The VEX-test for myocardial scintigraphy with thallium-201 and sestamibi: effect on abdominal background activity.

UNLABELLED: High abdominal background activity of 99mTc-sestamibi may interfere with the diagnosis in studies in which a coronary vasodilator is used; supplemental dynamic exercise might reduce this problem. METHODS: Clinical and angiographic determinants of subdiaphragmatic-to-myocardial activity ratios were measured on immediate poststress left anterior oblique images and on corresponding tomographic studies 1 hr after injection in 600 sestamibi studies. Similar measurements were made in 550 historic controls with planar 201Tl imaging. Patients performed symptom-limited ergometry when there were no limiting factors, dipyridamole-handgrip in which ergometry was not possible and VEX (vasodilator followed by symptom-limited ergometry) in which exercise capacity was reduced. RESULTS: Abdominal activity was higher with sestamibi than with 201Tl, in women versus men, and with dipyridamole-based tests compared to exercise alone. Compared to the dipyridamole-handgrip, 3 min of ergometry as part of VEX decreased abdominal background (p < or = 0.02) by 18% on immediate 201Tl images, by 13% on immediate sestamibi images and by 12% on 1-hr delayed sestamibi tomoacquisitions. CONCLUSIONS: Poststress abdominal background activity is influenced by similar factors with both agents. Supplemental exercise following dipyridamole reduces potentially interfering abdominal activity but perhaps not as efficiently with sestamibi as with 201Tl.

Three-phase bone scintigraphy. Asymmetric patterns in the upper extremities of asymptomatic normals and reflex sympathetic dystrophy patients.

Three-phase Tc-99m MDP scans of 61 patients with asymptomatic upper extremities randomly mixed with 17 studies of patients previously diagnosed with reflex sympathetic dystrophy were blindly interpreted by three observers. Asymmetry in any of the phases was recorded and a final diagnostic impression made. Thirteen of 17 reflux sympathetic dystrophy studies were rated abnormal by at least two observers. Mild to striking asymmetry was occasionally seen in all three phases in asymptomatic upper extremities. Twenty of 61 asymptomatic patients (33%) were rated abnormal by at least one observer, and 5 of 61 studies (8%) were rated abnormal by all observers. Asymmetries in normal patients occurred more commonly in the earlier phases, while asymmetry in the delayed images was mild in all but one. Tightening the criteria to exclude mild asymmetry in delayed images resulted in unacceptably low sensitivity for reflex sympathetic dystrophy (29%). Interobserver variability was most prominent in the flow and immediate images. In the diagnosis of reflex sympathetic dystrophy a greater reliance should be placed on the delayed images, which in themselves have an overall sensitivity of 94%. It is important, however, to recognize that occasional mild and rare moderate asymmetries in even the delayed images of normal individuals result in an overall lower specificity of 77%.

Markers of left ventricular dysfunction induced by exercise, dipyridamole or combined stress on ECG-gated myocardial perfusion scans.

An index of left ventricular contraction can be extracted from the cavitary time-activity curve of electrocardiographic (ECG)-gated myocardial perfusion scans. To assess the induction of stress-induced myocardial depression, we compared contraction indexes derived from immediate poststress and delayed 201Tl images with indexes of ventricular dilation and lung uptake in the prediction of severe coronary artery disease (defined as two or more 90% stenoses). Stress procedures were performed in 93 patients with symptom-limited supine bicycle exercise alone, and in 227 with intravenous dipyridamole, combined where possible with exercise. The immediate and delayed contraction indexes reflected left ventricular dysfunction on ventriculography (P < 0.0001), but additionally the immediate index was reduced (P < 0.0001) in severe coronary disease. Stress-induced hypokinesis was seen frequently after each of the test modes. The relationship with angiographic findings was better defined for indexes of contraction than for lung uptake or ventricular dilation (P < 0.01). The prediction of severe coronary disease was optimized by combining the poststress contraction index and lung uptake. These data support the use of ECG-gated myocardial scans in evaluating the functional consequences of stress/imaging procedures.

Pulmonary thallium-201 uptake following dipyridamole-exercise combination compared with single modality stress testing.

Angiographic and clinical determinants of pulmonary uptake of thallium-201 were assessed in a laboratory setting where supine bicycle exercise is used for stress testing in the absence of limiting pharmacologic or physical factors, and where symptom-limited exercise is added to intravenous dipyridamole infusion in other cases. Angiographic correlation was available in 400 patients, including 130 tested with exercise, 94 in whom only handgrip or abbreviated bicycle exercise could be used after dipyridamole, and 176 in whom intravenous dipyridamole was combined with a significant level of exercise. For each test mode, lung/myocardial ratios on the immediate image were highly correlated (p less than or equal to 0.001) with a score based on the number of critical coronary artery stenoses, with grading by contrast ventriculography, and with the number of stenosed (greater than or equal to 50%) arteries; relationships (p less than 0.05) to history of myocardial infarction and to gender were also present. Multiple regression analysis showed the critical stenosis score and ventricular dysfunction to be the only significant determinants. When dipyridamole based tests were compared with exercise, curves of receiver-operating characteristics showed a tendency to better diagnostic performance. When dipyridamole is incorporated in stress testing, the value of increased lung uptake as an ancillary diagnostic sign is similar to that established for exercise.

Endogenous prostaglandins, adenosine 3':5'-monophosphate and sodium transport across isolated frog skin.

1. Sodium transport across isolated frog skin, as measured by the short-circuit current, was decreased by acetylsalicylic acid, mefenamic acid, paracetamol and phenylbutazone. Indomethacin (6 X 10(-6) M) had a biphasic effect on the short-circuit current: a transient increase followed by a sustained decrease. 2. The release of prostaglandin-like material from the skin was reduced by acetylsalicylic acid and indomethacin. Paracetamol caused a significant reduction in the short-circuit current response of the skin to low doses of arachidonic acid, but the response to the highest dose tested was not significantly altered. 3. Indomethacin (6 X 10(-6) M) increased the sensitivity of the skin to applied prostaglandin E1. The other prostaglandin synthetase inhibitors did not have this effect. Indomethacin (6 X 10(-6) M) also enhanced the effect of antidiuretic hormone on the short-circuit current. 4. Indomethacin (30 X 10(-6) M) increased the short-circuit current and diminished the response to applied prostaglandin E1. 5. In sulphate Ringer, theophylline increased the short-circuit current and diminished the response to prostaglandin E1. 6. Prostaglandin E1 increased the levels of cyclic AMP in frog skin and these increases preceded the increases in short-circuit current. There was a seasonal variation in the level of cyclic AMP in the skin: the levels in winter exceeded those in summer. There was also a seasonal variation in the cyclic AMP response to prostaglandin E1: the winter response was greater than that in summer. 7. Indomethacin (6 X 10(-6) M) had a biphasic effect on cyclic AMP levels in the skin, an initial increase followed by a decrease. Indomethacin also potentiated prostaglandin E1 stimulated cyclic AMP accumulation. 8. Theophylline increased cyclic AMP levels in the skin and potentiated prostaglandin E1 stimulated cyclic AMP accumulation. 9. Pre-treatment of the skin with theophylline reversed the effects of cyclic AMP on the short-circuit current and open-circuit potential. 10. It is concluded that endogenous prostaglandins help to maintain sodium transport across isolated frog skin and that the effects of E-type prostaglandins on the short-circuit current are mediated by increased cyclic AMP levels. The transient increase in short-circuit current and the increased skin sensitivity caused by indomethacin (6 X 10(-6) M) are attributed to inhibition of phosphodiesterase activity. The failure of theophylline to potentiate the short-circuit current response of the skin to prostaglandin E1 is attributed to alteration of cyclic AMP action on the skin by theophylline.