Prognostic value of stress-gated Tc-99m sestamibi SPECT after acute myocardial infarction

doi:10.1016/S0002-9149(00)01387-4

The American Journal of Cardiology

Volume 87, Issue 4, 15 February 2001, Pages 381-386

https://doi.org/10.1016/S0002-9149(00)01387-4 Get rights and content

Abstract

Stress-gated technetium-99m (Tc-99 m) sestamibi single-photon emission computed tomography (SPECT) is used to risk stratify patients after acute myocardial infarction (AMI). In clinical practice, results of this test are used primarily to identify patients with myocardial ischemia for intervention. The value of this test to risk stratify patients with AMI not at high ischemic risk has not been addressed. More than 1-year follow-up was undertaken in 124 patients who underwent predischarge gated Tc-99m sestamibi SPECT studies and who did not undergo subsequent revascularization. Clinical variables and test-derived variables were evaluated to predict cardiac death, recurrent AMI, and hospitalization for unstable angina, congestive heart failure, or coronary revascularization. Independent predictors by multivariate analysis for cardiac death or recurrent AMI were a history of prior AMI (relative risk [RR] = 5.32, confidence interval [CI] 2.17 to 12.96), a low exercise capacity (RR = 6.84, CI 1.99 to 23.48), and left ventricular (LV) ejection fraction (EF) <40% (RR = 2.63, CI 1.04 to 6.38). The incidence of cardiac death or recurrent AMI was 29.8% in patients with a low exercise capacity versus 4.5% in those with good exercise capacity, and 38.1% in patients with LVEF <40% versus 9.4% in those with LVEF >40%. Independent predictors of cardiac death, AMI, or hospitalization for unstable angina, congestive heart failure, or revascularization were a history of prior AMI (RR = 2.24, CI 1.11 to 4.50) and LVEF <40% (RR = 3.13, CI 1.64 to 5.95). Among patients followed after AMI without revascularization Tc-99m sestamibi SPECT can identify a high-risk subset. The strongest independent predictors are poor exercise capacity and LVEF <40%.

Section snippets

Patient population

One hundred forty-six consecutive patients were identified who had undergone gated Tc-99m sestamibi SPECT before discharge after AMI from May 1996 to December 1998 at a single New England hospital. Myocardial infarction was determined by an elevation in creatine kinase and its MB fraction in the setting of characteristic electrocardiographic changes and clinical symptoms. Patients who had a revascularization procedure within 3 months after stress testing were withdrawn from the study group.

Patient characteristics

Of 146 patients with predischarge gated Tc-99m sestamibi SPECT after AMI, 18 were censored for early revascularization. Of the remaining 128, follow-up was complete in 124 (97%). Patient demographics are listed in Table 1. The mean age of the patients was 63.5 ± 13.5 years (range 29 to 88). Fifty-four had Q-wave and 70 had non–Q-wave AMI. Forty-four percent received thrombolytic therapy, and 9% had percutaneous revascularization before the stress test. Twenty-nine of the 124 patients (23%)

Discussion

Our study assessed the prognostic use of data obtained from predischarge gated stress Tc-99m sestamibi perfusion SPECT for patients undergoing risk stratification before hospital discharge after AMI, without intervention in the ensuing 3 months. Independent predictors of cardiac death or recurrent AMI were a history of prior AMI, impaired exercise capacity, and LVEF <40%. Independent predictors of all events, including hard events, were a history of prior AMI, diabetes, and LVEF <40%.

References (23)

R.D. Abraham et al.
Prediction of multivessel coronary artery disease and prognosis early after myocardial infarction by exercise electrocardiography and thallium-201 myocardial perfusion scanning
Am J Cardiol
(1986)
L.W. Gimple et al.
Prognostic utility of predischarge dipyridamole-thallium imaging compared to predischarge submaximal exercise electrocardiography and maximal exercise thallium imaging after uncomplicated acute myocardial infarction
Am J Cardiol
(1989)
P.L. Tilkemeier et al.
Prognostic value of predischarge low-level exercise thallium testing after thrombolytic treatment of acute myocardial infarction
Am J Cardiol
(1990)
T.D. Miller et al.
Limited prognostic value of thallium-201 exercise treadmill testing after myocardial infarction in patients treated with thrombolysis
Am Heart J
(1995)
M.I. Travin et al.
Use of exercise technetium-99m sestamibi SPECT imaging to detect residual ischemia and for risk stratification after acute myocardial infarction
Am J Cardiol
(1995)
H.G. Stratmann et al.
Risk stratification with pre-hospital discharge exercise technetium-99m sestamibi myocardial tomography in men after acute myocardial infarction
Am Heart J
(1998)
H. Greenberg et al.
Left ventricular dysfunction after acute myocardial infarctionresults of a prospective multicenter study
Am J Cardiol
(1984)
S. Ahnve et al.
First myocardial infarctionage and ejection fraction identify a low-risk group
Am Heart J
(1988)
L.L. Johnson et al.
Postischemic stunning can affect left ventricular ejection fraction and regional wall motion on post-stress gated sestamibi tomograms
J Am Coll Cardiol
(1997)
P. Vaduganathan et al.
Evaluation of left ventricular wall motion, volumes, and ejection fraction by gated myocardial tomography and technetium-99m labeled tetrofosmina comparison with cine magnetic resonance imaging
J Nucl Cardiol
(1999)

L.T. Younis et al.

Prognostic value of intravenous dipyridamole thallium scintigraphy after an acute myocardial ischemic event

Am J Cardiol

(1989)

Cited by (38)

Predictive value of NT-pro BNP after acute myocardial infarction: Relation with acute and chronic infarct size and myocardial function
2011, International Journal of Cardiology
Citation Excerpt :
Infarct size is an important prognostic variable with a strong correlation with mortality after acute myocardial infarction (AMI) [1,2]. Left ventricular function is a powerful prognostic indicator too, and is strongly and inversely related to patients’ outcome, with rapidly increasing mortality rates at left ventricular ejection fraction (LVEF) < 40% [3]. For an optimal management of patients presenting with AMI there is a need for reliable markers for diagnostic evaluation, therapeutic decision-making and estimation of prognosis.
We sought to assess the relation of N-terminal brain natriuretic peptide (NT-pro BNP) determined on day 3 after onset of acute myocardial infarction (AMI) symptoms with acute and chronic infarct size and functional parameters assessed by cardiac magnetic resonance (CMR) imaging. Furthermore, we wanted to investigate its predictive value for recovery of myocardial function.
CMR was performed in 49 consecutive patients within 6 days and in a subgroup 4 (n = 27) and 12 (n = 22) months after first acute ST-elevation AMI and successful primary angioplasty. NT-pro BNP was measured in the subacute phase at 66 ± 8 h after onset of symptoms.
Log-transformed NT-pro BNP (lgNT-pro BNP) significantly correlated with infarct size in % of left ventricular myocardial mass (r = 0.59 to 0.64; p < 0.004), with ejection fraction (EF) (r = − 0.49 to − 0.55; p < 0.004) as well as with segmental wall thickening (SWT, mm) (r = 0.41 to − 0.52; p < 0.04) at any time of assessment. Multiple linear regression analysis revealed baseline EF and lgNT-pro BNP to predict global functional recovery. Patients with NT-pro BNP concentrations < the mean level of 1115 pg/ml significantly improved in EF and SWT (all p < 0.02) during the study period, whereas patients with NT-pro BNP > 1115 pg/ml did not show significant functional recovery (all p = NS).
NT-pro BNP on day 3 after admission correlates with acute and chronic infarct size and myocardial function after AMI. Global and regional myocardial function did not recover in patients with higher NT-pro BNP (> 1115 pg/ml) during subacute phase of AMI.
Diagnosis of coronary artery disease by myocardial perfusion gated SPECT
2008, Revista Espanola de Cardiologia Suplementos
La gated-SPECT de perfusión miocárdica ha representado, desde su introducción hace algunos años, una mejora técnica muy importante dentro de las exploraciones de cardiología nuclear que se utilizan en el diagnóstico de la enfermedad coronaria. Actualmente es la exploración más utilizada, pues permite la valoración simultánea de la perfusión miocárdica y la función ventricular, tanto en condiciones de reposo como su respuesta al esfuerzo, aportando información de gran interés diagnóstico y también pronóstico. Se discuten los criterios diagnósticos de esta exploración en la cardiopatía isquémica, tanto aguda como crónica, las mejoras específicas aportadas por la gated-SPECT, así como las situaciones clínicas en que esta exploración es especialmente útil.
Since its introduction some years ago, myocardial perfusion gated SPECT has been seen as a very important technical advance in the nuclear cardiology explorations used to diagnose coronary artery disease. Today, it is the most frequently used technique because it enables myocardial perfusion and ventricular function to be assessed simultaneously, both at rest and stress, thereby providing extremely useful diagnostic as well as prognostic information. This article discusses the criteria used for diagnosing acute and chronic ischemic cardiopathy, the specific advantages offered by gated SPECT, and the clinical situations in which this technique is particularly useful.
Can the reversible regional wall motion abnormalities on stress gated Tc-99m sestamibi SPECT predict a future cardiac event?
2005, Journal of Nuclear Cardiology
Myocardial stunning has recently been demonstrated by use of stress gated technetium 99m sestamibi single photon emission computed tomography (SPECT) myocardial perfusion scintigraphy. However, its prognostic value is less well determined. The aim of this study was to investigate the prognostic value of reversible regional wall motion abnormalities (RWMAs).
We studied 303 consecutive subjects with known or suspected coronary artery disease who underwent 2-day stress-rest gated Tc-99m sestamibi SPECT and were followed up for 19 ± 16 months. Clinical and test-derived variables were evaluated to predict cardiac death, nonfatal myocardial infarction (MI), unstable angina, and early or late coronary revascularization. Reversible RWMAs were identified in 102 patients. On Cox analysis, the presence, site, degree, and extent of reversible RWMAs did not identify an adverse outcome, except in patients without prior MI. After adjustment for prescan data, the strongest predictors of hard events and all cardiac events were poststress RWMAs and the amount of ischemia. The addition of poststress RWMAs to the combined model of prescan and perfusion data yielded incremental prognostic value.
Poststress RWMAs and ischemia by perfusion were the most powerful predictive parameters of cardiac events. However, myocardial stunning should always be considered, particularly in patients without prior MI and in the referral of patients for early revascularization.
Prognostic value of gated myocardial perfusion SPECT
2004, Journal of Nuclear Cardiology
Technetium<sup>99m</sup> sestamibi myocardial perfusion imaging predicts clinical outcome in the community outpatient setting: The Nuclear Utility in the Community (NUC) Study
2004, Journal of the American College of Cardiology
Citation Excerpt :
In a follow-up study of 2,686 patients, Sharir et al. (22)separately evaluated the predictors of cardiac death and nonfatal MI, finding that gated SPECT post-stress EF best predicted cardiac death, while ischemia best predicted nonfatal MI. Kroll et al. (23)studied 120 inpatients after MI who were treated medically and found that predischarge post-stress gated SPECT EF provided incremental prognostic benefit among patients with an EF of <40%. Our study confirms and extends these findings; in particular, a 3% increase in risk was observed for every 1% decrease in EF (p = 0.0009).
The purpose of this study was to evaluate the prognostic value of community-based myocardial perfusion imaging (MPI) and to assess the incremental value of individual components of ^99mTc-sestamibi single photon emission computed tomography (SPECT).
Although the most rapid growth of MPI has been in community outpatient laboratories, its prognostic value has not been validated in this setting.
We prospectively followed 1,612 consecutive patients undergoing stress ^99mTc-sestamibi SPECT in an outpatient community laboratory who experienced 71 hard events over 24 ± 7 months (0.2% lost to follow-up).
Patients whose scans were normal incurred an annualized event rate of 0.4%, compared with 2.3% for those with abnormal scans (p < 0.0001). Subset analysis demonstrated comparable risk stratification for women and men, diabetics, patients with normal resting ECGs, and those referred for pharmacologic and exercise stress. After adjusting for pre-test variables, multivariable Cox regression analysis found the most potent independent components of MPI to be, in order of importance, transient ischemic dilation, extent of reversibility, post-stress ejection fraction, extent and severity of the stress perfusion defect, and the overall test result (normal or abnormal). Each 1% decrement of ejection fraction predicted a 3% increase in risk (p = 0.0009). Post-MPI angiography and revascularization increased commensurate with the extent and severity of MPI result.
The prognostic value of perfusion imaging is portable and transferable to the outpatient community setting, with multiple components of MPI providing incremental prognostic information.
ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging - Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to revise the 1995 guidelines for the clinical use of cardiac radionuclide imaging)
2003, Journal of the American College of Cardiology

View all citing articles on Scopus

View full text

Prognostic value of stress-gated Tc-99m sestamibi SPECT after acute myocardial infarction

Abstract

Section snippets

Patient population

Patient characteristics

Discussion

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am Heart J

Am J Cardiol

Am Heart J

Am J Cardiol

Am Heart J

J Am Coll Cardiol

J Nucl Cardiol

Am J Cardiol