Differential prognostic significance of peri-infarction versus remote myocardial ischemia on stress technetium-99m sestamibi tomography in patients with healed myocardial infarction

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Abstract

Peri-infarction and remote myocardial ischemia involve different myocardial substrates, but their differential clinical implications have not been previously studied. We assessed the differential prognostic significance of peri-infarction and remote ischemia during long-term follow-up in patients with healed myocardial infarction. We studied 345 patients (59 ± 12 years old; 282 men) with previous myocardial infarction who demonstrated reversible perfusion abnormalities on exercise or dobutamine stress technetium-99m sestamibi tomography. Follow-up events for 5.5 ± 2.6 years were 60 deaths (17%; 40 cardiac deaths) and 25 reinfarctions (7%). Reversible perfusion abnormalities were detected in the remote region in 129 patients (37%), the peri-infarction region in 142 patients (41%), and in both regions in 74 patients (21%). The annual rates of cardiac death in these groups were 1.2%, 2.8%, and 2.9%, respectively (p <0.01). The annual rates of reinfarction were 1%, 1.5%, and 0.9%, respectively (p = NS). In a multivariate analysis model, independent predictors of cardiac death were history of heart failure (risk ratio [RR] 2.8, 95% confidence interval [95% CI] 1.2 to 7), diabetes mellitus (RR 4.1, 95% CI 1.9 to 8.9), summed score at rest (RR 1.4, 95% CI 1.1 to 3.1), and peri-infarction ischemia (RR 2.6, 95% CI 1.1 to 6.1). Predictors of reinfarction were age (RR 1.03, 95% CI 1.01 to 1.07) and diabetes mellitus (RR 3.3, 95% CI 1.2 to 9.1). Peri-infarction ischemia assessed by stress technetium-99m sestamibi tomography is associated with a greater risk of cardiac death than is remote ischemia. The risk of reinfarction is not related to the location of ischemia.

Section snippets

Patient selection

The study population consisted of 350 consecutive patients with a history of myocardial infarction of >1 month (mean 3.5 ± 2.2 years) who demonstrated a reversible perfusion abnormality on stress technetium-99m sestamibi myocardial perfusion tomography in our laboratory between 1992 and 1995. The choice of stress test was based on ability to exercise. Patients with limited exercise capacity underwent a dobutamine stress test. Follow-up was successful in 345 patients (99%). The data of these

Clinical data

Mean age was 59 ± 10 years. There were 282 men (82%). Symptoms before the stress test were typical angina in 131 patients (38%) and atypical chest pain in 102 patients (30%). Risk factors for coronary artery disease were hypercholesterolemia in 126 (37%), hypertension in 122 (35%), smoking in 110 (32%), and diabetes mellitus in 59 (17%). Fifty-three patients (15%) had a history of heart failure. The infarct-related artery was determined to be the left anterior descending in 135 patients (39%),

Discussion

Identification of stress test parameters associated with increased risk of future cardiac events is important for planning appropriate management strategies in patients with known or suspected coronary artery disease. Stress myocardial perfusion imaging is an effective tool for the diagnosis of peri-infarction and remote ischemia.1, 2, 3, 15 Although previous studies have associated reversible perfusion abnormalities with increased risk of cardiac events in patients with healed myocardial

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