99mTc-DTPA dynamic SPECT/CT renogram in adults: feasibility and diagnostic benefit.

OBJECTIVE: The objective of this study is to investigate the feasibility and potential advantages of 99mTc-DTPA dynamic single photon emission computed tomography/computed tomography (SPECT/CT) renogram in adults. METHODS: Fifty-five patients aged 19-80 years (mean 56.3) were enrolled. The imaging protocol included: day 1: 99mTc-DTPA planar renogram, followed by planar 99mTc-DMSA scan. Day 3: attenuation-corrected dynamic 99mTc-DTPA SPECT renogram [DSPECT(AC)] and Cr-51 ethylenediamine tetraacetic acid (EDTA) glomerular filtration rate (GFR) calculation. DSPECT(AC) included an initial CT scan followed by 12 consecutive SPECT sessions acquired via continuous-mode acquisition for a total of 24 min. Fast SPECT sequences (1-2 s/projection, 60 projections, every 6°) were obtained for the first 8 min, followed by slower acquisitions (3-4 s/projection) during the rest of the study. Renal activity was measured in the total kidney volume by regions of interest drawn on consecutive transaxial slices of the third SPECT, which were then copied on the whole 12-SPECT series. Corresponding time-activity curves were created. DSPECT(AC) parameters were compared with those of planar renogram. The reference method for split renal function was 99mTc-DMSA (geometrical mean of anterior and posterior projection counts) and for GFR the Cr-51 EDTA 2-blood sample clearance method. RESULTS: DSPECT(AC) images were of good quality. There was good correlation between renogram parameters (time to peak activity and NORA20) comparing the two techniques (r = 0.959 and 0.933, respectively). In 21 cases with >30% absolute difference between the two kidneys, spilt renal function calculation by DSPECT(AC) correlated perfectly (r = 0.968) with the reference method, whereas planar renogram was less accurate (r = 0.843). Anatomic information provided by nonenhanced CT offered an integrated structural-functional view valuable for final diagnosis. DSPECT(AC) early kidney uptake as a fraction of injected dose correlated better with reference GFR (r = 0.789) than the Gates' method (r = 0.642). CONCLUSION: 99mTc-DTPA dynamic SPECT/CT renogram is feasible with conventional SPECT/CT systems. It allows accurate split renal function measurement, offers additional anatomical information and can be used for closer approximation of GFR compared with Gates' method.

Effectiveness of COVID-19 vaccine mandates in raising vaccination rates among the elderly and general population in Europe: Controlled interrupted time series analysis.

BACKGROUND: During the COVID-19 pandemic, three European countries (Austria, Greece, Italy) announced and/or implemented mandatory COVID-19 vaccination for high-risk groups in the general population. Besides the ethical justification for this policy, it is important to assess and quantify the effectiveness of the mandate in raising vaccination rates. METHODS: Controlled interrupted time series analysis of first-dose vaccination rates in the targeted age groups (Greece: ≥60 years; Italy: ≥50 years) relative to a control group (Greece: 50-59 years; Italy: 25-49 years) between week 35/2021 and week 50/2022. For Austria an uncontrolled analysis was performed, as the vaccine mandate targeted all adults ≥18 years. RESULTS: Announcement of mandatory vaccination substantially increased vaccination rates in the targeted age groups compared to control in both Greece (RR = 4.36, 95 % CI: 3.57-5.32) and Italy (RR = 2.90, 95 % CI: 2.37-3.56), an effect which persisted throughout the study period. There were 176,428 (95 % CI: 164,097-187,226) mandate-attributable first-dose vaccinations in Greece and 316,192 (95 % CI: 282,467-346,678) in Italy, most of which occurred before the mandate came into effect. In Austria no discernible increase in vaccination rates was observed after the announcement of mandatory vaccination. At the end of the study period, 9.5 % of ≥60 year-olds in Greece, 4.9 % of ≥50 year-olds in Italy and 13.8 % of ≥18 year-olds in Austria remained unvaccinated. CONCLUSIONS: In Greece and Italy - though not in Austria - simple announcement of a vaccine mandate rapidly increased COVID-19 vaccination rates in the targeted age groups, without fully closing the vaccination gap. Mandatory vaccination appears to effectively target complacency but not vaccine hesitancy, and its public health benefits need to be weighted against possible detrimental effects on confidence and trust.

Comparison of 18F-PSMA-1007 and 18F-Choline PET/CT in prostate cancer patients with biochemical recurrence: a phase 3, prospective, multicenter, randomized study.

OBJECTIVES: This prospective, multicenter, open-label, randomized, crossover trial study was to evaluate the diagnostic performance of 18F-PSMA-1007 (PSMA) vs. 18F-Choline PET/CT (FCH) in prostate cancer (PCa) patients (pts) with biochemical recurrence (BCR). METHODS: One hundred eighty-six pts, who have undergone primary definitive treatment for PCa with BCR, were recruited to this prospective study. All pts underwent one PSMA and one FCH PET/CT examination in randomized order within a time frame of 8 days and were followed up for at least 6 months (182 ±â€…10 days). RESULTS: Recurrence of PCa was observed in 176 out of 186 pts. The overall correct detection rate (DR) was 84% (95% CI 0.7967-0.8830) for PSMA and 69% (95% CI 0.6191-0.7489) for FCH, yielding a difference in proportion of 16% ( P  < 0.0001). PSMA had a sensitivity of 0.8464 and FCH 0.6857 with an odds ratio of 2.5259 ( P  < 0.0001), with statistically significant greater sensitivity of PSMA (ORs, 2.7877 and 2.1283 respectively) ( P  < 0.0001). PET/CT imaging led to a more accurate diagnosis in 166 (89.2%) pts, of which PSMA had contributed more than FCH in 91 (54.8%) of them. The DR for cutoff point PSA ≤ 1 ng/ml was higher for PSMA compared to FCH (61.8% vs. 39.5%). DR value of 51.6% for PSMA reached at PSA ≤ 0.3 ng/ml, while FCH reached that DR value with PSA ≤ 2.2 ng/ml. CONCLUSION: 18F-PSMA-1007 is more efficacious than 18F-Choline for the identification metastatic lesions both in patient and in regional level analysis in PCa patients with BCR.

A rare presentation of rapidly progressing myopathy in an adolescent.

We present a case of severe juvenile dermatomyositis with limited response to steroids in an adolescent who developed symptoms within hours after receiving Pfizer BNT162b2 coronavirus disease 2019 vaccine. The patient presented with severe weakness of proximal muscles, dyspnoea, and tachycardia. His muscle enzymes were raised, and he was diagnosed with severe juvenile dermatomyositis following magnetic resonance imaging and muscle biopsy. His management was challenging, requiring multidisciplinary input, and difficult decisions with regard to the appropriate immunomodulatory treatments. The patient had to undergo escalating immunosuppressive treatments before he began to recover clinically and biochemically. To our knowledge, this is the first case in an adolescent although a few cases of similar presentations following coronavirus disease 2019 vaccination have been reported in adults. Elucidating the potential relationship of the vaccine with this severe myopathy in an adolescent is important for global vaccination policies, but avoiding the conflation of association with causation is also crucial in the context of the pandemic.

Inferior myocardial wall ischemia on SPECT-MPI in patients with non dominant right coronary artery and non significant coronary artery disease.

BACKGROUND: The impact of a non-dominant right coronary artery (NDRCA), on single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI)has not been clarified. METHODS AND RESULTS: We compared SPECT-MPI results of consecutive patients without significant (diameter stenosis ≥50%)coronary artery disease (CAD) and a NDRCA (Group-1), with those of patients from our database without CAD and a dominant RCA (Group-2). All patients were subjected to SPECT-MPI with I.V. infusion of adenosine, and TC99-tetrofosmin. Group-1 included 69 patients (55 men, 79.7%), mean age 66.8 ± 9.8 years. Group-2 consisted of 79 patients (56 men, 70.9%), mean age 62.7 ± 11.5. There was no difference in demographics and CAD risk factors between the two groups. The SPECT-MPI revealed inferior wall ischemia, in 35 patients (50.7%), in Group-1 and 27 patients (34.1%), in Group-2 (P = 0.041). CONCLUSIONS: A relatively high rate of reversible SPECT-MPI perfusion defects may be anticipated in patients with an unobstructed NDRCA compared to patients with a dominant RCA.

Study on intraoperative localization of sentinel lymph nodes using freehand SPECT in breast cancer patients.

Introduction: The diagnostic and therapeutic approach to axillary lymph nodes is considered indispensable in the treatment of breast cancer patients. Aim: To investigate the effectiveness of 3D freehand SPECT (fhSPECT) in sentinel lymph node (SLN) mapping in breast cancer, compared with the use of a conventional gamma probe. Material and methods: We retrospectively compared the fhSPECT lymph node mapping modality, with gamma probe detection in early-stage, clinically node-negative breast cancer patients, with biopsy-confirmed malignancy. The two techniques were compared based on the average number of LNs excised per axilla. The duration of SLN mapping was also compared between the two groups. The performance of the two methods on obese and post-systemic therapy patients was evaluated. FhSPECT was used in 150 cases, while the gamma probe was employed in 50 cases. Results: FhSPECT detected at least 3 nodes in 83.3% of the patients vs. 72.0% with the γ-probe (p = 0.107). The mean number of SLNs excised per axilla was 3.66 using the γ-probe and 4.18 with fhSPECT (p = 0.03). The average surgical time was 39 ±7 min with the γ-probe and 37.54 ±17 min with fhSPECT (p = 0.228). Sentinel lymph node biopsy (SLNB) mean surgical time evolved from 40.2 ±20.77 min to 32.35 ±10.46 min (p = 0.033). In obese patients, a reduction in surgical times was noted from 45.5 ±3.09 min to 44.04 ±20.9 (p = 0.27), in addition to a significant increase in average LN detection in the fhSPECT group (4.26 ±1.44) compared to the γ-probe group (3.2 ±1.65) (p = 0.043). Conclusions: The use of the fhSPECT modality is effective and safe, and, when compared to the γ-probe, has significant advantages in SLN mapping.

Adult Medulloblastoma Depicted With 99mTc-HYNIC-[D-Phe1, Tyr3-Octreotide] SPECT/CT.

Although medulloblastoma constitutes the second most common malignant brain tumor in children, it encountered very rarely in adults. The incidence of adult medulloblastoma is approximately 0.6 to 1 case per million. It accounts for less than 1% of adult brain tumors and is located most commonly at the posterior cranial fossa. We present an extremely rare case of a 67-year-old man with cerebellar medulloblastoma with residual disease after surgery, chemotherapy, and radiation therapy, depicted with Tc-HYNIC-[D-Phe, Tyr-Octreotide] SPECT/CT. Somatostatin receptor scintigraphy was performed for staging and for the possibility of treatment with somatostatin analogs or peptide radionuclide therapy.

Whole body bone SPET/CT can successfully replace the conventional bone scan in breast cancer patients. A prospective study of 257 patients.

OBJECTIVE: Single photon emission tomography/computed tomography (SPET/CT) is usually recommended after ambiguous whole body bone scan (WBS) findings. We investigated the value of routine 2-field ("near" whole-body) SPET/CT application in breast cancer (BC) patients. SUBJECTS AND METHODS: In this prospective study planar WBS and 2-field SPET/CT was performed in 257 consecutive BC patients referred for a bone scan. Whole body scan and SPET/CT were interpreted separately. Additional imaging studies and clinical follow-up for 30±24 months elucidated uncertain findings. RESULTS: Bone metastases were confirmed in 65 patients (25.3%). Sensitivity, specificity, accuracy, positive and negative predictive value per-patient was 63.1%, 81.3%, 76.7%, 53.2% and 86.7% for WBS and 96.9%, 87.5%, 89.9%, 72.4% and 98,8% for SPET/CT; differences were statistically significant except for specificity. Respective values of sensitivity per-lesion were 47.6% and 98.9% (P<0.001). Eleven percent of true positive findings were noticed only in the low-dose CT images, while 7% only in SPET. Single photon emission tomography/CT exhibited higher specificity than WBS in the spine (94.8% vs. 88.7%, P=0.04). Whole body scan interpretation changed after SPET/CT in 74 (28.8%) patients. Thirty-two patients with positive/suspicious WBS turned to be metastases-free after the interpretation of SPET/CT while 42 with unremarkable WBS turned to be positive/suspicious. Of these cases, metastases were confirmed in one with negative and 23 with positive/suspicious SPET/CT. The SPET/CT results prompted treatment plan changes in 23 cases (8.9%). CONCLUSION: Whole-body bone SPET/CT scan outperformed WBS in terms of sensitivity, accuracy, positive and negative predictive value and impacted on patient management. Therefore, its use is recommended as a routine procedure in BC patients, even after a negative WBS.

Myocardial perfusion and left ventricular quantitative parameters obtained using gated myocardial SPECT: Comparison of three software packages.

BACKGROUND: The aim of the present study was to compare Emory Cardiac Toolbox, Myovation, and Quantitative Gated SPECT software regarding the automatic measurements of perfusion and functional left ventricular (LV) quantitative parameters, summed stress score (SSS), perfusion defect score, LV ejection fraction (LVEF), end-diastolic volume, and end-systolic volume (ESV). METHODS AND RESULTS: 99mTc-tetrofosmin gated SPECT studies were performed in 634 consecutive patients based on the one-day stress/rest protocol. Participants were divided into subgroups according to heart size (ESV cut-off value: 25 mL), perfusion (SSS >/≤3), and other patient/protocol-related factors. LVEF was categorized as normal (≥50%), mildly moderately impaired (35-49%), and severely abnormal (<35%). The concordance between the packages was good to excellent, in overall population, ESV ≤25 mL, ESV >25 mL, and SSS >3 subgroups (intraclass correlation coefficients, ICCs 0.73-0.93). In SSS ≤3 subgroup, the correlation was excellent for LV functional parameters, but suboptimal for perfusion variables (ICCs 0.30-0.83). LVEF categorization revealed similar variability (discordance 18.1 and 11.1% for stress/rest LVEF values, respectively). Pair comparisons demonstrated considerable differences concerning all parameters for all patient subgroups. The statistical significance of our findings by ESV and SSS classifications was evaluated. CONCLUSIONS: Despite the significant concordance between software packages, considerable differences in mean values of myocardial perfusion and LV functional parameters were demonstrated.

Percutaneous Nephrolithotomy Puncture and Tract Dilation: Evidence on the Safety of Approaches to the Infundibulum of the Middle Renal Calyx.

OBJECTIVE: To investigate the anatomical relations of the papillary, infundibular, and pelvic approach to percutaneous nephrolithotomy and evaluate the amount of vascularization at the respective sites. MATERIALS AND METHODS: 99mTc-dimercaptosuccinic acid single-photon emission computed tomography/computed tomography (SPECT/CT) renal scintigraphies or computed tomography perfusion (CTP) was performed in 40 patients (prone n = 20 or supine position n = 20). The angle of approach (AoA) for access tracts and the respective regions of interest to the mid-calyceal papilla and infundibulum as well as renal pelvis were designed and compared. RESULTS: The design of access tracts aiming to the renal pelvis, papilla, and infundibulum of the renal calyx was impossible for the nondilated collecting systems as all these tracts were in close vicinity. In both SPECT/CT and CTP, there was no statistical difference between the AoA for infundibular or pelvic access in comparison with the papillary puncture in either prone or supine position regardless of the degree of dilation of the system. The comparison of the measurements in the regions of interest showed that there was no difference in blood supply between the infundibular and pelvic access in comparison with the papillary approach in both positions regardless of the degree of collecting system dilation. CONCLUSION: The use of SPECT/CT and CTP showed that the punctures to the mid-calyceal renal papilla-fornix and infundibulum as well as the renal pelvis at the same level have similar AoA. The sites of the parenchyma involved in the tract dilation of the respective approaches are not related to significant differences in terms of vascularization.

What is the benefit of CT-based attenuation correction in myocardial perfusion SPET?

In multimodality imaging, CT-derived transmission maps are used for attenuation correction (AC) of SPET or PET data. Regarding SPET myocardial perfusion imaging (MPI), however, the bene����t of CT-based AC (CT-AC) has been questioned. Although most attenuation-related artifacts are removed by this technique, new false defects may appear while some true perfusion abnormalities may be masked. The merits and the drawbacks of CT-AC in MPI SPET are reviewed and discussed in this editorial. In conclusion, CT-AC is most helpful in men, overweight in particular, and in those with low or low to intermediate pre-test probability of coronary artery disease (CAD). It is also useful for the evaluation of myocardial viability. In high-risk patients though, CT-AC may underestimate the presence or the extent of CAD. In any case, corrected and non-corrected images should be viewed side-by-side and both considered in the interpretation of the study.

A multicenter evaluation of the appropriate use of single-photon emission tomography myocardial perfusion imaging in Greece.

BACKGROUND: This study evaluates the appropriate use of myocardial perfusion imaging (MPI) and determines patterns and variables associated with inappropriate testing. METHODS: Over a 10-month period data were collected prospectively from consecutive patients referred for MPI in four academic departments and an appropriate use grade was assigned (appropriate, uncertain, inappropriate, and unclassifiable scans) according to established criteria. RESULTS: Among 3,032 referrals appropriate MPI had 72.8% of patients and 19.2% of studies were inappropriate, the remaining being uncertain (7.2%) or unclassifiable (0.8%). In multivariate analysis the asymptomatic status (odds ratio 10.7, P < .001), good functional capacity (odds ratio 1.9, P < .001), an interpretable resting electrocardiogram (odds ratio 1.8, P = .004), an age <65 years (odds ratio 1.5, P = .001) and the absence of diabetes (odds ratio 1.7, P < .001) or dyslipidemia (odds ratio 1.3, P = .014) were independent predictors of inappropriate scintigraphy. The most common indication for inappropriate testing was the assessment of asymptomatic patients <2 years after percutaneous coronary intervention (PCI) (38.9%). CONCLUSIONS: The appropriate use of MPI is relatively high, but a considerable proportion of inappropriate scans is noted which is associated with markers of lower risk. The most common source of inappropriate testing is the assessment of asymptomatic patients <2 years after PCI.

Active plasmonics in WDM traffic switching applications.

With metal stripes being intrinsic components of plasmonic waveguides, plasmonics provides a "naturally" energy-efficient platform for merging broadband optical links with intelligent electronic processing, instigating a great promise for low-power and small-footprint active functional circuitry. The first active Dielectric-Loaded Surface Plasmon Polariton (DLSPP) thermo-optic (TO) switches with successful performance in single-channel 10 Gb/s data traffic environments have led the inroad towards bringing low-power active plasmonics in practical traffic applications. In this article, we introduce active plasmonics into Wavelength Division Multiplexed (WDM) switching applications, using the smallest TO DLSPP-based Mach-Zehnder interferometric switch reported so far and showing its successful performance in 4×10 Gb/s low-power and fast switching operation. The demonstration of the WDM-enabling characteristics of active plasmonic circuits with an ultra-low power × response time product represents a crucial milestone in the development of active plasmonics towards real telecom and datacom applications, where low-energy and fast TO operation with small-size circuitry is targeted.

Evaluation of zotarolimus-eluting metal stent in animal ureters.

BACKGROUND AND PURPOSE: Drug-eluting stents proved to minimize neointimal hyperplasia in coronary vessels. Hyperplastic reaction is the most common unwelcome event related to the use of metal mesh stents in the ureter. We evaluated the effect of zotarolimus-eluting stent (ZES) Endeavor Resolute in the porcine and rabbit ureter. MATERIALS AND METHODS: A ZES and a bare metal stent (BMS) were inserted in each ureter of 10 pigs and 6 rabbits. The insertion was performed by the retrograde approach. CT was used for the evaluation of porcine ureters while intraoperative intravenous urography (IVU) was used for rabbit ureters. The follow-up included CT or IVU every week for the following 4 weeks for pigs and 8 weeks for rabbits. Renal scintigraphies were performed before stent insertion and during the third week in all animals. Optical coherence tomography (OCT) has been used for the evaluation of the luminal and intraluminal condition of the ureters with stents. Histopathologic examination of the these ureters embedded in glycol-methacrylate was performed. RESULTS: Hyperplastic reaction was present in both stent types. BMSs in seven porcine ureters were completely obstructed while porcine ureters with ZES stents had hyperplastic tissue that did not result in obstruction. Two rabbit ureters with BMS stents were occluded while no ZES was associated with ureteral obstruction. The function of the seven porcine renal units and the two rabbit units with obstructed ureters with stents was compromised. The OCT revealed increased hyperplastic reaction in the ureters with BMS stents in comparison with those with ZESs. Although, hyperplastic reaction was present in all cases, pathologic examination revealed significantly more hyperplastic reaction in BMSs. CONCLUSION: ZESs in the pig and rabbit ureter were not related to hyperplastic reaction resulting in stent occlusion. These stents were related to significantly lower hyperplastic reaction in comparison with BMSs while inflammation rates were similar for both stent types.

Erdheim-Chester disease: a rare syndrome with a characteristic bone scintigraphy pattern.

Erdheim-Chester disease is a rare noninherited, non-Langerhans' cell histiocytosis, with multiorgan involvement. The skeleton is frequently involved in as many as 70-80% of all cases. In nearly half of the cases, there is an involvement of other organs such as the cardiovascular system, lung, kidneys, brain, and orbits. Extra-skeletal involvement is correlated with increased morbidity and mortality. In recent years, the disease is being described with increasing frequency although fewer than 200 cases have been identified worldwide. Besides its rarity, the disease has a characteristic almost pathognomonic bone scan appearance, which in some cases facilitates diagnosis of the syndrome. Bone scans also contribute to the qualitative assessment of skeletal involvement.

201Tl gated single photon emission computed tomographic myocardial perfusion imaging in the assessment of global and regional left ventricular function. Would it be favoured over equilibrium radionuclide angiography?

BACKGROUND: This study investigates the clinical performance of routine 201Tl gated single photon emission computed tomographic (201Tl GSPECT) myocardial perfusion imaging. Equilibrium radionuclide angiography (ERNA) was used as the standard for comparison. METHODS AND RESULTS: One hundred and seventy-two consecutive patients were submitted to both myocardial 201Tl GSPECT imaging, at stress and in redistribution, and ERNA. Left ventricular ejection fractions (LVEF) and regional wall motion were assessed from both stress and redistribution 201Tl GSPECT datasets, and from ERNA. Linear regression analysis showed a good correlation between LVEF calculated by ERNA and 201Tl GSPECT (r=0.73 at stress, r=0.75 in redistribution, P<0.0001). However, the 95% prediction intervals of 201Tl GSPECT LVEF from ERNA LVEF were wide (minimum 35.4% at stress and 33.2% in redistribution). Moreover, a difference in LVEF > or =10% between ERNA and 201Tl GSPECT was found in 26.4% of cases at stress and 28.6% of cases in redistribution. A fair agreement between ERNA and 201Tl GSPECT was found in regional wall motion assessment in segments with normal or mildly reduced tracer uptake (kappa=0.32 at stress and kappa=0.33 in redistribution). In segments with moderately to severely reduced tracer uptake, a moderate agreement was found in regional wall motion assessment between ERNA and 201Tl GSPECT (kappa=0.44 at stress and kappa=0.42 in redistribution). CONCLUSIONS: Left ventricular function may be misinterpreted in a significant proportion of patients if the calculation of LVEF is based on 201Tl GSPECT. Moreover, the evaluation of regional wall motion by 201Tl GSPECT appears unsatisfactory.

Contribution of the sST elevation/T-wave normalization in Q-wave leads during routine, pre-discharge treadmill exercise test to patient management and risk stratification after acute myocardial infarction: a 2.5-year follow-up study.

OBJECTIVES: This study investigated whether ST-segment elevation and T-wave normalization (TWN) in Q-wave leads on pre-discharge exercise electrocardiogram (ECG) can contribute to patient management after a recent myocardial infarction (MI). BACKGROUND: The clinical relevance of these exercise ECG changes remains controversial despite accumulating evidence of their association with myocardial viability. Because discrepancies of previous studies may depend on patient selection, the value of these ST/T abnormalities in the thrombolytic era should be better defined. METHODS: One-hundred one patients, age 58 +/- 11 years, with a recent, first Q-wave MI (57% thrombolyzed, ejection fraction 43 +/- 7%) underwent pre-discharge, submaximal treadmill testing followed, in the absence of severe ischemia, by dobutamine stress echocardiography, thallium-201 single photon emission computed tomography, and coronary angiography. RESULTS: ST elevation at peak exercise, but not TWN, was associated with more severe infarctions as indicated by higher peak creatine kinase (p < 0.05) and with a greater number of scarred segments both on echocardiography (p < 0.05) and scintigraphy (p < 0.01). However, the incidence of myocardial viability and ischemia did not differ between groups with or without these ST/T changes. Anterior infarction location and >or=3 echocardiographically scarred segments were among the independent predictors of ST elevation at peak ergometric exercise. During follow-up (31 +/- 13 months), the rate of hard events was low (8%) and similar between the study groups. CONCLUSIONS: In patients after acute Q-wave MI without severe ischemia according to clinical and standard ECG criteria, exercise-induced ST elevation, but not TWN, is associated with larger infarctions. The contribution of these ST/T abnormalities toward identifying patients with myocardial viability or ischemia and determining risk stratification is poor. In-hospital management of such patients based on routine clinical practice is sufficient for selection of a population with a relatively low long-term risk.