Usefulness of thallium-201 Scintigraphy in predicting the development of angina pectoris in hypertensive patients with left ventricular hypertrophy

doi:10.1016/0002-9149(89)90651-6

The American Journal of Cardiology

Volume 64, Issue 1, 1 July 1989, Pages 45-49

https://doi.org/10.1016/0002-9149(89)90651-6 Get rights and content

Abstract

Hypertension and left ventricular (LV) hypertrophy are independent risk factors for the development of coronary artery disease. To determine whether patients at higher risk for coronary artery disease can be identified, 40 asymptomatic hypertensive men with LV hypertrophy were prospectively studied using exercise thallium-201 scintigraphy and exercise radionuclide angiography. Endpoints indicative of coronary artery disease were defined as the subsequent development of typical angina pectoris, which occurred in 8 patients during a median follow-up of 38 months, or myocardial infarction, which did not occur. The exercise electrocardiogram was interpreted by standard ST-segment criteria and by a computerized treadmill exercise score. Abnormal ST-segment responses were present in 16 of the 40 hypertensives (40%), whereas the treadmill score was positive in 8 of those same 40 patients (20%). Scintigraphic perfusion defects assessed both visually and semiquantitatively were observed in 8 of 40 (20%) patients. An abnormal ejection fraction response to exercise was present in 40% (16 of 40) of patients, and 3 of 40 (7.5%) developed new wall motion abnormalities during exercise. Six of 8 patients with either perfusion defects or abnormal treadmill score developed typical angina during follow-up. All 5 patients with concordant positive exercise scintigrams and treadmill score developed chest pain during follow-up and had coronary artery disease confirmed by coronary angiography. However, only 7 of 16 (44%) patients with positive ST changes or abnormal ejection fraction responses during exercise developed chest pain during follow-up. In contrast, of 32 patients with negative scintigrams only 2 developed atypical chest pain syndromes, and significant coronary artery disease was excluded by angiography in 1 patient. Thus, both thallium-201 scintigraphy and treadmill score accurately detect coronary artery disease in asymptomatic hypertensive patients with LV hypertrophy and predict the future development of angina symptoms.

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Cited by (21)

Hypertensive patients with false-positive Thallium-201 scintigraphic results in the infero-posterior wall are in high risk for coronary artery disease development
2007, International Journal of Cardiology
Citation Excerpt :
Positive scintigraphic results seem to predict ischemic heart disease development in high risk patients with no previous history of CAD. Tubau et al. have reported that either scintigraphic perfusion defects or abnormal treadmill score could predict typical angina development during follow-up in asymptomatic patients with hypertension and LVH [16]. Furthermore, in asymptomatic high-risk individuals, with a family history of premature coronary disease, positive scintigraphic results could predict the development of clinical CAD, according to Blumenthal et al. [17].
It has been previously postulated that Thallium-201 (Tl²⁰¹) scintigraphy is characterized by relatively low specificity in hypertensive patients. This study was undertaken to assess any possible influence of false-positive scintigraphic results on the prognosis of hypertensive patients.
The study group comprised 179 consecutive hypertensive patients (128 men and 51 women), aged 50 ± 7 years, who underwent exercise Tl²⁰¹ scintigraphy and coronary angiography (patients with normal scintigraphic results underwent coronary angiography due to persistent angina-like symptoms). All patients with normal coronary arteries underwent a second Tl²⁰¹ scintigraphy within 36 ± 6 months. Patients with reversible ischemia in the second scintigraphy underwent also a second coronary angiography.
Coronary artery disease (CAD) was detected in 78 (44%) patients, while the rest 101 (56%) patients had normal coronary arteries. Abnormal scintigraphic results were revealed in 66 (85%) patients with CAD and in 38 (38%) patients without CAD. Twenty-two (58%) of the 38 hypertensive patients with false-positive scintigraphic results presented reversible ischemia of the infero-posterior wall of the left ventricle. Coronary artery disease was detected in 7 (32%) of these patients during the follow-up period.
Hypertensive patients with normal coronary arteries and false-positive scintigraphic results usually present with reversible ischemia of the infero-posterior wall of the left ventricle. This group of patients seems to be at increased risk of developing CAD in a long-term follow-up period.
Clinical outcome and reversibility of systolic dysfunction in patients with dilated cardiomyopathy due to hypertension and chronic heart failure
2004, Revista Espanola de Cardiologia
Hay poca información sobre la evolución clínica y funcional de los pacientes con insuficiencia cardíaca secundaria a miocardiopatía dilatada de origen hipertensivo. Los objetivos de nuestro trabajo son estudiar la evolución clínica y funcional de estos pacientes, así como identificar los posibles factores predictores de esta evolución.
Para ello, hemos evaluado a una serie de 57 pacientes diagnosticados en nuestro centro entre 1994 y 2003 con dicho problema. La edad media de los pacientes fue de 63 ± 11 años, y el 40% eran mujeres. La fracción de eyección ventricular izquierda era del 30,1 ± 4,8%. El tiempo de seguimiento fue de 45 ± 23 meses (mediana, 41 meses).
La supervivencia a los 4 años fue 0,84, la tasa de reingresos por insuficiencia cardíaca, 0,12 y la supervivencia libre de reingresos, 0,80. La fracción de eyección aumentó desde el 30,1 ± 4,8% hasta el 57,6 ± 13,5% (p < 0,001). En conjunto, sólo el 40% de los pacientes presentó mala evolución clínica y/o funcional (muerte, reingreso por insuficiencia cardíaca, persistencia de miocardiopatía dilatada) al final del seguimiento. En el estudio multivariable (modelo de Cox), el adecuado control de la presión arterial fue el único predictor independiente de buena evolución clínica (ausencia de muerte y/o reingreso por insuficiencia cardíaca; razón de riesgo = 4,58; intervalo de confianza del 95%, 1,32-9,83; p = 0,032).
La evolución de los pacientes con miocardiopatía dilatada hipertensiva severa es buena en el 60% de los casos. El control de la presión arterial fue el único predictor independiente de buena evolución clínica.
There is little information on the clinical and functional course of patients with heart failure secondary to dilated cardiomyopathy due to hypertension. The objectives of our study were to assess the clinical and functional course of these patients, and to identify possible predictors of prognosis.
We evaluated a series of 49 patients with this condition diagnosed in our hospital from 1994 to 2003. Mean age was 63(11) years, and 40% were women. Left ventricular ejection fraction was 30.1(4.8)%. Follow-up was 45(23) months (median, 41 months).
Four-year survival was 0.84, the 4-year rate of hospitalization due to heart failure was 0.12, and likelihood of readmission-free survival was 0.80 at 4 years. Left ventricular ejection fraction increased from 30.1(4.8)% to 57.6(13.5)% (P<.001). An unfavorable clinical and functional outcome at 4 years (death, readmission for heart failure or persistence of dilated cardiomyopathy) was recorded in only in 40% of the patients. Multivariate analysis with the Cox model showed appropriate control of blood pressure to be the only independent predictor of a favorable clinical outcome (absence of death or readmission for heart failure) (hazard ratio = 4.58; 95% CI, 1.32-9.83; P=.032).
The course of patients with severe dilated cardiomyopathy due to hypertension was favorable in 60% of cases. Adequate control of blood pressure was the only independent predictor of a favorable clinical outcome.
Hypertension and coronary artery disease
1997, Medical Clinics of North America
The concept of factors of risk has revolutionized the approach to the prevention and treatment of cardiovascular disease. Cigarette smoking, hypercholesterolemia, and hypertension are accepted universally as major risk factors for coronary artery disease (CAD). The painstaking epidemiologic methods used to establish these and other risk factors, however, are often forgotten. Contributions in this regard from studies such as the Framingham Heart Study are profound. Not only have these studies established factors of risk, but also they have identified subgroups who have a particularly ominous prognosis. Two clear-cut examples of this are patients with left ventricular hypertrophy (LVH) and patients with multiple cardiovascular risk factors. The establishment of risk factors has led to studies of risk factor modification and how these affect morbidity and mortality. This article addresses the interface between hypertension and CAD by focusing on hypertension as a risk factor, by discussing the pathophysiologic relationship between hypertension and CAD, by looking at appropriate investigation of patients with hypertension and suspected CAD, and by evaluating the therapeutic implications when these two disorders coexist.
Detection of coronary artery disease in the presence of left ventricular hypertrophy
1996, International Journal of Cardiology
To evaluate the accuracy of exercise echocardiography for the recognition of coronary artery disease in the presence of left ventricular hypertrophy 70 patients were studied. Significant coronary artery disease was present in 25 patients and left ventricular hypertrophy had 29 patients. All patients underwent an exercise ECG and echocardiographic test during which cine-loop digitized echocardiography was obtained. Wall motion was analyzed and a regional wall motion score index was calculated. The overall sensitivities of exercise ECG and echocardiography for detecting coronary artery disease were 60% and 64%, respectively, and the specificities were 49% and 78%, respectively. In patients with left ventricular hypertrophy the specificity of exercise echocardiography was higher (71%) compared to exercise ECG (21%) while in patients without hypertrophy the sensitivity was higher (70% vs. 40%, respectively). Of the 19 patients with a non-diagnostic stress ECG, echocardiography correctly identified 100% of those with coronary artery disease but only 53% of those without disease. It is concluded that exercise digital echocardiography represents a good diagnostic alternative to the exercise ECG for identifying coronary artery disease in the presence of left ventricular hypertrophy and should be useful in patients with a non-diagnostic exercise ECG.
Diagnostic usefulness of postexercise systolic blood pressure response for detection of coronary artery disease in patients with electrocardiographic left ventricular hypertrophy
1995, The American Journal of Cardiology
Patients with left ventricular (LV) hypertrophy often have a positive result on exercise testing despite a normal coronary arteriogram. This indicates that exercise-induced ST depression is not always an accurate indicator of the presence of coronary artery disease (CAD) in such patients. We evaluated the usefulness of the postexercise systolic blood pressure (BP) response for detection of CAD in 51 patients with both electrocardiographic evidence of LV hypertrophy and positive ST depression on treadmill exercise testing. Coronary cineangiograms showed normal coronary arteries in 23 patients (45%) (group 1) and significant CAD in 28 patients (55%) (group 2). The systolic BP ratio (systolic BP at 3 minutes of recovery divided by systolic BP at peak exercise) was significantly higher in group 2 than in group 1 (1.01 ± 0.19 vs 0.80 ± 0.09; p < 0.001). Analysis of the relative cumulative frequency revealed that a systolic BP ratio of 0.86 was the cutoff point for distinguishing a patient with CAD from one with normal coronary arteries. The sensitivity, specificity, and accuracy of a systolic BP ratio ≥0.86 for detection of CAD in patients with LV hypertrophy were 79%, 83%, and 82%, respectively. Our results suggest that the use of an abnormal BP ratio, in combination with ST depression, improves the accuracy of treadmill exercise testing for detecting CAD in patients with electrocardiographic evidence of LV hypertrophy.
Scintigraphic and electrocardiographic evidence of silent coronary artery disease in asymptomatic hypertension: A case-control study
1993, Journal of the American College of Cardiology
Objectives. This study was conducted to determine the incidence of physiologically significant coronary artery disease in a group of asymptomatic high risk men with essential hypertension and to assess the validity of noninvasive tests in a subset of these patients undergoing coronary arteriography.
Methods. Two hundred twenty-six asymptomatic men (mean age 61 ± 8 years) with essential hypertension and no clinical evidence of coronary artery disease but with at least one additional coronary risk factor were studied prospectively. Fifty age- and risk factor-matched normotensive subjects were evaluated as a control group. After a minimum of 4 days without medication, subject's underwent stress thallium-201 scintigraphy, exercise and 48-h ambulatory electrocardiography, and echocardiography. Coronary angiography was performed in a subset of 34 (40%) of 84 patients with one or more positive test results.
Results. A positive thallium-201 scintigram (18% vs. 6%; odds ratio 3.4, confidence interval 0.91 to 10.8, p = 0.056), exercise electrocardiograms (ECGs) (37% vs. 13%; odds ratio 4.1, confidence interval 1.5 to 11.2, p < 0.003) and ambulatory ECG (15% vs. 0%, p < 0.05) were more common in the hypertensive group than in the control group. In the cohort undergoing coronary angiography, thallium-201 scintigraphy was both sensitive and specific for epicardial atherosclerotic coronary disease (90% and 79%, respectively), but positive exercise and ambulatory ECGs occurred frequently in the absence of significant coronary stenoses. In the 39% of hypertensive patients who had mild to moderate left ventricular hypertrophy, positive exercise and ambulatory ECGs occurred at a higher rate.
Conclusions. These findings suggests that physiologically significant coronary artery disease occurs more frequently in asymptomatic hypertensive men than in comparable normotensive control subjects. In the subgroup undergoing coronary arteriography, reversible scintigraphic defects were both sensitive and specific for diagnosing epicardial coronary artery disease, but exercise and ambulatory ECGs appeared to yield frequent false positive results, especially when left ventricular hypertrophy was present. These results indicate that patients with “silent” coronary artery disease can be identified among high risk hypertensive patients, but the appropriate application of such screening in clinical practice remains to be determined.

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Usefulness of thallium-201 Scintigraphy in predicting the development of angina pectoris in hypertensive patients with left ventricular hypertrophy

Abstract

Prog Cardiovasc Dis

Am J Med

Am J Cardiol

Am Heart J

Am J Med

Prog Cardiovasc Dis

Am J Cardiol

Am Heart J

Am J Cardiol

Implications of the clinical trials on the management of hypertension

Hypertension

Results in patients with diastolic pressures averaging 90–114

JAMA

Risk factor changes and mortality results

JAMA

The Australian therapeutic trial in mild hypertension. Report by the management committee

Lancet

Cardiovascular risk and risk factors in a randomized trial based on the beta-blocker oxprenolol: the International Prospective Primary Prevention Study in Hypertension (IPPPSH)

J Hypertens

Coronary heart disease in the Medical Research Council trial of treatment of mild hypertension

Br Med J

Left ventricular hypertrophy in hypertension: prognostic and pathogenetic implications (the Framingham Study)