Morphological and functional carotid vessel wall properties in relation to cerebral white matter lesions in myocardial infarction patients.

OBJECTIVE: Atherosclerotic large vessel disease is potentially involved in the pathogenesis of cerebral small vessel disease related to occurrence of white matter lesions (WMLs) in the brain. We aimed to assess morphological and functional carotid vessel wall properties in relation to WML using magnetic resonance imaging (MRI) in myocardial infarction (MI) patients. MATERIALS AND METHODS: A total of 20 MI patients (90 % male, 61 ± 11 years) underwent carotid artery and brain MRI. Carotid vessel wall thickness (VWT) was assessed, by detecting lumen and outer wall contours. Carotid pulse wave velocity (PWV), a measure of elasticity, was determined using the transit-time method. Patients were divided according to the median VWT into two groups. Brain MRI allowed for the WML score. RESULTS: Mean VWT was 1.41 ± 0.29 mm and mean carotid PWV was 7.0 ± 2.2 m/s. A significant correlation (Pearson r = 0.45, p = 0.046) between VWT and PWV was observed. Furthermore, in the group of high VWT, the median WML score was higher as compared with the group with lower VWT (4.0 vs 3.0, p = 0.035). CONCLUSIONS: Carotid artery morphological and functional alterations are correlated in MI patients. Patients with high VWT showed a higher amount of periventricular WMLs. These findings support the hypothesis that atherosclerotic large vessel disease is potentially involved in the pathogenesis of cerebral small vessel disease.

No difference in cardiac event-free survival between positron emission tomography-guided and single-photon emission computed tomography-guided patient management: a prospective, randomized comparison of patients with suspicion of jeopardized myocardium.

OBJECTIVES: We sought to prospectively compare nitrogen-13 (13N)-ammonia/18fluorodeoxyglucose (18FDG) positron emission tomography (PET)-guided management with stress/rest technetium-99m (99mTc)-sestamibi single-photon emission computed tomography (SPECT)-guided management. BACKGROUND: Patients with evidence of jeopardized (i.e., ischemic or viable) myocardium may benefit from revascularization, whereas patients without it should be treated with drugs. Both PET and SPECT imaging have been proven to delineate jeopardized myocardium. When patient management is based on identification of jeopardized myocardium, it is unknown which technique is most accurate for long-term prognosis. METHODS: In a clinical setting, 103 patients considered for revascularization with left ventricular wall motion abnormalities and suspicion of jeopardized myocardium underwent both PET and SPECT imaging. The imaging results were used in a randomized fashion to determine management (percutaneous transluminal coronary angioplasty [PTCA], coronary artery bypass graft surgery [CABG] or drug treatment). Follow-up for cardiac events (cardiac death, myocardial infarction and revascularization) was recorded for 28 +/- 1 months. The study was designed to have a power of 80% to detect a 20% difference in the event rate between PET- and SPECT-based management. RESULTS: Management decisions in 49 patients randomized to PET (12 who had PTCA, 14 CABG and 23 drug therapy) were comparable with 54 patients randomized to SPECT (15 who had PTCA, 13 CABG and 26 drug therapy). In terms of cardiac event-free survival, no differences between PET and SPECT were observed (11 vs. 13 cardiac events for PET and SPECT, respectively; p = NS by the Kaplan-Meier statistic). CONCLUSIONS: No difference in patient management or cardiac event-free survival was demonstrated between management based on 13N-ammonia/18FDG PET and that based on stress/rest 99mTc-sestamibi SPECT imaging. Both techniques may be used for management of patients considered for revascularization with suspicion of jeopardized myocardium.

Impairment of myocardial blood flow reserve in patients with asymptomatic left ventricular dysfunction: effects of ACE-inhibition with perindopril.

Myocardial blood flow (MBF) reserve is impaired in patients with symptomatic chronic heart failure. Whether this is already present in asymptomatic left ventricular (LV) dysfunction, and whether it is affected by angiotensin converting enzyme (ACE) inhibition, is unknown. We examined MBF in 20 patients with asymptomatic LV dysfunction and compared them to healthy volunteers. MBF (reserve) was assessed with positron emission tomography (PET) and N-13 ammonia at rest, during dipyridamole stress test (DST) and during cold pressor test (CPT). Further, in the LV-dysfunction group, we studied the effects of 3 months treatment with ACE inhibition with a second PET study. Patients were randomized double-blind to perindopril 4 mg daily or placebo. MBF at rest was similar in controls and patients. DST-induced MBF reserve, however, was decreased in patients vs. controls (1.71+/-0.2 vs. 2.62+/-0.5, respectively p < 0.05). Also CPT-induced MBF was lower in patients (1.14+/-0.06 vs. 1.23+/-0.03, p < 0.05). After 3 months double-blind treatment, CPT-induced MBF decreased in the placebo group (from 1.12+/-0.02 to 0.93+/-0.06), but was preserved in the perindopril group (from 1.16+/-0.08 to 1.14+/-0.08 shifts from baseline: -0.19+/-0.05 vs. -0.02+/-0.07 respectively p = 0.07). This was compatible with a trend to a smaller increase in coronary vascular resistance during CPT (1.23+/-0.08 vs. 1.03+/-0.06, placebo vs. perindopril, p = 0.06). In patients with asymptomatic LV dysfunction, MBF, both after vasodilation and after CPT, is already impaired. ACE inhibition with perindopril during this short-term treatment had no significant effects.

Regional myocardial blood flow reserve impairment and metabolic changes suggesting myocardial ischemia in patients with idiopathic dilated cardiomyopathy.

OBJECTIVES: We performed positron emission tomography (PET) to evaluate myocardial ischemia in patients with idiopathic dilated cardiomyopathy (IDC). BACKGROUND: Patients with IDC have anatomically normal coronary arteries, and it has been assumed that myocardial ischemia does not occur. METHODS: We studied 22 patients with IDC and 22 control subjects using PET with nitrogen-13 ammonia to measure myocardial blood flow (MBF) at rest and during dipyridamole-induced hyperemia. To investigate glucose metabolism, fluorine-18 deoxyglucose (18FDG) was used. For imaging of oxygen consumption, carbon-11 acetate clearance rate constants (k(mono)) were assessed at rest and during submaximal dobutamine infusion (20 microg/kg body weight per min). RESULTS: Global MBF reserve (dipyridamole-induced) was impaired in patients with IDC versus control subjects (1.7 +/- 0.21 vs. 2.7 +/- 0.10, p < 0.05). In patients with IDC, MBF reserve correlated with left ventricular (LV) systolic wall stress (r = -0.61, p = 0.01). Furthermore, in 16 of 22 patients with IDC (derived by dipyridamole perfusion) mismatch (decreased flow/increased 18FDG uptake) was observed in 17 +/- 8% of the myocardium. The extent of mismatch correlated with LV systolic wall stress (r = 0.64, p = 0.02). The MBF reserve was lower in the mismatch regions than in the normal regions (1.58 +/- 0.13 vs. 1.90 +/- 0.18, p < 0.05). During dobutamine infusion k(mono) was higher in the mismatch regions than in the normal regions (0.104 +/- 0.017 vs. 0.087 +/- 0.016 min(-1), p < 0.05). In the mismatch regions 18FDG uptake correlated negatively with rest k(mono) (r = -0.65, p < 0.05), suggesting a switch from aerobic to anaerobic metabolism. CONCLUSIONS: Patients with IDC have a decreased MBF reserve. In addition, low MBF reserve was paralleled by high LV systolic wall stress. These global observations were associated with substantial myocardial mismatch areas showing the lowest MBF reserves. In geographically identical regions an abnormal oxygen consumption pattern was seen together with a switch from aerobic to anaerobic metabolism. These data support the notion that regional myocardial ischemia plays a role in IDC.

Quantitative comparison of single-isotope and dual-isotope stress-rest single-photon emission computed tomographic imaging for reversibility of defects.

BACKGROUND: Dual-isotope rest/stress single-photon emission computed tomographic (SPECT) imaging is a time-saving imaging protocol. However, the stress radiotracer, technetium 99m-labeled sestamibi, and the rest radiotracer, thallium 201, have different physical properties and myocardial kinetics. In patients with abnormal resting myocardial perfusion, these differences may affect quantification of rest defect size and defect reversibility. The purpose of the study was to compare myocardial perfusion defect reversibility quantitatively by single-isotope (rest/stress sestamibi) and dual-isotope (rest thallium/stress sestamibi) SPECT. METHODS AND RESULTS: Thirty patients with prior myocardial infarction underwent rest/stress sestamibi SPECT imaging and rest thallium SPECT imaging. Defects were quantified according to circumferential count profiles with a normal sestamibi database. The images of a subgroup of 21 patients were processed with radiotracer-specific normal databases. Defect size and defect reversibility were compared quantitatively for single-isotope and dual-isotope SPECT. Rest sestamibi defect size was significantly larger than rest thallium defect size (19 +/- 15 vs 14 +/- 16; p = 0.007). Defect reversibility was larger with thallium than with sestamibi (10 +/- 9 vs 6 +/- 6; p = 0.002). With radiotracer-specific normal databases, mean rest sestamibi and thallium defect sizes in 21 patients were not different (23 +/- 19 vs 21 +/- 17; difference not significant). With radiotracer-specific normal databases, mean defect reversibility was not different with either sestamibi or thallium (6 +/- 6 vs 8 +/- 9; difference not significant), although correlation among individual patients was only fair (r2 = 0.48). CONCLUSION: In patients with prior myocardial infarction, stress-induced defect reversibility is quantitatively larger with dual-isotope imaging than with single-isotope imaging. Quantitative processing of dual-isotope images requires radiotracer-specific normal databases. Because of different characteristics of sestamibi and thallium, assessment of defect reversibility on dual-isotope images should be made with caution. Only relatively large defect reversibility can be assumed to represent true stress-induced myocardial ischemia.

Cardiac anatomy, function and metabolism in elite cyclists assessed by magnetic resonance imaging and spectroscopy.

We investigated whether left ventricular hypertrophy in elite cyclists is associated with functional changes or abnormal energy metabolism. Left ventricular hypertrophy is a powerful risk factor for sudden cardiac death with different prognostic significance among the various geometric forms. Cyclists may have a combination of mixed eccentric and concentric hypertrophy. Magnetic resonance imaging was used to define left ventricular mass, geometry and function. Thirteen highly trained male cyclists and 12 healthy controls were investigated. Proton-decoupled phosphorus-31 cardiac spectroscopy was performed to assess parameters of myocardial high-energy phosphate metabolism. Left ventricular mass and end-diastolic volumes normalized for body surface area were significantly higher in cyclists (124.1 +/- 9.4 g.m-2 and 106.2 +/- 11.4 ml.m-2, respectively) than in controls (85.9 +/- 9.3 g.m-2 and 79.1 +/- 11.6 ml.m-2, respectively), (both P < 0.0001). The left ventricular mass to end-diastolic volume ratio, as a parameter of left ventricular geometry, was not significantly increased in cyclists compared to controls. Resting left ventricular ejection fraction, cardiac index, and systolic wall stress in cyclists did not differ significantly from those of controls. The phosphocreatine to adenosine triphosphate ratio was not significantly different between cyclists and controls (2.2 +/- 0.34 vs 2.2 +/- 0.17, ns). Cyclists show prominent left ventricular hypertrophy with normal geometry. The finding that the hypertrophic hearts of the cyclists had normal left ventricular function and a normal phosphocreatine to adenosine triphosphate ratio suggests that sport-induced left ventricular hypertrophy is a physiological adaptation rather than a pathophysiological response.

Head-to-head comparison of 201Tl rest-redistribution scintigraphy and stress-immediate reinjection scintigraphy in the detection of myocardial viability.

Reinjection imaging with thallium-201 (201Tl) provides a reliable method of identifying viable myocardium. Reinjection of 201Tl immediately after completing the stress images followed by imaging 1 h after reinjection shortens the examination time to a maximum of 2.5 h and provides an alternative imaging approach in patients with coronary artery disease. In this study, we investigated whether immediate 201Tl reinjection imaging provides adequate information on myocardial viability compared with separate-day 201Tl rest or rest-redistribution imaging. In 23 patients with anterior or anteroseptal wall infarction first documented more than 3 months previously, we performed 201Tl stress-immediate reinjection, separate-day 201Tl rest imaging and rest-stress radionuclide angiography. In 13 patients, 201Tl rest scintigraphy was followed by redistribution imaging 3 h later. On the three-view planar 201Tl images, eight myocardial segments were analysed visually and quantitatively. Stress 201Tl images were compared with 201Tl reinjection images, 201Tl rest images and 201Tl 3-h redistribution images after rest injection. When comparing the stress images both with the immediate reinjection images and the rest images, concordant scintigraphic classification was found in 181 of 184 myocardial segments (kappa = 0.97). Comparing the stress images both with the immediate reinjection images and with the 3-h redistribution images following 201Tl injection at rest, concordant scintigraphic classification was found in 102 of 104 myocardial segments (kappa = 0.97). In 16 of 23 (70%) patients, 201Tl stress-immediate reinjection scintigraphy and radionuclide angiography provided concordant information on myocardial viability. In 6 (26%) patients, we observed a function-perfusion mismatch (i.e. 201Tl uptake in dyskinetic/adyskinetic regions) indicative of jeopardized but viable myocardium, demonstrating the additional value of 201Tl as a marker of viability. We conclude that stress-immediate 201Tl reinjection images provide information on myocardial viability and ischaemia in patients with previous myocardial infarction in addition to that obtained regarding wall motion abnormalities as assessed by rest-stress radionuclide angiography.