Influence of coronary collateral vessels on the results of thallium-201 myocardial stress imaging

doi:10.1016/0002-9149(79)90396-5

The American Journal of Cardiology

Volume 44, Issue 3, September 1979, Pages 452-458

https://doi.org/10.1016/0002-9149(79)90396-5 Get rights and content

Abstract

Although collateral vessels are commonly seen in patients with coronary disease, their functional significance has been debated. In this study segmental analysis of thallium-201 perfusion scintigrams obtained at rest and after exercise was made in 124 patients with angiographically proved coronary artery disease to determine whether collateral vessels could provide protection front myocardial ischemia during stress. All 15 coronary arteries that were completely occluded and had no collateral vessels showed a corresponding stress perfusion abnormality, but only 65 of 92 occluded arteries with angiographically visualized collateral vessels showed a corresponding stress defect (P < 0.05). In 13 hearts with stenosed arteries (more than 50 percent narrowing) without collateral vessels, the scintigraphic region supplied by the most severely stenosed vessel always became abnormal. When collateral vessels were present only 19 of 29 such regions showed a stress-induced perfusion defect (P < 0.05). The 10 protected scintigraphic areas were supplied in eight cases by collateral vessels originating from nondiseased arteries (nonjeopardized) and in two cases by collateral vessels that originated distal to a significant arterial stenosis (jeopardized). Fourteen of the 19 arteries that failed to show protection were supplied by jeopardized collateral vessels. The results (1) demonstrate that nonjeopardized coronary collateral vessels may account for a normal-appearing thallium-201 scintigram in segments supplied by severely narrowed coronary arteries, and (2) suggest that coronary collateral vessels çan provide, at least relative protection from stress-induced ischemia.

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Cited by (104)

Coronary flow velocity reserve in the three main coronary arteries assessed with transthoracic doppler: A comparative study with quantitative coronary angiography
2011, Journal of the American Society of Echocardiography
Citation Excerpt :
QCA may overestimate the individual stenosis, giving the impression of false-normal CFVR measurements. Coronary collaterals may significantly mitigate the effects of severe stenoses or occlusions.38 Hemodynamically significant stenoses in the main coronary arteries may elude detection if CFVR is measured proximally to the stenosis.
The purpose of this study was to evaluate the potential of combined use of transthoracic Doppler echocardiographic coronary flow velocity reserve (CFVR) measurements and findings of retrograde coronary flow in the three main coronary arteries for the assessment of borderline (angiographic diameter stenosis, 50%–75%) and high-grade (angiographic diameter stenosis, 76%–100%) coronary artery stenoses.
A total of 108 patients scheduled for coronary angiography because of chest pain or acute coronary syndromes were studied. CFVR was measured during adenosine-induced hyperemia in the mid to distal segments of the left anterior descending coronary artery, the marginal branches of the left circumflex coronary artery, and the posterior descending coronary artery, with peak CFVR (pCFVR) <2.0 implying hemodynamic significant stenosis. CFVR results were compared with results from quantitative coronary angiography, with stenosis severity in the left main and three major coronary arteries divided into three groups: (1) diameter stenosis 0% to 49%, (2) diameter stenosis 50% to 75%, and (3) diameter stenosis 76% to 100%.
In patients with antegrade flow in the relevant coronary artery segment, CFVR was successfully measured in the mid to distal left anterior descending artery, the marginal branches of the left circumflex artery, and the posterior descending artery in 97%, 63%, and 75% of patients, respectively. CFVR was significantly different among the stenosis groups, with pCFVR of 2.79 ± 0.77 in group 1, 2.01 ± 0.72 in group 2, and 1.50 ± 0.69 in group 3 (P < .001 among groups). Angiography confirmed retrograde flow in seven of the nine arteries found by transthoracic echocardiography. Findings of pCFVR <2.0 or retrograde coronary artery flow correctly identified 42 of 49 patients with stenoses in group 3, with sensitivity, specificity, and positive and negative predictive values of 86%, 70%, 70%, and 85%, respectively. In group 2, pCFVR values were widely distributed above or below the defined pCFVR cutoff value.
CFVR measurement in the mid to distal left anterior descending artery was feasible in almost all patients, and in the marginal branches of the left circumflex artery and the posterior descending artery in two thirds and three quarters of patients, respectively. Use of the combined echocardiographic criteria had high precision for diagnosing severe coronary stenoses (diameter stenosis, 76%–100%). The functional significance of angiographically borderline stenoses (diameter stenosis, 50%–75%) may be further differentiated by the use of CFVR measurements. (ClinicalTrials.gov NCT00281346)
Comparison of stress-induced myocardial ischemia in patients with and without coronary arterial collaterals
2004, American Journal of Cardiology
Citation Excerpt :
Studies that examined thallium-201 imaging during stress have suggested that collaterals provide a protective effect during stress-induced ischemia. However, these studies were performed with planar imaging and in a small number of patients who had uncertain exercise levels.11,12 Although angiography is routinely used in clinical practice to evaluate the presence and extent of collaterals, it has major limitations.
Coronary artery collaterals may have a protective role against myocardial ischemia at rest. However, their role during stress is controversial and poorly defined. We evaluated 212 consecutive patients (57 ± 16 years; 70% men) who underwent coronary angiography and stress echocardiography within a 3-month period. This cohort of patients (all had significant epicardial coronary artery disease) was divided into 3 groups based on the presence and type of collaterals: group A, no collaterals; group B, collaterals supplied by vessels without flow-limiting stenosis; and group C, collaterals supplied by vessels with flow-limiting stenosis. In all patients, angiographic jeopardy score, ejection fraction, and regional and cumulative wall motion score indexes (WMSIs) at rest and during stress were evaluated. Angiographic jeopardy scores were 2.9, 3.5, and 7.3 for groups A, B, and C, respectively. Baseline ejection fraction was similar between groups A and B (48% vs 46%, p = NS) but lower in group C (31%, p <0.01). During stress echocardiography, all groups demonstrated a significant increase in WMSI from baseline (WMSI at rest vs that during stress 1.72 ± 0.06 vs 1.79 ± 0.04 for group A, 1.97 ± 0.06 vs 2.09 ± 0.03 for group B, 2.35 ± 0.11 vs 2.41 ± 0.07 for group C; p <0.01 for all groups). In addition, the number of ischemic segments increased significantly in all groups (2.96 ± 0.07 in group A vs 4.52 ± 0.11 in group B vs 5.61 ± 0.13 in group C, p <0.01). Coronary artery collaterals do not offer protection against stress-induced myocardial ischemia. Moreover, the presence of jeopardized angiographic coronary collaterals (group C) is associated with a higher angiographic jeopardy score, higher baseline WMSI, and decreased ejection fraction.
Dynamic change in collateral flow associated with myocardial ischemia in humans
2001, International Journal of Cardiology
Background: This study sought to investigate how collateral flow changes during myocardial ischemia in patients. Methods: Myocardial contrast echocardiography (MCE) and rapid atrial pacing were performed in 20 patients with angiographically evidenced coronary collaterals from the right coronary artery (RCA) to the occluded left anterior descending coronary artery. Sonicated contrast medium was injected into the RCA before and immediately after atrial pacing to determine the peak background-subtracted contrast intensity (PI) in the collateral territory (PIA) and its ratio to PI in the control territory (PI ratio) as parameters of collateral blood flow. Lactate production in the coronary circulation during pacing was determined to assess myocardial ischemia in the collateral territory. Results: PIA showed a significant correlation with regional wall motion either before (r(squared)=−0.64, P<0.01) or after pacing (r(squared)=−0.65, P<0.01). Similarly, PI ratio was significantly correlated with regional wall motion either before (r(squared)=−0.54, P<0.05) or after pacing (r(squared)=−0.64, P<0.01). Rapid atrial pacing decreased both PIA and PI ratio significantly greater in patients with lactate production than in those without (PIA: −67±53 vs. −15±34%, P<0.05; PI ratio: −68±49 vs. −8.2±32%, P<0.05, respectively), while neither PIA nor PI ratio differ between the two groups of patients before pacing (PIA: 13.8±19. vs. 16.2±13.3U, P=0.75; PI ratio: 0.70±0.71 vs. 0.87±0.65, P=0.58, respectively). Conclusions: We concluded that (1) collateral flow determined by MCE was closely associated with regional cardiac function, and (2) not the amount of collateral flow at rest, but pacing-induced change of collateral flow seemed to be a determinant of regional ischemia in patients with coronary collaterals.
Myocardial perfusion in patients with total occlusion of a single coronary artery with and without collateral circulation
2001, Journal of Nuclear Cardiology
Background. Previous studies that investigated the effects of coronary collateral circulation on myocardial perfusion were compromised by inclusion of patients with multivessel coronary artery disease, incomplete occlusion, prior myocardial infarction, or a combination of these. In this study we ascertained the relationship between angiographic collateral circulation and myocardial perfusion only in patients with total occlusion of a single coronary artery, in the absence of myocardial infarction or significant stenosis in the other coronary arteries. Methods and Results. Seventy-one consecutive patients underwent stress myocardial single photon emission computed tomography within 90 days of angiography. Collateral circulation was present in 49 patients and absent in 22 patients. All but 2 patients had abnormal perfusion by single photon emission computed tomography imaging, with a mean defect size of 19% ± 12%, and most (83%) had reversible perfusion defects. Defect count activities improved from stress to rest (or redistribution) (45% ± 13% to 59% ± 14%, P < .001). Abnormal myocardial perfusion occurred with similar frequency in patients with collateral circulation and in those without it. Total defect size was 19% ± 12% in patients with and 18% ± 11% in those without collateral circulation (P = not significant). The extent of reversibility and defect count activity during stress and rest were similar in patients with collateral circulation and in those without it. Conclusions. In patients with a single-vessel total coronary occlusion and without myocardial infarction, stress-induced myocardial ischemia is almost always present, irrespective of presence or absence of angiographic collaterals. These data lend support to the premise that collateral circulation is rather insufficient to prevent stress-induced ischemia, although it can preserve myocardial viability. (J Nucl Cardiol 2001;8:452-7.)
Reversible perfusion defects on exercise tomographic thallium imaging in patients with and without collateral flow
1998, American Journal of Cardiology
Impact of intensive physical exercise and low-fat diet on collateral vessel formation in stable angina pectoris and angiographically confirmed coronary artery disease
1995, The American Journal of Cardiology
This randomized study was performed to assess the effects of >3 hours of physical exercise per week and low-fat diet on collateral formation in nonselected patients with coronary artery disease (intervention group, n = 56). Results were compared with those of patients in a control group (n = 57), who received usual care by their private physicians. Coronary lesions were assessed by quantitative coronary angiography at the beginning and after 1 year of study (n = 92). As previously reported, after 1 year there was a significant retardation of progression of coronary artery disease in the intervention group as compared with the control group. In this study, evaluation of collateral formation revealed no significant difference between both groups, and changes in hemodynamic and metabolic variables or leisure time physical activity were not related to changes in collateral formation. Although progression of the disease was significantly related to an increase in collateral formation, regression was significantly related to a decrease in collateral formation (p < 0.00001). Because patients in the intervention group exercised for >3 hours/week, and patients with regression of coronary artery disease even dedicated 5 to 6 hours to leisure time physical activity per week, these findings question whether an exercise program within the safety tolerance of patients will be able to induce coronary collateralization in the presence of regression of coronary artery disease.

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^☆: This study was supported by U.S. Public Health Service Grant P50-HL-17655 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland.

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Clinical studyInfluence of coronary collateral vessels on the results of thallium-201 myocardial stress imaging☆

Abstract

Am Heart J

Am J Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

Value and limitations of thallium-201 scintigraphy in the acute phase of myocardial infarction

N Engl J Med

Thallium-201 myocardial perfusion imaging at rest and during exercise

Circulation

Myocardial imaging with thallium-201 at rest and during exercise: comparison with coronary arteriography and resting and stress electrocardiography

Circulation

Potassium-43 myocardial perfusion scanning for the non-invasive evaluation of patients with falsepositive exercise test

Circulation

Reliability of myocardial imaging with thallium-201 to visualize myocardial ischemia in coronary artery disease

Role of the coronary collateral circulation in the preservation of left ventricular function

Radiology

Determinants of reversible asynergy. Effect of pathologic Q waves, coronary collaterals and anatomic location

Circulation

A reporting system on patients evaluated for coronary artery disease

Circulation

Clinical study
Influence of coronary collateral vessels on the results of thallium-201 myocardial stress imaging☆