Comparison of late outcome in patients with versus without angina pectoris having reversible perfusion abnormalities during dobutamine stress technetium-99m sestamibi single-photon emission computed tomography

doi:10.1016/S0002-9149(02)03152-1

The American Journal of Cardiology

Volume 91, Issue 3, 1 February 2003, Pages 264-268

https://doi.org/10.1016/S0002-9149(02)03152-1 Get rights and content

Abstract

The aim of this study was to assess the prognostic significance of reversible perfusion abnormalities in patients without angina during dobutamine stress technetium-99m sestamibi single-photon emission computed tomography (SPECT). The study comprised 224 patients (age 60 ± 11 years, 144 men) with completely or partially reversible perfusion abnormalities during dobutamine stress sestamibi SPECT. Follow-up end points were hard cardiac events (cardiac death and nonfatal myocardial infarction). Angina occurred in 93 patients (42%) during the dobutamine stress test (symptomatic ischemia group). The 131 patients without dobutamine-induced angina represented the silent ischemia group. There was no significant difference between patients with and without angina with regard to summed stress perfusion score (5.3 ± 2.5 vs 5.2 ± 2.2, p = 0.9) or summed ischemic score (3.1 ± 1.7 vs 3.2 ± 1.4, p = 0.7). During a median follow-up of 7.2 years, cardiac death occurred in 14 patients (15%) with and in 21 patients (16%) without angina. Nonfatal myocardial infarction occurred in 8 patients (9%) with and in 13 patients (10%) without angina. In a multivariate analysis model of clinical and perfusion data, independent predictors of cardiac events were age (hazard ratio 1.02, confidence intervals [CI] 1.01 to 1.05 per year increment), diabetes mellitus (hazard ratio 1.9, CI 1.2 to 3.4), and ischemic perfusion score (hazard ratio 2.1, CI 1.3 to 3.8). Patients with silent ischemia defined as reversible perfusion abnormalities without associated angina during dobutamine stress sestamibi SPECT imaging had similar incidences of ischemia and similar cardiac event rates compared with patients with symptomatic ischemia. Therefore, the absence of angina in association with reversible perfusion abnormalities should not be interpreted as a sign of a more benign prognosis.

Section snippets

Study population

The study included 224 consecutive patients with limited exercise capacity who were referred for dobutamine-atropine stress technetium-99m sestamibi SPECT imaging for the evaluation of suspected or known coronary artery disease between 1990 and 1995 in our institute. These patients had completely or partially reversible perfusion abnormalities. All patients gave informed consent before testing. The medical ethics commission approved the study protocol. A structured interview and clinical

Clinical characteristics and hemodynamic data

There were 144 men and 80 women (mean age 60 ± 12 years). A history of myocardial infarction was found in 113 patients (50%). Ninety-two patients (41%) had typical anginal complaints before the test.

There was a significant increase in heart rate (68 ± 13 to 133 ± 17 beats/min, p <0.0001) and systolic blood pressure (139 ± 22 to 148 ± 24 mm Hg, p <0.01) from rest to peak dobutamine-atropine stress test. No patient experienced myocardial infarction or ventricular fibrillation during the test.

Discussion

In this study, we assessed the outcome of patients with reversible perfusion abnormalities who did not have angina during dobutamine stress technetium-99m sestamibi SPECT compared with patients who experienced angina during the test. Among 224 patients with reversible abnormalities, 93 patients (42%) had angina. There was no significant difference between patients with and without angina with regard to extent and severity of reversible or fixed perfusion abnormalities. Patients with angina

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Cited by (17)

Asymptomatic myocardial ischemia forecasts adverse events in cardiovascular magnetic resonance dobutamine stress testing of high-risk middle-aged and elderly individuals
2018, Journal of Cardiovascular Magnetic Resonance
Current guidelines for assessing the risk of experiencing a hospitalized cardiovascular (CV) event discourage stress testing of asymptomatic individuals; however, these recommendations are based on evidence gathered primarily from those aged < 60 years, and do not address the possibility of unrecognized “silent myocardial ischemia” in middle aged and older adults.
We performed dobutamine cardiovascular magnetic resonance (CMR) stress testing in 327 consecutively recruited participants aged > 55 years without CV-related symptoms nor known coronary artery disease, but otherwise at increased risk for a future CV event due to pre-existing hypertension or diabetes mellitus for at least 5 years. After adjusting for the demographics and CV risk factors, log-rank test and Cox proportional hazards models determined the additional predictive value of the stress test results for forecasting hospitalized CV events/survival. Either stress-induced LV wall motion abnormalities or perfusion defects were used to indicate myocardial ischemia.
Participants averaged 68 ± 8 years in age; 39% men, 75% Caucasian. There were 38 hospitalized CV events or deaths which occurred during a mean follow-up of 58 months. Using Kaplan-Meier analyses, myocardial ischemia identified future CV events/survival (p < 0.001), but this finding was more evident in men (p < 0.001) versus women (p = 0.27). The crude hazard ratio (HR) of myocardial ischemia for CV events/survival was 3.13 (95% CI: 1.64–5.93; p < 0.001). After accounting for baseline demographics, CV risk factors, and left ventricular ejection fraction/mass, myocardial ischemia continued to be associated with CV events/survival [HR: 4.07 (95% CI: 1.95–8.73) p < 0.001].
Among asymptomatic middle-aged individuals with risk factors for a sentinel CV event, the presence of myocardial ischemia during dobutamine CMR testing forecasted a future hospitalized CV event or death. Further studies are needed in middle aged and older individuals to more accurately characterize the prevalence, significance, and management of asymptomatic myocardial ischemia.
(ClinicalTrials.gov identifier): NCT00542503 and was retrospectively registered on October 11th, 2007.
Value of left atrial dilation in the diagnosis of silent myocardial ischemia in diabetes mellitus patients
2008, Annales de Cardiologie et d'Angeiologie
Le développement d’une maladie athérothrombotique accélérée constitue la principale cause de morbi-mortalité des patients diabétiques. Le dépistage précoce de l’ischémie myocardique silencieuse (IMS) revêt chez ces patients, une importance particulière.
Évaluer l’intérêt : (i) du dosage de marqueurs d’activité de la maladie athérothrombotique reflétant les processus inflammatoires (fibrinogène, CRP, MCP-1), l’apoptose (microparticules [MP]), l’activation plaquettaire (CD40-L, P-sélectine, GP V, MPs plaquettaires) et endothéliale (VCAM-1, vWF, PAI-1, MPs endothéliales), la stimulation neurohormonale et les pressions de remplissage (BNP) ; (ii) de paramètres issus de l’échographie cardiaque ou carotidienne dans le dépistage de l’ischémie myocardique identifiée par la réalisation d’une scintigraphie myocardique de perfusion.
Cinquante-cinq patients diabétiques (62 ± dix ans) et 15 patients non diabétiques (46 ± 14 ans) ont été inclus. Le diagnostic d’IMS est établi chez 23 patients diabétiques (42 %). Une élévation du statut inflammatoire et de l’activation/apoptose leucocytaire est retrouvée dans la population diabétique. Dans l’ensemble de la population étudiée, une élévation des MPs porteuses de CD31 et de CD11a est retrouvée chez les patients présentant une ischémie myocardique. Dans la population diabétique aucun des marqueurs d’activité de la maladie athérothrombotique étudiés n’est associé à l’IMS. Au contraire, la masse ventriculaire gauche et la surface de l’oreillette gauche sont associées en analyse univariée à l’IMS. En analyse multivariée, seule la surface de l’oreillette gauche (supérieure à 18,5 cm²) est un facteur indépendamment associé à l’existence d’une ischémie myocardique silencieuse (OR 4,14 ; IC [1,7–16,13] ; p = 0,039).
Aucun des paramètres d’activité de la maladie athérothrombotique étudiés ne permet d’identifier les patients diabétiques présentant une IMS. En analyse multivariée, seule la dilatation de l’oreillette gauche est associée au développement d’une ischémie myocardique silencieuse. Ce paramètre pourrait s’intégrer dans la stratification du risque myocardique des patients diabétiques.
Accelerated atherothrombosis is a common feature in diabetes mellitus patients (DM), which can be related to abnormalities in vascular cell apoptosis and activation leading to the release of procoagulant microparticles (MPs). In DM patients, we hypothesized that circulating levels of biomarkers involved in atherothrombosis processes as well as cardiac and carotid echocardiography variables could be useful in the detection of silent myocardial diagnosed by myocardial perfusion imaging.
We investigated, in 55 patients with diabetes (mean age 62 ± 10 years) and 15 nondiabetics (46 ± 14 years) patients the prevalence of silent myocardial ischemia (SMI) detected by a treadmill exercise or dipyridamole (^99m)Tc-sestamibi stress test. Echocardiographic and -carotid variables were obtained using standardized methods. Biomarkers assessing endothelial apoptosis or activation (CD31⁺-MPs, CD62⁺-MPs, VCAM-1), inflammatory status (CD11a ± MPs, MCP-1, CRP), platelet activation (GPIb ± MPs, CD40-L, P-selectin, GPV) ventricular stretch (BNP) were measured in the plasma. SMI was diagnosed in 23/55 (42%) diabetics patients and in 3/15 (20%) nondiabetics patients. Enhanced inflammatory status and leukocyte damage (CD11a⁺-MPs) were evidenced in diabetic patients. Within the diabetic population, biomarkers levels of atherothrombosis were not significantly associated to the detection of SMI. In multivariable analyses adjusted for LV hypertophy, left atrial surface (LA) remained independent predictor of silent myocardial ischemia (OR 4.14; IC [1.7–16.13]; P = 0.039).
In diabetes mellitus patients, LA surface independently predicted silent myocardial ischemia after adjustment for established echocardiographic, and inflammatory risk factors. This simple measure of LA dilation could be helpful in the identification of diabetes mellitus patients at heightened cardiovascular risk.
Silent ischemia: Silent after all?
2008, Canadian Journal of Cardiology
To examine the association of nonpain symptoms in men and women with exercise-related silent ischemia, as well as the independence of these findings from other clinical factors.
A prospective study of 482 women and 425 men (mean age 58 years) undergoing exercise stress testing with myocardial perfusion imaging. Analyses were performed on 60 women and 155 men with no angina but medical perfusion imaging evidence of ischemia during exercise.
The presence of various non-pain-related symptoms. Ischemia is indicated by myocardial perfusion defects on exercise stress testing with single photon emission computed tomography.
Women reported more nonangina symptoms than men (P < 0.05). They experienced fatigue, hot flushes, tense muscles, shortness of breath and headaches more frequently (P < 0.05). Symptoms relating to muscle tension and diaphoresis were associated with ischemia after controlling for pertinent clinical covariates. However, the direction of association differed according to sex and history of coronary artery disease events or procedures. Sensitivity of the detection models showed modest improvements with the addition of these symptoms.
While patients who experience silent ischemia experience a number of nonpain symptoms, those symptoms may not be sufficiently specific to ischemia, nor sensitive in detecting ischemia, to be of particular help to physicians in the absence of other clinical information.
Examiner l’association des symptômes non douloureux chez les hommes et les femmes à l’ischémie silencieuse reliée à l’exercice, ainsi que l’indépendance de ces observations par rapport à d’autres facteurs cliniques.
Une étude prospective de 482 femmes et 425 hommes (âge moyen de 58 ans) subissant une épreuve à l’effort avec imagerie par perfusion myocardique. Les auteurs ont analysé 60 femmes et 155 hommes ne faisant pas d’angine mais démontrant une ischémie à l’effort d’après l’imagerie par perfusion médicale.
Présence de divers symptômes non douloureux. L’ischémie est indiquée par des anomalies de la perfusion myocardique pendant l’épreuve à l’effort avec tomographie d’émission monophotonique.
Les femmes ont déclaré plus de symptômes non angineux que les hommes (P < 0,05). Elles ressentaient plus de fatigue, de bouffées de chaleur, de tensions musculaires, d’essoufflements et de céphalées (P < 0,05). Les symptômes reliés aux tensions musculaires et à la diaphorèse s’associaient à l’ischémie après le contrôle des covariables cliniques pertinentes. Cependant, la direction de l’association différait selon le sexe et les antécédents d’événements ou d’interventions coronaropathiques. La sensibilité aux modèles de détection a révélé de modestes améliorations avec l’ajout de ces symptômes.
Les patients qui souffrent d’ischémie ont des symptômes non douloureux, mais qui ne sont peut-être ni assez caractéristiques de l’ischémie ni assez sensibles à la déceler pour être utiles aux médecins en l’absence d’autre information clinique.
Silent ischemia versus angina in TI-201 tomoscintigraphy
2004, Revista Espanola de Medicina Nuclear
El propósito del presente estudio fue describir las variables que se asocian a la isquemia silente en los pacientes a los que se les realiza ergometría con gammagrafía de perfusión miocárdica y presentan defectos reversibles de la perfusión.
Se analizan retrospectivamente de forma cuantitativa las gammagrafías con Tl201-SPECT de 522 pacientes que presentaban defectos de perfusión total o parcialmente reversibles durante la prueba de esfuerzo máxima. Se relacionó la aparición de angina con el tamaño del defecto de perfusión y la presencia de diferentes factores de riesgo.
En 412 (73 %) pacientes la isquemia fue silente. En 176 (33 %) pacientes la ergometría fue eléctricamente positiva. No hubo diferencias en el tamaño del defecto de perfusión entre los pacientes con y sin angina (27 ± 12 vs 27 ± 14), pero en los pacientes que presentaron angina durante la ergometría el grado de reversibilidad fue mayor sobre todo en el territorio de la arteria descendente anterior (ADA) (56 ± 40 vs 45 ± 40 p < 0,01). La isquemia silente fue más frecuente en los pacientes que habían tenido IAM previo (46 % vs 35 %). No se halló relación entre la aparición de angina durante la ergometría y los factores de riesgo analizados.
Una elevada proporción de los pacientes con defectos de la perfusión reversibles en la gammagrafía tuvieron isquemia silente. En los pacientes con angina el grado de reversibilidad en el territorio de la ADA fue mayor. La isquemia silente es más frecuente en los pacientes con IAM previo.
The aim of this work was to describe the variables associated to silent ischemia in patients with reversible perfusion defects in poststress myocardial perfusion scintigraphy.
Tl-201 myocardial perfusion SPECT of 522 patients showing total or partially reversible perfusion defects after exercise testing were quantitatively analyzed retrospectively. Relationship between silent ischemia, size of perfusion defect and presence of risk factors was performed.
Ischemia was silent in 412 (73 %) patients. In 176 (33 %) patients exercise test was electrically positive. There were no differences in perfusion defect size between patients with and without angina in exercise test (27 ± 12 vs 27 ± 14), but patients with angina had a greater degree of reversibility, in left descending artery (LDA) territory (56 ± 40 vs 45 ± 40 p < 0,01). Silent ischemia was more frequently observed in patients with previous acute myocardial infarction (46% vs 35 %). There was no relationship between the production of exertional angina and the presence of risk factors.
A high number of patients with reversible perfusion defects on SPECT had silent ischemia. Patients with angina during exercise test had more defect reversibility in LDA territory. Silent ischemia is more frequent in patients with previous acute myocardial infarction.
Prognostic value of gated myocardial perfusion SPECT
2004, Journal of Nuclear Cardiology
Coronary Artery disease prevalence in Patients having essential hypertension with or without Diabetes Mellitus Detected by Cardiac MIBI Scan
2022, Journal of University Medical and Dental College

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Regular paperComparison of late outcome in patients with versus without angina pectoris having reversible perfusion abnormalities during dobutamine stress technetium-99m sestamibi single-photon emission computed tomography

Abstract

Section snippets

Study population

Clinical characteristics and hemodynamic data

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am Heart J

J Nucl Cardiol

Regular paper
Comparison of late outcome in patients with versus without angina pectoris having reversible perfusion abnormalities during dobutamine stress technetium-99m sestamibi single-photon emission computed tomography