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PubMed1991

Usefulness of technetium-99m-MIBI and thallium-201 in tomographic imaging combined with high-dose dipyridamole and handgrip exercise for detecting coronary artery disease.

Forty-two patients with known stable coronary artery disease, referred for coronary angiography, were examined with technetium-99m-hexakis-2-methoxy-2-methylpropyl-isonitrile (MIBI) tomography combined with a high-dose dipyridamole infusion (0.7 mg/kg) and handgrip stress. MIBI tomography was unable to show coronary artery disease only in 2 patients, thus yielding a sensitivity figure of 95%. MIBI tomography correctly identified 27 (82%) of 33 stenotic lesions (greater than or equal to 50% diameter stenosis) of the left anterior descending artery, 17 (61%) of 28 of those of the left circumflex artery, and 28 (90%) of 31 of those of the right coronary artery. The overall vessel sensitivity was 78%. The computed lumen diameter stenoses were more advanced in cases detected than in those not detected with MIBI tomography: 87 +/- 14 vs 76 +/- 14% (p less than 0.01). The 50 to 69% stenoses did not show any tendency to produce less positive findings than those with greater than or equal to 70% stenoses. In the subgroup of 21 patients who also presented for thallium scintigraphy, the overall diseased vessel identification rate was 76% for thallium tomography and 83% for MIBI tomography (p = not significant). Minor noncardiac side effects related to the dipyridamole-handgrip test occurred only in 5% of 63 study sessions. A high-dose dipyridamole combined with isometric exercise is a safe stress method, and when used during scintigraphy, MIBI tomography is at least as efficient a tool as thallium tomography in detecting diseased vessel territories in patients in coronary artery disease.

Aged↗
PubMed1992

Exclusion of coronary artery disease by exercise thallium-201 tomography in patients with aortic valve stenosis.

In many patients with valvular aortic stenosis (AS), management decisions may be possible without invasive studies if coexistent coronary artery disease (CAD) can be ruled out noninvasively. The use of thallium-201 single-photon emission computed tomography to the exclusion of CAD was studied in 44 patients aged 41 to 78 years with AS. In addition to cardiac catheterization and selective coronary angiography, patients underwent a cardiac ultrasound study and thallium-201 myocardial perfusion imaging at rest and after bicycle ergometer exercise. Two thirds of the patients had critical AS (valve area index less than or equal to 0.5 cm2/m2) but none had left ventricular systolic dysfunction. Twenty-one patients had angiographically significant CAD (greater than or equal to 50% diameter stenosis in greater than or equal to 1 coronary artery), whereas 23 had either a fully normal angiogram (n = 17) or mild (less than 50%) stenoses (n = 6). Each patient with significant CAD had an abnormal thallium-201 tomogram, either a strictly segmental perfusion defect (n = 19), or a patchy nonsegmental abnormality (n = 2); however, 10 of 23 patients free of significant CAD had similar results. Thus, the sensitivity and specificity of an abnormal scintigram were 100 and 57%, respectively. If only segmental perfusion defects typical of CAD had been considered abnormal, then the sensitivity of the test would have been 90% and the specificity 70%. Patients with false abnormal scintigrams had more severe AS and more angiographically nonsignificant CAD than those with true normal findings.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic Valve Stenosis↗
PubMed1992

Identification of viable myocardium by dipyridamole-induced improvement in regional left ventricular function assessed by echocardiography in myocardial infarction and comparison with thallium scintigraphy at rest.

In patients with coronary artery disease and left ventricular impairment, the distinction between ventricular dysfunction due to myocardial fibrosis and postischemic, viable, although dys-synergic, myocardium has important clinical implications. Experimental studies have shown that dipyridamole can increase myocardial function in stunned segments, outlining a potential role of dipyridamole-induced functional recovery as an ultrasonic marker of myocardial viability. The aim of this study was to assess whether the increase of regional left ventricular function early during dipyridamole infusion in basally asynergic segments could identify viable myocardium recognized by rest injected, delayed (greater than 14 hours from tracer injection) thallium and (in a subset of patients) late functional recovery evaluated by a follow-up echocardiogram at rest. Twenty-two patients with angiographically documented coronary artery disease and regional dysfunction in resting conditions (average left ventricular ejection fraction 43 +/- 8%) were studied by echocardiography. All patients underwent a dipyridamole-echocardiographic test (up to 0.84 mg/kg over 10 minutes) and a delayed planar thallium study. A 13-segment model was used for both techniques. A score index ranging from 1 (normokinesia) to 4 (dyskinesia) was used for echocardiography. Thallium-201 activity was expressed in each segment as the percentage of maximal activity in the corresponding view. After dipyridamole, the wall motion score was assigned to each segment in resting conditions and at peak hyperkinesia before possible mechanical signs of ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary Angiography↗
PubMed1992

A new method for evaluating lung uptake of thallium-201 during stress myocardial scintigraphy.

A novel, multipurpose device has been designed that allows thallium activity to be continuously studied from a given lung area at rest and at peak exercise. The information gained from this technique proves to be relevant and reliable because lung thallium activity is displayed in real time and the interpretation of thallium distribution is not based on qualitative or quantitative comparison with that in the myocardium or mediastinum. The time-activity curves obtained in our study group are reported and the relation of peak activity to plateau activity (peak/plateau ratio) is proposed as an index that is easy to obtain for identifying patients with normal and impaired left ventricular function.

Adult↗
PubMed1992

Usefulness of single-photon emission computed tomography of thallium-201 uptake after dipyridamole infusion for detection of coronary artery disease.

The diagnostic performance of single-photon emission computed tomography (SPECT) and planar imaging of thallium-201 uptake for the detection of coronary artery disease (CAD) was compared in 79 patients who underwent both dipyridamole thallium-201 scintigraphy and coronary angiography. Clinical subgroups were assigned by severity of CAD, presence of a prior myocardial infarction and the number of narrowed coronary arteries. The overall detection of CAD was 89% for SPECT and 67% for planar (p less than 0.001). For the anterior vascular territory, sensitivities for SPECT and planar imaging were 69 and 44% (p less than 0.01), respectively; for the posterior vascular territory, sensitivities were 80 and 54% (p less than 0.01). Receiver-operating characteristic analysis, using a 5-point evaluation scale, was performed for the anterior and posterior vascular territories. Receiver-operating characteristic curves generated for SPECT and planar studies demonstrated improved diagnostic performance by SPECT in the anterior vascular territory, but showed similar performance in the posterior territory because of lower SPECT specificity despite higher sensitivity at clinically relevant decision thresholds. In each clinical subgroup of patients, the detection of CAD by SPECT was significantly superior to that by planar imaging, regardless of the severity of stenosis or the number of significantly narrowed coronary arteries, or whether a myocardial infarction was present. Thus, SPECT thallium-201 scintigraphy is an important and necessary clinical tool for detecting CAD after dipyridamole infusion.

Adult↗
PubMed1992

Diagnosis of right ventricular acute myocardial infarction by dual isotope thallium-201 and indium-111 antimyosin SPECT imaging.

To assess the diagnostic value of indium-111 antimyosin for detecting right ventricular (RV) wall acute infarction, 30 patients with electrocardiographic-documented left ventricular inferior (posterior) wall acute myocardial infarction underwent simultaneous dual isotope indium-111 antimyosin and thallium-201 single-photon emission computed tomography (SPECT) within 2 days of admission. RV necrosis was defined as uptake of indium-111 antimyosin anterior and to the right of septal thallium uptake. Twenty-nine of the 30 patients (97%) had indium-111 antimyosin uptake in the inferior, posterior or lateral walls of the left ventricle and 14 of 30 (47%) had additional RV antimyosin uptake. Three different patterns of RV uptake of indium-111 antimyosin were observed: crescent-shaped, focal and apical. Twenty-seven patients underwent gated blood pool scanning before hospital discharge. Twelve of the 14 patients with RV antimyosin uptake had gated blood pool scintigraphy and 7 of 12 had RV dysfunction; 5 had normal RV function. Except for 1 patient who had questionable RV antimyosin uptake and had RV dysfunction, no patient without RV antimyosin uptake had RV dysfunction. In summary, right and left ventricular necrosis can be detected on tomographic images of indium-111 antimyosin uptake in patients with inferior infarctions when simultaneous uptake of a perfusion tracer, thallium-201, is imaged and used as an aid to reconstruction and anatomic localization.

Adult↗
PubMed1992

Usefulness of dipyridamole-thallium scanning for preoperative evaluation of cardiac risk for nonvascular surgery.

The ability to stratify cardiac risk before nonvascular surgery using clinical markers and dipyridamole-thallium scanning (DTS) was assessed for patients with known or suspected coronary artery disease unable to exercise. Of 100 consecutively studied patients who proceeded to nonvascular surgery, 9 (9%) experienced greater than or equal to 1 perioperative cardiac ischemic event, including death in 2 patients (2%) and nonfatal myocardial infarction in 2 (2%). Logistic regression identified 2 clinical predictors (age greater than 70 years and history of heart failure), and 1 DTS (thallium redistribution) predictor of events. Of 45 patients with neither clinical variable, none (0%; 95% confidence intervals [CI] 0 to 8%) had events. Of 55 patients with greater than or equal to 1 clinical marker, 9 (16.4%; 95% CI 7 to 26%) had events. Within this subgroup, 1 of 31 patients (3.2%; 95% CI 0 to 16%) without thallium redistribution had events compared with 8 of 24 (33.3%; 95% CI 14 to 52%) with redistribution. An algorithm combining 5 independent clinical and 2 DTS predictors, derived previously in vascular surgery patients, was validated in the 100 nonvascular surgery patients. It is concluded that preoperative planar DTS is most useful to stratify selected nonvascular surgery patients at intermediate or high risk by clinical assessment. However, for almost half of those patients with known or suspected coronary artery disease, DTS may be unnecessary because of sufficiently low predictive value based on simple clinical descriptors.

Aged↗
PubMed1992

Comparison of accuracy for detecting coronary artery disease and side-effect profile of dipyridamole thallium-201 myocardial perfusion imaging in women versus men.

Intravenous dipyridamole planar thallium-201 imaging is a safe and effective test for detection and prognosis of coronary artery disease (CAD) in the general population. The relative diagnostic accuracy and side-effect profile of dipyridamole thallium-201 stress imaging in women is not defined. Forty-three consecutive female and 71 male patients who underwent dipyridamole thallium-201 imaging (0.56 mg/kg) within 3 months of cardiac catheterization were studied. Scans were considered abnormal if fixed or reversible perfusion defects were detected. Stenosis severity of greater than or equal to 50% luminal diameter reduction of any artery defined CAD. Overall sensitivity for detection of CAD was 0.87 in women and 0.94 in men; specificity was 0.58 in women and 0.63 in men (p = not significant). Sensitivity for detection of 1-vessel CAD was 0.60 in women and 0.94 in men (p = 0.001). The sensitivity for detection of multivessel CAD (with or without surgical revascularization) was 1.0 and 0.94 in women and men, respectively. Adverse effects were reported in 62% of women and in 38% of men (p = 0.01). There was no significant difference in the incidences of chest pain, headache, nausea, flushing or electrocardiographic changes. The incidences of severe ischemia and dizziness were higher in women. Possible explanations for this difference in adverse effects include gender differences in the volume of distribution of dipyridamole due to varied fat-to-muscle ratios and different subjective nocioceptive sensitivities to the effects of dipyridamole. Overall sensitivity and specificity are comparable between the sexes.

Chi-Square Distribution↗
PubMed1993

Prevalence and significance of transient--predominantly asymptomatic--myocardial ischemia on Holter monitoring in unstable angina pectoris, and correlation with exercise test and thallium-201 myocardial perfusion imaging.

The prevalence and clinical significance of transient myocardial ischemia was evaluated prospectively in 43 patients with a clinical diagnosis of unstable angina. Continuous 2-channel Holter electrocardiographic monitoring was begun < 24 hours after admission. In 3,558 hours of recordings (mean 83 +/- 20 hours/patient), there were 1,671 episodes of transient ischemia; > 90% were asymptomatic. All patients but 1 had at least 1 episode of transient ischemia. Twenty-two patients (group 1) had a total ischemic duration of > or = 30 minutes/day, whereas 21 patients (group 2) had a total ischemic duration of < 30 minutes/day. A predischarge symptom-limited exercise test was performed in 40 of these patients after medical stabilization and 39 patients underwent exercise thallium-201 imaging, an average of 3 days after the exercise test. During a follow-up period of 39.9 +/- 9 months (range 28 to 49), 4 patients developed myocardial infarction and 22 required revascularization because of medically refractory angina. There were significantly more patients with total cardiac events (myocardial infarction or a need for revascularization) in group 1 than in group 2 (p < 0.05). Among patients undergoing an exercise test and exercise thallium-201 imaging, a positive exercise electrocardiogram and the presence of a reversible thallium-201 perfusion defect were also significant predictors of subsequent cardiac events (p < 0.05 and p < 0.001, respectively). The results of the Holter recordings did not add significantly more prognostic information.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMed1993

Regional thallium-201 washout and myocardial hypertrophy in hypertrophic cardiomyopathy and its relation to exertional chest pain.

The mechanism of exertional chest pain in hypertrophic cardiomyopathy is uncertain, but may relate to myocardial ischemia. To study the mechanism of exertional chest pain in hypertrophic cardiomyopathy, dipyridamole-stress thallium-201 single-photon emission computed tomography was performed in 82 consecutive patients, and the 3-hour washout of thallium in relation to the tomographic image, regional wall thickness on echocardiography, and other clinical findings was analyzed. There was a weak inverse correlation of regional washout and wall thickness in 298 analyzed quadrant areas (r = -0.29; p = 0.0001). Twenty-five patients (31%) had history of exertional chest pain, and showed a significantly lower total washout and greater maximal left ventricular wall thickness than did those without chest pain (32 +/- 10% vs 37 +/- 9% [p = 0.03], and 27 +/- 7 vs 23 +/- 7 mm [p = 0.03], respectively). Even in mildly and nonhypertrophied areas, patients with chest pain had a significantly lower regional washout than did those without pain (33 +/- 10% vs 38 +/- 9%; p = 0.02), despite similar left ventricular wall thickness (12 +/- 2 vs 11 +/- 3 mm; p = NS). Reduced washout was strongly associated with exertional chest pain and was observed in myocardial regions that had normal as well as increased thickness, which indicates that this abnormality of thallium kinetics is a function of the disease process and not the magnitude of left ventricular hypertrophy.

Adolescent↗
PubMed1993

Diagnosis of right ventricular infarction by overlap images of simultaneous dual emission computed tomography using technetium-99m pyrophosphate and thallium-201.

The validity of dual energy single-photon emission computed tomography (SPECT) with technetium-99m pyrophosphate (Tc-99m PPi) and thallium-201 for the diagnosis of right ventricular (RV) infarction, and the clinical features of RV infarction, were investigated in 190 patients with acute myocardial infarction. Diagnosis of RV infarction was performed by Tc-99m PPi accumulation in the RV myocardium on thallium-201 and Tc-99m PPi over-lay images at the dual SPECT with simultaneous imaging taken 2 to 9 days after the onset of myocardial infarction. Thirty RV infarctions were found among the 190 patients with left ventricular infarction (15.8%): 29 (97%) in association with the inferior and 1 (3%) with the lateral infarction. Tc-99m PPi accumulation was mostly observed in the posterior wall of the right ventricle. A total occlusion or a severe stenosis of the right coronary artery was demonstrated angiographically in 92% of the patients with RV infarction. The prevalence of RV infarctions was significantly lower in patients who achieved successful early reperfusion than in those who did not (26.7 vs 68.4%, respectively, p < 0.01). However, a successful early reperfusion therapy could not significantly decrease the rate of RV involvement in patients without significant collateral flow (p < 0.01). Thus, dual isotope SPECT with Tc-99m PPi and thallium-201 can be used as a reliable method for the diagnosis of RV infarction.

Aged↗
PubMed1994

Correlation of resting electrocardiographic ST-T wave abnormalities with exercise thallium-201 stress testing in patients with known or suspected coronary artery disease.

Resting ST-T wave abnormalities have been associated with an increased risk of adverse cardiac events. Because increased myocardial ischemia represents a possible mechanism for these abnormalities, this study sought to determine whether patients with resting ST-T have greater myocardium in jeopardy as evidenced by stress-induced thallium-201 perfusion abnormalities. One hundred thirty-two consecutive patients not taking digitalis were prospectively studied with combined symptom-limited exercise testing and quantitative thallium-201 imaging. Patients with (n = 43) versus without (n = 89) resting ST-T were older and more frequently had diabetes mellitus. No difference between the 2 groups was seen with respect to gender, cardiac medications, systemic hypertension, prior myocardial infarction, or coronary artery bypass surgery. The results of stress testing were similar for the 2 groups with respect to maximal heart rate, maximal blood pressure, and METs achieved. The mean depth of ST depression was similar in the 2 groups, although patients without resting ST-T were more likely to have upsloping ST depression, and had a shorter duration of ST depression after exercise. With use of an 11 segment model analysis of stress and rest planar thallium-201 scintigrams, patients with versus without resting ST-T had significantly more scan segments showing redistribution defects (1.1 +/- 1.7 vs 0.5 +/- 1.1; p = 0.03) and total (both redistribution and persistent) defects (2.5 +/- 2.5 vs 1.3 +/- 1.9; p = 0.002). The lung-heart ratios (normal < 0.51) were similar in the 2 groups (0.44 +/- 0.07 vs 0.43 +/- 0.10; p = 0.44).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Correlation of exercise-induced ST depression in precordial electrocardiographic leads after inferior wall acute myocardial infarction with thallium-201 stress scintigraphy, coronary angiography and two-dimensional echocardiography.

Fifty-eight of 220 consecutive patients had exercise-induced ST depression in some or all precordial leads 3 to 12 months after a first inferior myocardial infarction. All 58 patients underwent thallium-201 exercise testing, 2-dimensional echocardiography and coronary angiography. ST depression was confined to leads V1-4 in 22 patients (group A); thallium-201 exercise testing showed reversible anterior perfusion defects and left anterior descending coronary artery disease in 11 of the 22 patients (50%). None of the other 11 with negative thallium-201 exercise test results had significant left anterior descending narrowing, and the anterior ST depression could be explained by asynergy of the posterior wall found on 2-dimensional echocardiography in 10. ST depression appeared in leads V5-6 in 22 patients (group B); reversible anterior perfusion defects and left anterior descending disease was demonstrated in 18 patients (82%). In the other 4 patients posterior wall asynergy was demonstrated. ST depression was seen from leads V1-6 in 14 patients (group C); reversible anterior perfusion defects were seen in 6 patients (43%), 5 of whom had significant left anterior descending disease. Among the other 8 patients without reversible anterior perfusion defects, posterior wall asynergy was found in 6.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1985

Normal results of post-race thallium-201 myocardial perfusion imaging in marathon runners with elevated serum MB creatine kinase levels.

Elevated cardiac enzyme values in asymptomatic marathon runners after competition can arise from skeletal muscle through exertional rhabdomyolysis, silent injury to the myocardium, or a combined tissue source. Peak post-race levels of the MB isoenzyme of creatine kinase are similar to values in patients with acute myocardial infarction. Previously reported normal results of infarct-avid myocardial scintigraphy with technetium 99m pyrophosphate in runners after competition suggest a non-cardiac source but cannot exclude silent injury to the myocardium. Therefore, thallium 201 myocardial perfusion imaging was performed in runners immediately after competition together with determination of sequential cardiac enzyme levels. Among 15 runners tested, the average peak in serum MB creatine kinase 24 hours after the race was 128 IU/liter with a cumulative MB creatine kinase release of 117 IU/liter; these values are comparable to those in patients with acute transmural myocardial infarction. Thallium 201 myocardial scintigraphic results were normal in five runners randomly selected from those who volunteered for determination of sequential blood levels. Serum lactate dehydrogenase isoenzymes showed only a peripheral pattern of release. It is concluded that elevations of serum MB creatine kinase in marathon runners arise from a skeletal muscle source and that thallium 201 myocardial scintigraphy is useful to assess runners for myocardial injury when clinical questions arise.

Creatine Kinase↗
PubMed1992

Prognostic implications of a negative dipyridamole-thallium scan: results in 360 patients.

PATIENTS AND METHODS: A total of 360 patients with either normal perfusion (314) or fixed defects (46) on dipyridamole-thallium scans were followed over an average period of 16 months. Of the 360 patients, 194 subsequently underwent major noncardiac surgery. RESULTS: There were a total of eight cardiac events including two postoperative complications (one fatal and one nonfatal myocardial infarction) and six cardiac events during long-term follow-up (one sudden death and five nonfatal infarctions). During the follow-up period, three patients underwent coronary artery bypass surgery. The low cardiac event rate could not be explained by a low pretest likelihood of coronary artery disease: 77% of the 360 patients had either typical angina pectoris, a previous myocardial infarction, or peripheral vascular disease, which is associated with a high prevalence of coronary artery disease. CONCLUSIONS: In patients with a high pretest likelihood of coronary artery disease, the absence of thallium redistribution on a dipyridamole-thallium scan denotes a very low (1%) cardiac risk for major noncardiac surgery as well as low long-term cardiac mortality (0.3%) and morbidity (1.4%) rates. The coronary death rate is comparable to that of patients with minimal (less than 50%) coronary stenoses.

Clinical Protocols↗
PubMed1984

Localization of abnormal parathyroid glands using thallium-201.

Ectopically located parathyroid adenomas may be difficult to find during initial neck exploration. They account for over 70 percent of missed adenomas found at reexploration. Preoperative localization of parathyroid adenomas would reduce unnecessary dissection and possibly reduce the number of negative results of initial neck exploration. Before reoperative parathyroid surgery is performed, some means of localization is mandatory to detect ectopic adenomas in the neck and mediastinum. Computed tomography and ultrasonography cannot effectively evaluate the mediastinum. Angiography and venous parathyroid hormone sampling are invasive, costly, and tedious to perform. We have shown that thallium-201 will accurately localize ectopic parathyroid adenomas. All 10 adenomas found in positions not immediately adjacent to the thyroid gland were detected by thallium-201 scintigraphy. One was a mediastinal adenoma resected with a median sternotomy. Our results suggest that thallium-201 scintigraphy should be the initial localization procedure of choice before all reexplorations. Its use before initial explorations, as well, will enable the surgeon to immediately direct attention to the area of the localized adenoma. If mediastinal uptake is found to be present, then median sternotomy may be performed during initial surgery provided a thorough neck exploration is performed first.

Adenoma↗
PubMed1992

Thallium imaging in preoperative evaluation of the pulmonary resection candidate.

The major determinants of morbidity and mortality after pulmonary resection are the physiologic status of the cardiac and pulmonary systems. The role of thallium 201 imaging was reviewed in 151 consecutive patients to determine its significance in physiologic assessment. 10.3% of patients were found to have serious asymptomatic coronary artery disease, and thallium imaging made a difference in the management of 50% of these patients. When used appropriately, thallium imaging is an important modality in physiologic assessment of the pulmonary resection candidate.

Cardiac Catheterization↗
PubMed1993

Tomographic thallium-201 myocardial perfusion imaging after intravenous dipyridamole in asymptomatic subjects with quadriplegia.

Cardiovascular disease is the leading cause of mortality in those with a spinal cord injury (SCI). As a consequence of changes in body composition and level of activity, individuals with a SCI tend to have a high prevalence of multiple risk factors for coronary artery disease (CAD). In this report, we have demonstrated the usefulness of tomographic thallium-201 myocardial perfusion imaging after intravenous dipyridamole in six clinically asymptomatic subjects with quadriplegia. The average age of the subjects was 47 +/- 2 years, and they had a duration of injury of 15 +/- 2 years. On average, the individuals had five risk factors for CAD. After intravenous administration of dipyridamole and mild upper extremity exercise, the subjects reported no adverse symptoms and had no electrocardiographic evidence suggestive of ischemia. By contrast, three of the six subjects had reversible defects noted on thallium scintigraphy, and one additional subject had a fixed defect that was suggestive of infarction. The remaining two subjects had abnormal scans with fixed defects of the inferioposterior region, which may be ascribed to diaphragmatic attenuation, perhaps a result of partial diaphragmatic paralysis. Thus, dipyridamole thallium myocardial imaging is a safe and effective noninvasive method for the detection of myocardial ischemia or infarction in individuals with quadriplegia who are at increased risk for CAD.

Adult↗