Diagnostic accuracy of myocardial perfusion imaging with czt technology. Systemic review and meta-analysis of comparison with invasive coronary angiography

OBJECTIVES: This study sought to summarize the evidence on stress myocardial perfusion imaging (MPI) using cadmium-zinc-telluride (CZT) technology for the diagnosis of obstructive coronary artery disease (CAD). The CZT cameras are newly introduced, and comparative data with the conventional Anger technology (Anger-MPI) are lacking. BACKGROUND: The diagnostic accuracy of Anger-MPI for detection of angiographically significant CAD is well established; however, less evidence is available on the diagnostic accuracy of CZT-MPI. METHODS: Clinical studies comparing CZT-MPI and invasive coronary angiography were systematically searched and abstracted. Calculations of diagnostic accuracy, including sensitivity, specificity, likelihood ratios, and diagnostic odds ratio, were obtained with fixed and random effects, reporting point estimates and 95% confidence intervals. RESULTS: Based on our search, a total of 16 studies (N = 2,092) were included. The sensitivity of CZT-MPI was 0.84 (95% confidence interval [CI]: 0.78 to 0.89), whereas the specificity of 0.69 (95% CI: 0.62 to 0.76) was significantly reduced. The positive likelihood ratio was 2.73 (95% CI: 2.21 to 3.39), the negative likelihood ratio was 0.24 (95% CI: 0.17 to 0.31), and the diagnostic odds ratio was 11.93 (95% CI: 7.84 to 17.42). At subgroup and meta-regression analyses, the diagnostic accuracy between D-SPECT and Discovery cameras was similar (p = 0.711) and not impacted upon by smaller sample size studies (p = 0.573). CONCLUSIONS: CZT-MPI has satisfactory sensitivity for angiographically significant CAD, but its suboptimal specificity warrants further development and research

Adenosine-induced ST segment depression with normal perfusion

Background: Intravenous adenosine in conjunction with myocardial perfusion imaging is commonly used for the detection of coronary artery disease and risk assessment. We have previously shown that patients with ischemic changes on the 12-lead electrocardiogram (ECG) in response to adenosine but with normal perfusion pattern have a benign outcome on shortintermediate follow-up. The long-term outcome of these patients is unknown. Methods: Patients with ischemic ECG response (≥ 1 mm ST depression) to adenosine infusion but with normal perfusion on single-photon emission computed tomography (SPECT) imaging in the absence of a history of myocardial infarction or coronary revascularization were followed up for mortality, myocardial infarctions, and coronary revascularization. Results: The cohort consisted of 73 patients (81% women) who were followed up for mortality for a mean of 61 ± 15 months. There were 10 deaths, and the cause of death was determined to be non-cardiac in half of those. Follow-up for the other endpoints was complete for 21 ± 10 months during which no patient had myocardial infarction and seven underwent coronary revascularization. Conclusions: Patients with ischemic ECG response to intravenous adenosine administration and normal perfusion on SPECT are at low risk of cardiovascular events. The ST segment response to adenosine in this setting is likely related to non-ischemic mechanisms

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

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Cardiolog

Correction to: The role of editors (Dec, 10.1007/S12350021-02862-W, 2021)

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Echocardiographic Confirmation of Mitral Valve Prolapse: A New Finding on Radionuclide Ventriculography- A Case Report

A prominent filling defect was depicted on a radionuclide ventriculogram in a patient with mitral regurgitation. This defect was later shown, by cardiac ultrasound, to be due to mitral valve prolapse into the left ventricle during diastole. This case illustrates that mitral valve prolapse should be added to the list of clinical entities that can result in an intraventricular defect on a radionu clide ventriculogram.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/67208/2/10.1177_000331978904000209.pd

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 &lt; 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&apos;L or complete redistribution in the delayed images. Our method for obtaining the exercise thallium-201 scintigrams has been described.&quot; 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&apos; 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