cardiac apex. The model can be used to integrate radiomic and biochemical markers of cardiotoxicity to inform early therapeutic intervention and human translational studies.

Effect of Smoking on Outcomes of Primary PCI in Patients With STEMI

BackgroundSmoking is a well-established risk factor for ST-segment elevation myocardial infarction (STEMI); however, once STEMI occurs, smoking has been associated with favorable short-term outcomes, an observation termed the “smoker’s paradox.” It has been postulated that smoking might exert protective effects that could reduce infarct size, a strong independent predictor of worse outcomes after STEMI. ObjectivesThe purpose of this study was to determine the relationship among smoking, infarct size, microvascular obstruction (MVO), and adverse outcomes after STEMI. MethodsIndividual patient-data were pooled from 10 randomized trials of patients with STEMI undergoing primary percutaneous coronary intervention. Infarct size was assessed at median 4 days by either cardiac magnetic resonance imaging or technetium-99m sestamibi single-photon emission computed tomography. Multivariable analysis was used to assess the relationship between smoking, infarct size, and the 1-year rates of death or heart failure (HF) hospitalization and reinfarction. ResultsAmong 2,564 patients with STEMI, 1,093 (42.6%) were recent smokers. Smokers were 10 years younger and had fewer comorbidities. Infarct size was similar in smokers and nonsmokers (adjusted difference: 0.0%; 95% confidence interval [CI]: −3.3% to 3.3%; p = 0.99). Nor was the extent of MVO different between smokers and nonsmokers. Smokers had lower crude 1-year rates of all-cause death (1.0% vs. 2.9%; p < 0.001) and death or HF hospitalization (3.3% vs. 5.1%; p = 0.009) with similar rates of reinfarction. After adjustment for age and other risk factors, smokers had a similar 1-year risk of death (adjusted hazard ratio [adjHR]: 0.92; 95% CI: 0.46 to 1.84) and higher risks of death or HF hospitalization (adjHR: 1.49; 95% CI: 1.09 to 2.02) as well as reinfarction (adjHR: 1.97; 95% CI: 1.17 to 3.33). ConclusionsIn the present large-scale individual patient-data pooled analysis, recent smoking was unrelated to infarct size or MVO, but was associated with a worse prognosis after primary PCI in STEMI. The smoker’s paradox may be explained by the younger age and fewer cardiovascular risk factors in smokers compared with nonsmokers.

Cost-effectiveness Analysis of 99mTc-sestamibi SPECT/CT to Guide Management of Small Renal Masses

BackgroundIncidentally detected small renal masses (SRMs) may be one of several benign or malignant tumor histologies, and are heterogeneous in oncologic potential. Renal mass biopsy can be used to determine the histology of SRMs. However, this invasive approach has significant limitations. Technetium-99m sestamibi single photon emission computed tomography/computed tomography (99mTc-sestamibi SPECT/CT) is a promising imaging tool that can aid in identifying benign renal oncocytomas and hybrid oncocytic/chromophobe tumors. ObjectiveTo evaluate the clinical and economic value of 99mTc-sestamibi SPECT/CT in guiding the management of SRMs. Design, setting, and participantsWe developed a decision analysis model to estimate the costs and health outcomes of competing management strategies for a healthy 65-yr-old patient with an asymptomatic SRM. InterventionEmpiric surgery (reference); real-world clinical practice (RWCP) consisting of empiric surgery, thermal ablation, and active surveillance (alternative reference); renal mass biopsy (option 1); 99mTc-sestamibi SPECT/CT (option 2); and 99mTc-sestamibi SPECT/CT followed by biopsy to confirm benign SRMs (option 3). Outcome measurements and statistical analysisWe assessed lifetime health utilities, measured in quality-adjusted life years (QALYs), and direct medical costs from a health payer perspective. We calculated the incremental cost-effectiveness ratio (ICER) for options 1–3 versus the reference and alternative reference arms, with a willingness-to-pay threshold of $50 000/QALY. Univariate, multivariate, and probabilistic sensitivity analyses were performed. Results and limitationsOption 3 had a very low risk of untreated malignant tumors (0.2%, vs 2.1% for option 1, 4.2% for option 2, and 0% for empiric surgery) and the highest probability of leaving benign tumors untreated (84.4%, vs 53.9% for option 1, 51.7% for option 2, and 0% for empiric surgery). Option 3 dominated empiric surgery and options 1 and 2 (ie, lower costs and higher QALYs). Compared with RWCP, options 1–3 were all cost effective; option 3 had the lowest ICER of $18 821/QALY. These findings were robust to alternative input values. Study limitations included data uncertainties and a limited number of centers from which 99mTc-sestamibi SPECT/CT performance data were collected. Conclusions99mTc-sestamibi SPECT/CT followed by confirmatory biopsy helps avoid surgery for benign SRMs, minimizes untreated malignant SRMs, and is cost effective compared with existing strategies. Patient summaryOur research suggests that by using a noninvasive imaging test, known as technetium-99m sestamibi single photon emission computed tomography/computed tomography, to diagnose small renal masses, urologists may avoid unnecessary surgery for benign tumors and minimize the risk of leaving a malignant tumor untreated. Moreover, the use of this strategy to diagnose small renal masses is cost effective for the health care system.

Fluorine-18 fluorodeoxyglucose positron emission tomography in assessing myocardial viability in a tertiary academic centre in Johannesburg, South Africa: a pilot study.

Positron emission tomography detects patients with myocardial contractile dysfunction secondary to ischaemic heart disease who may benefit from coronary revascularisation. We reviewed technetium-99m sestamibi singlephoton emission computed tomography (SPECT) and fluorine-18 fluorodeoxyglucose (F18-FDG) positron emission tomography (PET) data from 236 patients imaged between January 2009 and June 2015. The patients were grouped into three groups: no evidence of viability, viability 1-10% and viability > 10%. Viability exceeding 10% was evident in 55% of the patients. On multivariate analysis, aspirin intake [OR: 1.92; 95% CI: 1.08-3.41; p = 0.026] and hypertension [OR: 1.89; 95% CI: 1.07-3.33; p = 0.029] were clinical factors associated with the presence of myocardial viability. Our study demonstrated that F18-FDG PET was able to identify 55% of patients with ischaemic heart disease with viability in more than 10% of the total myocardium when using a 17-segment model.

Relationship Between Infarct Size and Outcomes Following Primary PCI: Patient-Level Analysis From 10 Randomized Trials

BackgroundPrompt reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) reduces infarct size and improves survival. However, the intuitive link between infarct size and prognosis has not been convincingly demonstrated in the contemporary era. ObjectivesThis study sought to determine the strength of the relationship between infarct size assessed early after primary percutaneous coronary intervention (PCI) in STEMI and subsequent all-cause mortality, reinfarction, and hospitalization for heart failure. MethodsWe performed a pooled patient-level analysis from 10 randomized primary PCI trials (total 2,632 patients) in which infarct size was assessed within 1 month after randomization by either cardiac magnetic resonance (CMR) imaging or technetium-99m sestamibi single-photon emission computed tomography (SPECT), with clinical follow-up for ≥6 months. ResultsInfarct size was assessed by CMR in 1,889 patients (71.8%) and by SPECT in 743 patients (28.2%). Median (25th, 75th percentile) time to infarct size measurement was 4 days (3, 10 days) after STEMI. Median infarct size (% left ventricular myocardial mass) was 17.9% (8.0%, 29.8%), and median duration of clinical follow-up was 352 days (185, 371 days). The Kaplan-Meier estimated 1-year rates of all-cause mortality, reinfarction, and HF hospitalization were 2.2%, 2.5%, and 2.6%, respectively. A strong graded response was present between infarct size (per 5% increase) and subsequent mortality (Cox-adjusted hazard ratio: 1.19 [95% confidence interval: 1.18 to 1.20]; p < 0.0001) and hospitalization for heart failure (adjusted hazard ratio: 1.20 [95% confidence interval: 1.19 to 1.21]; p < 0.0001), independent of age, sex, diabetes, hypertension, hyperlipidemia, current smoking, left anterior descending versus non–left anterior descending infarct vessel, symptom-to-first device time, and baseline TIMI (Thrombolysis In Myocardial Infarction) flow 0/1 versus 2/3. Infarct size was not significantly related to subsequent reinfarction. ConclusionsInfarct size, measured by CMR or technetium-99m sestamibi SPECT within 1 month after primary PCI, is strongly associated with all-cause mortality and hospitalization for HF within 1 year. Infarct size may, therefore, be useful as an endpoint in clinical trials and as an important prognostic measure when caring for patients with STEMI.

Left ventricular remodeling after late revascularization correlates with baseline viability.

The ideal management of stable patients who present late after acute ST-elevation myocardial infarction (STEMI) is still a matter of conjecture. We hypothesized that the extent of improvement in left ventricular function after successful revascularization in this subset was related to the magnitude of viability in the infarct-related artery territory. However, few studies correlate the improvement of left ventricular function with the magnitude of residual viability in patients who undergo percutaneous coronary intervention in this setting. In 68 patients who presented later than 24 hours after a confirmed first STEMI, we performed resting, nitroglycerin-enhanced, technetium-99m sestamibi single-photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) before percutaneous coronary intervention, and again 6 months afterwards. Patients whose baseline viable myocardium in the infarct-related artery territory was more than 50%, 20% to 50%, and less than 20% were divided into Groups 1, 2, and 3 (mildly, moderately, and severely reduced viability, respectively). At follow-up, there was significant improvement in end-diastolic volume, end-systolic volume, and left ventricular ejection fraction in Groups 1 and 2, but not in Group 3. We conclude that even late revascularization of the infarct-related artery yields significant improvement in left ventricular remodeling. In patients with more than 20% viable myocardium in the infarct-related artery territory, the extent of improvement in left ventricular function depends upon the amount of viable myocardium present. The SPECT-MPI can be used as a guide for choosing patients for revascularization.

Efficacy of upfront sestamibi SPECT-CT for localisation of parathyroid adenomas prior to minimally invasive parathyroidectomy (MIP).

Purpose: The accuracy of a new pre-operative algorithm for patients proceeding to MIP, using upfront Technetium-99m Sestamibi single-photon emission computed tomography-computed tomography (SPECT-CT) followed by neck ultrasound only in equivocal or negative cases, was evaluated.

Tc-99m SPECT Sestamibi for the Measurement of Infarct Size

There are a variety of approaches to assess the efficacy of reperfusion therapy, and myocardial protection, in acute myocardial infarction. This review summarizes the available evidence validating the use of technetium-99m sestamibi single-photon emission computed tomography (SPECT) for this purpose. Multiple lines of evidence have validated its clinical utility. SPECT sestamibi infarct size has been used as an endpoint in multiple randomized clinical trials. A smaller number of clinical trials have used both early and later imaging with SPECT sestamibi to assess myocardium at risk and myocardial salvage. SPECT sestamibi has a number of limitations which must be recognized. Nevertheless, SPECT sestamibi infarct size is a well-validated measurement with a long track record of performance as an endpoint in multicenter, randomized clinical trials.

Cardiac abnormalities in severe acute dichlorvos poisoning*

Patients with organophosphorus poisoning sometimes die suddenly during rigorous treatment, possibly from myocardial injury. This study sought to elucidate the mechanisms underlying organophosphorus poisoning-induced cardiotoxicity. Prospective observational study. Urban, tertiary teaching hospital emergency intensive care unit with 10 beds. Forty-one patients with severe acute dichlorvos poisoning were consecutively enrolled (n = 92) at emergency intensive care unit and followed for 3 months. Levels of serum creatine kinase isoenzyme myocardium, cardiac troponin I, acetylcholinesterase, acetylcholine, epinephrine, and norepinephrine were tested on hospital days 1, 3, and 5 and on discharge day. Electrocardiography was recorded on admission and then every other day. Transthoracic echocardiography was performed at admission, in the acute phase, before discharge, and during follow-up. Technetium 99m-sestamibi myocardial single photon emission computed tomography was conducted in four patients. Thirty-seven (90.2%) patients survived and four (9.8%) patients died during treatment. We observed sinus tachycardia in 37 (90.2%) patients and ST-T changes in 33 (80.4%) patients. Creatine kinase isoenzyme myocardium and cardiac troponin I levels peaked at day 3 postadmission and then decreased to normal levels. Serum acetylcholine, epinephrine, and norepinephrine peaked at day 1 after admission and then decreased. Echocardiography revealed marked decreases in wall motion of the interventricular septum and left ventricle in the acute phase but returned to normal in the recovery phase. The left ventricular ejection fraction improved significantly from 42 ± 5% to 59 ± 4% (p = .001). Single photon emission computed tomography showed abnormal left ventricle perfusion. Severe acute dichlorvos poisoning is associated with reversible myocardial dysfunction, possibly through an increase in catecholamine levels.

The Occluded Artery Trial (OAT) Viability Ancillary Study (OAT-NUC): Influence of infarct zone viability on left ventricular remodeling after percutaneous coronary intervention versus optimal medical therapy alone

The Occluded Artery Trial (OAT) showed no difference in outcomes between percutaneous coronary intervention (PCI) versus optimal medical therapy (MED) in patients with persistent total occlusion of the infarct-related artery 3 to 28 days post-myocardial infarction. Whether PCI may benefit a subset of patients with preservation of infarct zone (IZ) viability is unknown. The OAT nuclear ancillary study hypothesized that (1) IZ viability influences left ventricular (LV) remodeling and that (2) PCI as compared with MED attenuates adverse remodeling in post-myocardial infarction patients with preserved viability. Enrolled were 124 OAT patients who underwent resting nitroglycerin-enhanced technetium-99m sestamibi single-photon emission computed tomography (SPECT) before OAT randomization, with repeat imaging at 1 year. All images were quantitatively analyzed for infarct size, IZ viability, LV volumes, and function in a core laboratory. At baseline, mean infarct size was 26% ± 18 of the LV, mean IZ viability was 43% ± 8 of peak uptake, and most patients (70%) had at least moderately retained IZ viability. There were no significant differences in 1-year end-diastolic or end-systolic volume change between those with severely reduced versus moderately retained IZ viability, or when compared by treatment assignment PCI versus MED. In multivariable models, increasing baseline viability independently predicted improvement in ejection fraction (P = .005). There was no interaction between IZ viability and treatment assignment for any measure of LV remodeling. In the contemporary era of MED, PCI of the infarct-related artery compared with MED alone does not impact LV remodeling irrespective of IZ viability.

Myocardial perfusion imaging using a technetium-99m Sestamibi in asymptomatic and low risk for coronary artery disease patients with diagnosed systemic lupus erythematosus

The aim of the present study was to evaluate technetium-99m sestamibi single photon emission tomography (SPECT) myocardial perfusion imaging (MPI) and its association with some clinical and laboratory parameters in an asymptomatic systemic lupus erythematosus (SLE) population. Twenty-one subjects with SLE and no suspected or documented coronary artery disease (CAD) accomplished myocardial perfusion imaging. Some SLE and CAD parameters were also evaluated in association with myocardial SPECT. Twenty-one women with a diagnosis of SLE (mean age 36.9 ± 12.8) entered the study. All patients were in the low-risk category for CAD pretest; however, abnormal myocardial perfusion results were found in eight (38%) patients. Amongst the traditional CAD risk factors, there was a significant association between the presence of dyslipidemia and myocardial perfusion abnormalities (P= 0.047). However, we found no significant association between other traditional and SLE-specific risk factors. This study's significant finding was that asymptomatic CAD is common in SLE patients, even in those thought to be low risk for CAD and in the absence of cardiac symptoms.

Effect of Spironolactone on Left Ventricular Ejection Fraction and Volumes in Patients With Class I or II Heart Failure

The beneficial effects of spironolactone in chronic heart failure (HF) have been demonstrated in patients with New York Heart Association (NYHA) class III to IV HF. This study examined the effect of spironolactone on left ventricular (LV) function and functional capacity of patients with mild to moderate HF (NYHA class I to II). One hundred sixty-eight patients with NYHA class I to II HF and LV ejection fraction ≤40% were randomized to spironolactone or placebo and assessed by echocardiography, gated single-photon emission computed tomography, technetium-99m sestamibi single-photon emission computed tomographic radionuclide ventriculography, and cardiopulmonary exercise testing at baseline and after 6 months of treatment. In the spironolactone group LV ejection fraction increased from 35.2 ± 0.7% to 39.1 ± 3.5% (p <0.001), with a decrease in LV end-diastolic and end-systolic volumes and myocardial mass and an improvement in LV diastolic filling pattern. Cardiopulmonary exercise testing parameters did not change. In conclusion, administration of spironolactone to patients with NYHA class I to II HF has beneficial effects on LV remodeling and diastolic function.

Peak Cardiac Troponin-T Level, Scintigraphic Myocardial Infarct Size and One-Year Prognosis in Patients Undergoing Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction

Current guidelines recommend troponin T (TnT) as the biomarker of choice in the diagnosis of myocardial infarction. In patients with ST-elevation myocardial infarction (STEMI) however, its role in providing a measurement of infarct size and its association with survival is less well established. We sought to assess the correlation of TnT and creatine kinase-MB (CK-MB) with scintigraphically determined infarct size and to assess the predictive value of all 3 parameters on 12-month mortality. Patients presenting with STEMI managed with primary percutaneous intervention underwent serial TnT and CK-MB measurements at admission and for ≥72 hours after presentation. Before hospital discharge patients underwent assessment of infarct size by technetium-99m sestamibi single-photon emission computed tomographic (SPECT) scan. Clinical follow-up was performed up to 1 year. Data were available for 1,237 patients. Mean age was 62.9 ± 12.9 years. Infarct location was anterior in 509 patients (41%); 75 (6.1%) had cardiogenic shock. Median admission and peak TnT were 0.74 μg/L (0.10 to 2.70) and 3.70 μg/L (1.69 to 6.99), respectively. Corresponding values for CK-MB were 44.1 U/L (21.0 to 108.8) and 160.0 U/L (69.0 to 301.0), respectively. Median infarct size on SPECT scan was 12.0% (3.0 to 25.0) of the left ventricle. Peak TnT and CK-MB demonstrated similar moderate correlation with final infarct size (r = 0.45, p <0.001, and r = 0.41, p <0.001 respectively). This correlation was not affected by Thrombolysis In Myocardial Infarction flow grade after intervention. At 1 year, 47 patients (3.8%) had died. Final infarct size at SPECT scanning better predicted mortality than peak TnT or CK-MB. In conclusion, this study is the largest investigation on the value of cardiac troponin for assessment of infarct size in acute STEMI. Compared to peak CK-MB, peak TnT shows similar correlation with scintigraphic infarct size, although scintigraphic infarct size remains a better correlate of 1-year mortality than either biomarker.

Comparison of Exercise Electrocardiography, Technetium-99m Sestamibi Single Photon Emission Computed Tomography, and Dobutamine and Dipyridamole Echocardiography for Detection of Coronary Artery Disease in Hypertensive Women

To assess the performance of currently used stress tests for the detection of coronary artery disease (CAD) in a series of female hypertensive patients. We performed exercise electrocardiography (ECG), technetium-99m sestamibi (MIBI) single photon emission computed tomography, dobutamine and dipyridamole echocardiography, and coronary angiography in 76 hypertensive women. Of the 76 study patients, 31 (41%) had significant CAD. The sensitivity of exercise ECG (81%), MIBI scanning (90%), and dobutamine echocardiography (87%) was greater than that of dipyridamole echocardiography (61%). This finding resulted from the lower sensitivity of dipyridamole echocardiography in the detection of single-vessel CAD (47% vs 76%, 88%, and 82% for the other 3 methods). In contrast, the sensitivity of the 4 tests was similar in the detection of multivessel CAD. The specificity of exercise ECG (56%) and MIBI scanning (53%) was less than that of dobutamine (82%, both p <0.01) and dipyridamole (91%, both p <0.001) echocardiography. This finding related to the lower specificity of exercise ECG in patients with either left ventricular hypertrophy or ST-T abnormalities at rest compared to the specificity in patients without these disorders (33% vs 89%, p <0.01). A lower MIBI scan specificity was found only in patients with left ventricular hypertrophy (31% vs 66%, p <0.05). The overall accuracy of dobutamine echocardiography reached 84% compared to exercise ECG (66%, p <0.01), MIBI scan (68%, p <0.05), and dipyridamole echocardiography (79%, p <0.05). In conclusion, dobutamine echocardiography yielded satisfactory diagnostic accuracy for identifying CAD in hypertensive women. Although dipyridamole echocardiography had the greatest specificity, it might be limited in detecting mild CAD. Both exercise ECG and MIBI scanning had fare sensitivity; however, our findings limit the usefulness of these 2 tests in unselected patients.

Regional wall-motion abnormalities on post-stress electrocardiographic-gated technetium-99m sestamibi single-photon emission computed tomography imaging predict cardiac events

The global left-ventricular (LV) ejection fraction (EF) is a powerful predictor of cardiac death (CD). There are limited data on the prognostic value of regional LV function. We examined the role of visually assessed regional wall motion in risk stratification for future cardiac events. A prospectively gathered database of 10,336 patients who underwent technetium (Tc)-99m sestamibi-gated single-photon emission computed tomography (SPECT) was analyzed. The summed stress score (SSS) and summed wall-motion score (SWMS) were calculated using a standard 17-segment model. The post-stress EF was generated using QGS software. The follow-up was 90.2% complete over 28.6 +/- 16 months. Patients with early (<or=60 days) revascularization were censored, leaving 8,767 for analysis. A multivariate analysis demonstrated that abnormal wall motion (SWMS >or=5) was an independent predictor of cardiac death (odds ratio = 1.78, 95% confidence interval = 1.11 to 2.85, P = .016). Among patients with an EF >or=45%, abnormal wall motion was the only gated SPECT variable that independently predicted cardiac death (odds ratio = 1.69, 95% confidence interval = 1.06 to 2.7, P = .028). In patients with an EF >or=45% and reversible perfusion defects, abnormal wall motion predicted an intermediate (2.2%/year) risk for CD, and a high (4.2%/year) risk for the combined endpoint of cardiac death and nonfatal MI. Regional LV function data from gated SPECT provide important prognostic information, and may identify a subgroup of patients with preserved EF and ischemia who are at significant risk for future cardiac events.