Transient ischemic dilation for coronary artery disease in quantitative analysis of same-day sestamibi myocardial perfusion SPECT

doi:10.1007/s12350-012-9527-8

Journal of Nuclear Cardiology

Volume 19, Issue 3, June 2012, Pages 465-473

https://doi.org/10.1007/s12350-012-9527-8 Get rights and content

Abstract

Background

Transient ischemic dilation (TID) of the left ventricle in myocardial perfusion SPECT (MPS) has been shown to be a clinically useful marker of severe coronary artery disease (CAD). However, TID has not been evaluated for 99mTc-sestamibi rest/stress protocols (Mibi-Mibi). We aimed to develop normal limits and evaluate diagnostic power of TID ratio for Mibi-Mibi scans.

Methods

TID ratios were automatically derived from static rest/stress MPS (TID) and gated rest/stress MPS from the end-diastolic phase (TID_ed) in 547 patients who underwent Mibi-Mibi scans [215 patients with correlating coronary angiography and 332 patients with low likelihood (LLk) of CAD]. Scans were classified as severe (≥70% stenosis in proximal left anterior descending (pLAD) artery or left main (LM), or ≥90% in ≥2 vessels), mild to moderate (≥90% stenosis in 1 vessel or ≥70%-90% in ≥1 vessel except pLAD or LM), and normal (<70% stenosis or LLk group). Another classification based on the angiographic Duke prognostic CAD index (DI) was also applied: DI ≥ 50, 30 ≤ DI < 50 and DI < 30 or LLk group.

Results

The upper normal limits were 1.19 for TID and 1.23 for TID_ed as established in 259 LLk patients. Both ratios increased with disease severity (P < .0001). Incidence of abnormal TID increased from 2% in normal patients to >36% in patients with severe CAD. Similarly, when DI was used to classify disease severity, the average ratios showed significant increasing trend with DI increase (P < .003); incidence of abnormal TID also increased with increasing DI. The incidence of abnormal TID in the group with high perfusion scores significantly increased compared to the group with low perfusion scores (stress total perfusion deficit, TPD < 3%) (P < .0001). The sensitivity for detecting severe CAD improved for TID when added to mild to moderate perfusion abnormality (3% ≤ TPD < 10%): 71% vs 64%, P < .05; and trended to improve for TID_ed/TID_es: 69% vs 64%, P = .08, while the accuracy remained consistent if abnormal TID was considered as a marker in addition to stress TPD. Similar results were obtained when DI was used for the definition of severe CAD (sensitivity: 76% vs 66%, P < .05 when TID was combined with stress TPD).

Conclusion

TID ratios obtained from gated or ungated Mibi-Mibi MPS and are useful markers of severe CAD.

Introduction

Transient ischemic dilation (TID) ratio has been clinically acknowledged as a measurement that provides clinically relevant information for the management of patients with coronary artery disease (CAD).1, 2, 3, 4, 5, 6, 7, 8, 9 The change in left ventricular (LV) volume as quantified by TID is probably related to a combination of myocardial and endocardial ischemia,¹⁰ although the exact mechanism remains unclear. When incorporated into stress/rest SPECT screening protocols, TID could provide additional information for severe CAD.⁴^,⁸ Although the exact significance of quantitatively elevated TID in patients with normal or minimal perfusion abnormality remains unclear and some studies showed that TID had a low prevalence and poor predictive value in the otherwise normal MPI,¹¹^,¹² the presence of TID in patients with abnormal myocardial perfusion abnormality, such as those in our study, has previously been shown to be associated with extensive and severe CAD,¹^,⁴^,⁷^,¹³^,¹⁴ as well as a strong independent predictor of future cardiac events.¹⁵^,¹⁶

Different scanning protocols may have different normal limits for TID ratios,⁸^,⁹ and these have not been well established. To avoid averaging errors from static images, this study establishes the normal limits not only for ungated SPECT but also for gated SPECT without attenuation correction using a single isotope ^99mTc-sestamibi tracer. This study also evaluates the Mibi-Mibi TID ratios’ incremental diagnostic value in detection of severe and extensive CAD in patients with suspected CAD by fully quantitative analysis.

Section snippets

Patients

The subjects who were referred to the Nuclear Medicine Department, Sacred Heart Medical Center, Eugene, Oregon, from March 1, 2003 to December 31, 2006 for rest and stress electrocardiography (ECG)-gated myocardial perfusion SPECT (MPS) were consecutively selected.¹⁷ All patients with a prior history of CAD, cardiomyopathy, significant valve disease, left bundle branch block, paced rhythm, and pharmacologic stress testing were excluded. Since the primary goal of this project is to show the

Normal Limits

The upper normal limit of each TID ratio was defined as the term of its mean plus two SDs generated from 259 stress and rest MPS patients with LLk of CAD randomly selected from our LLk patients on the basis of the random number generator results. The small differences of mean TID ratios between small hearts and regular hearts (0.98 ± 0.12 vs 0.98 ± 0.09 for TID, 1.05 ± 0.09 vs 1.07 ± 0.08 for TID_ed, and 0.99 ± 0.27 vs 1.03 ± 0.15 for TID_es) were not significant (P > .05). We also obtained TID

Discussion

TID ratio of the LV are an important marker of severe and extensive CAD.⁴^,⁸ In this study, we subsequently extended these observations to patients with suspected CAD undergoing single isotope ^99mTc-sestamibi tracer. Both gated and ungated Mibi-Mibi MPS images were used to derive TID ratios. The normal limits of TID ratios were 1.19, 1.23, and 1.46 for static and gated MPS on the end-diastolic and end-systolic phase, respectively. The evaluation of incremental diagnostic value of TID ratios

Conclusion

We have established the normal limits for the ungated or gated 1-day Mibi-Mibi MPS and evaluated performance of TID for the detection of severe CAD. The results suggest that the TID ratios could provide incremental diagnostic information to standard perfusion analysis in fully automated quantitative analysis for the identification of severe and extensive disease in patients with suspected CAD.

Acknowledgments

This research was supported in part by Grant R0HL089765 from the National Heart, Lung, and Blood Institute/National Institutes of Health (NHLBI/NIH) (PI: Piotr Slomka). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NHLBI. We would like to thank Arpine Oganyan for editing and proof-reading the text.

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Quality metrics for single-photon emission computed tomography myocardial perfusion imaging: an ASNC information statement
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Quantitative Clinical Nuclear Cardiology, Part 1: Established Applications
2020, Journal of Nuclear Cardiology
Single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has attained widespread clinical acceptance as a standard of care for patients with known or suspected coronary artery disease (CAD). A significant contribution to this success has been the use of computer techniques to provide objective quantitative assessment in the standardization of the interpretation of these studies. Software platforms have been developed as a pipeline to provide the quantitative algorithms researched, developed and validated to be clinically useful so diagnosticians everywhere can benefit from these tools. The goal of this CME article (PART 1) is to describe the many quantitative tools that are clinically established and more importantly how clinicians should use them routinely in the interpretation, clinical management and therapy guidance of patients with CAD.
Prognostic Value of Combined Clinical and Myocardial Perfusion Imaging Data Using Machine Learning
2018, JACC: Cardiovascular Imaging
This study evaluated the added predictive value of combining clinical information and myocardial perfusion single-photon emission computed tomography (SPECT) imaging (MPI) data using machine learning (ML) to predict major adverse cardiac events (MACE).
Traditionally, prognostication by MPI has relied on visual or quantitative analysis of images without objective consideration of the clinical data. ML permits a large number of variables to be considered in combination and at a level of complexity beyond the human clinical reader.
A total of 2,619 consecutive patients (48% men; 62 ± 13 years of age) who underwent exercise (38%) or pharmacological stress (62%) with high-speed SPECT MPI were monitored for MACE. Twenty-eight clinical variables, 17 stress test variables, and 25 imaging variables (including total perfusion deficit [TPD]) were recorded. Areas under the receiver-operating characteristic curve (AUC) for MACE prediction were compared among: 1) ML with all available data (ML-combined); 2) ML with only imaging data (ML-imaging); 3) 5-point scale visual diagnosis (physician [MD] diagnosis); and 4) automated quantitative imaging analysis (stress TPD and ischemic TPD). ML involved automated variable selection by information gain ranking, model building with a boosted ensemble algorithm, and 10-fold stratified cross validation.
During follow-up (3.2 ± 0.6 years), 239 patients (9.1%) had MACE. MACE prediction was significantly higher for ML-combined than ML-imaging (AUC: 0.81 vs. 0.78; p < 0.01). ML-combined also had higher predictive accuracy compared with MD diagnosis, automated stress TPD, and automated ischemic TPD (AUC: 0.81 vs. 0.65 vs. 0.73 vs. 0.71, respectively; p < 0.01 for all). Risk reclassification for ML-combined compared with visual MD diagnosis was 26% (p < 0.001).
ML combined with both clinical and imaging data variables was found to have high predictive accuracy for 3-year risk of MACE and was superior to existing visual or automated perfusion assessments. ML could allow integration of clinical and imaging data for personalized MACE risk computations in patients undergoing SPECT MPI.
Diagnostic and prognostic significance of transient ischemic dilation (TID) in myocardial perfusion imaging: A systematic review and meta-analysis
2018, Journal of Nuclear Cardiology
Transient ischemic dilatation (TID) of the left ventricle is a potential marker of high risk obstructive coronary artery disease on stress myocardial perfusion imaging (MPI). There is, however, interstudy variation in the diagnostic performance of TID for identification of severe and extensive coronary disease anatomy, and varied prognostic implications in the published literature.
We searched MEDLINE, EMBASE, and COCHRANE databases for studies where TID was compared with invasive or CT coronary angiography for evaluation of coronary artery stenosis. Two reviewers independently evaluated and abstracted data from each study. A bivariate random effects model was used to derive pooled sensitivities and specificities, in order to account for correlation between TID in MPI and anatomic disease severity.
A total of 525 articles were reviewed, of which 51 met inclusion criteria. Thirty-one studies contributed to the analysis, representing a total of 2037 patients in the diagnostic meta-analysis and 9003 patients in the review of prognosis. The ratio above which TID was deemed present ranged from 1.13 to 1.38. Pooled sensitivity was 44% (95% CI 30%-60%) and specificity was 88% (95% CI 83%-92%) for the detection of extensive or severe anatomic coronary artery disease. Analysis of outcome data demonstrated increased cardiac event rates in patients with TID and an abnormal MPI. In otherwise normal perfusion, TID is an indicator of poor prognosis in patients with diabetes and/or a history of coronary disease.
Among patients undergoing MPI, the presence of TID is specific for the detection of extensive or severe coronary artery disease.
La Dilatación Isquémica Transitoria (TID) del ventrículo izquierdo es un marcador potencial de enfermedad arterial coronaria obstructiva de alto riesgo en la fase de estrés del estudio de perfusión miocárdica (EPM). Existe, sin embargo, una variación entre los estudios en el rendimiento diagnóstico de la TID para identificar la severidad y extensión de la enfermedad coronaria anatómica, así como diversas implicaciones pronosticas en la literatura publicadas.
Buscamos en las bases de datos de MEDLINE, EMBASE y COCHRANE estudios donde el TID fue comparado con la angiografía coronaria invasiva o por TC (Tomografía Computada) para la evaluación de la estenosis arterial coronaria. Dos revisores evaluaron de forma independiente resumieron y evaluaron los datos de cada estudio. Se utilizo un modelo de efectos aleatorios bivariante para derivar las sensibilidades y especificidades combinadas, a fin de obtener la correlación entre la TID en el EPM y la severidad de la enfermedad anatómica.
Se revisaron un total de 525 artículos, de los cuales 51 cumplieron el criterio de inclusión. Treinta y un estudios contribuyeron al análisis, representando un total de 2037 pacientes para el meta-análisis diagnóstico y 9003 pacientes para la revisión del pronóstico. La proporción por encima de la cual la TID se consideró presente osciló entre 1.13 y 1.38. La sensibilidad combinada fue del 44% (IC del 95%: 30-60%) y la especificidad fue del 88% (IC del 95%: 83-92%) para la detección de enfermedad coronaria anatómica extensa o grave. El análisis de los datos de resultado demostró un aumento de las tasas de eventos cardíacos en pacientes con TID y un EPM anormal. En la perfusión normal, la TID es un indicador de mal pronóstico en pacientes con diabetes y/o antecedentes de enfermedad coronaria.
En pacientes que son llevados a un EPM, la presencia de TID es especifico para la detección de enfermedad arterial coronaria extensa o severa.
负荷心肌灌注显像 (MPI) 下, 左心室短暂缺血性扩张 (TID) 是高风险冠心病的一个潜在指标。然而, 现有的文献对于 TID 诊断严重冠心病以及评价预后的报道不尽相同。
我们利用 MEDLINE, EMBASE 和 COCHRANE 数据库, 检索了 TID 与冠脉造影或 CT 对比来评估冠状动脉狭窄的文献。两个评审者独立的从每个研究中评估和提取数据。为了了解 TID 和冠状动脉狭窄之间的关联性, 用一个二元随机效应模型来获得合并的敏感性和特异性。
总归回顾了 525 篇文献, 其中 51 篇符合入选标准。 31 个研究有助于本文的分析, 在诊断性分析中共 2037 个病人, 预后分析中共 9003 病人。TID 定义为比值超过 1.13~1.38。此时, 诊断严重冠心病的合并敏感性是 44% (95%CI; 30-60%), 特异性是 88% (95%CI; 83-92%)。在 MPI 异常的患者中, TID 能够增加心血管事件的发生率; 在 MPI 正常, 有糖尿病和/或冠心病的患者中, TID 也是一个独立的预后指标。
在 MPI 患者中, TID 是一个诊断严重冠心病以及评价预后的特异性指标。
La dilatation ischémique transitoire (DIT) du ventricule gauche mesurée par scintigraphie de perfusion myocardique est un factor pronostique relativement important dans l’évaluation des risques liés à la maladie coronarienne obstructive. Néanmoins les protocoles d’évaluation de la DIT et la signification des résultats obtenus dans la maladie coronarienne sévère sont assez variables dans les études publiées dans la littérature.
Dans cet article nous avons recherché dans les bases de données MEDLINE, EMBASE et COCHRANE les études où les résultats de la DIT ont été comparés à une angiographie coronaire obtenue de manière invasive ou par tomodensitométrie. Deux experts ont extrait et évalué indépendamment les données de chaque étude. De manière à tenir compte de la corrélation entre la DIT et la sévérité de la maladie coronaire une analyse bi-variée des effets aléatoires a été utilisée pour déterminer la sensibilité et la spécificité globales.
Au total, 525 articles ont été examinés, dont 51 répondant aux critères d’inclusion. Trente et une études ont contribué à l’analyse, incluant un total de 2037 patients dans la méta-analyse diagnostique et 9003 patients dans l’examen du pronostic. Le rapport au-dessus duquel la DIT a été jugé anormal varie de 1,13 à 1,38. La sensibilité globale est de 44% (IC à 95% ; 30 à 60%) et la spécificité globale est de 88% (IC 95%; 83-92%) pour la détection d’une maladie coronaire étendue ou sévère. Une augmentation du nombre d’événements cardiaques est présente chez les patients démontrant une DIT avec étude anormale de perfusion myocardique. Lorsque la perfusion myocardique est normale, une DIT est également un facteur de mauvais pronostic chez les patients atteints de diabète et/ou d’un antécédent de maladie coronarienne.
La présence d’une DIT obtenue par scintigraphie myocardique est spécifique pour la détection de la maladie coronaire étendue ou sévère.
Prognostic impact of TID in regadenoson MPI: Some patients and certain events
2016, Journal of Nuclear Cardiology
Improving predictive value of transient ischemic dilation ratio after correction based on the left ventricular mass
2023, Iranian Journal of Nuclear Medicine

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: This research was supported in part by Grant R0HL089765 from the National Heart, Lung, and Blood Institute/National Institutes of Health (NHLBI/NIH).

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Original ArticleTransient ischemic dilation for coronary artery disease in quantitative analysis of same-day sestamibi myocardial perfusion SPECT

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Patients

Normal Limits

Discussion

Conclusion

Acknowledgments

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Nucl Cardiol

J Am Coll Cardiol

J Nucl Cardiol

J Nucl Cardiol

J Nucl Cardiol

J Nucl Cardiol

Am Heart J

Am J Cardiol

J Nucl Cardiol

J Nucl Cardiol

Original Article
Transient ischemic dilation for coronary artery disease in quantitative analysis of same-day sestamibi myocardial perfusion SPECT