Integración de los parámetros de remodelado, sincronía y velocidad máxima de vaciado para evaluar la función sistólica del ventrículo izquierdo / Integration of ventricular remodeling, synchrony and filling rate parameters to improve the assessment of left ventricular systolic function

Objetivos El objetivo es estudiar la relación entre los parámetros estructurales, de remodelado, de sincronía y de función sistólica del ventrículo izquierdo (VI) mediante gSPECT. Obtener los valores de corte del VI para el índice de la forma telediastólica (iFTD), el índice de la forma telesistólica (iFTS), el índice de excentricidad (iEX) y la velocidad máxima de vaciado (VMV). Desarrollar un nuevo índice para evaluar diferentes patrones de función sistólica del VI. Material y métodos Analizamos prospectivamente 238 pacientes (edad: 63,4±13 años) estudiados mediante gSPECT de esfuerzo-reposo (grupo-control, n=148; pacientes con infarto de miocardio [IM] previo, n=90). Estudio aprobado por el Comité de Ética del Hospital (PR[AG]168.2010). Resultados En el grupo-control, el índice del volumen telediastólico (iVTD) y el iEX influyeron en el iFTD (r2: 0,52, p<0,001). El iVTD, la VMV, ser varones y el iEX (r2: 0,44; p<0,001) influyeron en el iFTS. El iFTD, iFTS, la fracción de eyección VI (FEVI) y el volumen de eyección sistólica (r2: 0,62; p<0,001) influyeron en el iEX. La FEVI, la frecuencia cardíaca, el ancho de banda (AB) y la desviación estándar influyeron (r2: 0,76; p<0,001) en la VMV. Los valores de corte para iFTD, iFTS, iEX y VMV fueron 0,59, 0,42, 0,87 y −3,3 respectivamente. La VMV, el iFTS y el AB fueron los parámetros mejor relacionados con los pacientes con IM previo (AUC: 0,89), y sumados a la FEVI permitieron obtener distintos patrones de función sistólica (índice PERRS). Conclusiones Los parámetros de remodelado, sincronía y función sistólica del VI deben interpretarse simultáneamente, ya que esto permite obtener distintos patrones de función sistólica del VI (AU)

Introduction and objectives The aim of this study is to assess the relationship between structural, remodeling, synchrony, and systolic left ventricular (LV) function parameters using gated-SPECT myocardial-perfusion-images (gSPECT-MPI). In addition, obtaining the cut-off values for end-diastolic LV-shape-index (EDLVsi), end-systolic LV-shape-index (ESLVsi), ECC (eccentricity-index) and PER, and developing a new index to evaluate different patterns of the LV systolic function. Methods The study was approved by the Hospital's Ethical-Committee (PR[AG]168.2010), and all patients gave their informed consent. We analyzed prospectively 238 patients (age 63.4±13 years) who underwent stress-rest gSPECT-MPI (control-group, n=148; patients with previous myocardial infarction [MI], n=90). Results In the control group, with regard to remodeling parameters: the end-diastolic-volume-index (EDV) and the ECC were the parameters that influenced the EDLVsi (r2: 0.52, P<.001). EDV, PER, men, and the ECC were the parameters (r2: 0.44; P<.001) which influenced the ESLVsi. EDLVsi, ESLVsi, LVEF and the stroke-volume were the parameters (r2: 0.62; P<.001) which influenced the ECC. With regards to PER: LVEF, heart-rate, bandwidth, and the standard-deviation were the influencing parameters (r2: 0.76; P<.001). The cut-off values for EDLVsi, ESLVsi, ECC, and PER were 0.59, 0.42, 0.87, and 3.3, respectively. The PER, the ESLVsi and the bandwidth were the parameters related to patients with previous MI (AUC: 0.89); and they allow the assessment of different patterns of systolic function (PERRS-index: Peak-Emptying-Rate, left ventricular-Remodeling and Synchrony). Conclusions The remodeling, synchrony and the systolic function parameters of the LV should be interpreted together (PERRS-index). In this way, we obtain different patterns of LV systolic function (AU)

Integration of ventricular remodeling, synchrony and filling rate parameters to improve the assessment of left ventricular systolic function.

INTRODUCTION AND OBJECTIVES: The aim of this study is to assess the relationship between structural, remodeling, synchrony, and systolic left ventricular (LV) function parameters using gated-SPECT myocardial-perfusion-images (gSPECT-MPI). In addition, obtaining the cut-off values for end-diastolic LV-shape-index (EDLVsi), end-systolic LV-shape-index (ESLVsi), ECC (eccentricity-index) and PER, and developing a new index to evaluate different patterns of the LV systolic function. METHODS: The study was approved by the Hospital's Ethical-Committee (PR[AG]168.2010), and all patients gave their informed consent. We analyzed prospectively 238 patients (age 63.4 ±â€¯13 years) who underwent stress-rest gSPECT-MPI (control-group, n = 148; patients with previous myocardial infarction [MI], n = 90). RESULTS: In the control group, with regard to remodeling parameters: the end-diastolic-volume-index (EDV) and the ECC were the parameters that influenced the EDLVsi (r2: 0.52, p < 0.001). EDV, PER, men, and the ECC were the parameters (r2: 0.44; p < 0.001) which influenced the ESLVsi. EDLVsi, ESLVsi, LVEF and the stroke-volume were the parameters (r2: 0.62; p < 0.001) which influenced the ECC. With regards to PER: LVEF, heart-rate, bandwidth, and the standard-deviation were the influencing parameters (r2: 0.76; p < 0.001). The cut-off values for EDLVsi, ESLVsi, ECC, and PER were 0.59, 0.42, 0.87, and 3.3, respectively. The PER, the ESLVsi and the bandwidth were the parameters related to patients with previous MI (AUC: 0.89); and they allow the assessment of different patterns of systolic function (PERRS-index: peak-emptying-rate, left ventricular-remodeling and synchrony). CONCLUSIONS: The remodeling, synchrony and the systolic function parameters of the LV should be interpreted together (PERRS-index). In this way, we obtain different patterns of LV systolic function.

Coste-efectividad de la SPECT de perfusión miocárdica y de la prueba de esfuerzo en relación con la revascularización coronaria, eventos cardíacos y mortalidad total. Registro de 8.496 pacientes / Cost-effectiveness of myocardial perfusion SPECT and stress test according to coronary revascularization therapy, cardiac events and total mortality: Register of 8,496 patients

OBJETIVO: Análisis de la relación coste-efectividad (RCE) del electrocardiograma de esfuerzo y de la SPECT de perfusión miocárdica esfuerzo-reposo en relación con la revascularización coronaria (RC), eventos cardíacos (EC) y mortalidad total (MT). MATERIAL Y MÉTODOS: Se estudiaron 8.496 pacientes con SPECT y seguimiento medio de 5,3±3,5años. Evaluamos la RCE para la RC quirúrgica (RCQ) y percutánea (RCP) (45,6%/54,4%) de acuerdo con los resultados de la isquemia electrocardiográfica y gammagráfica. La efectividad se evaluó como MT, EC, LYSO (life-year-saved-observed) y EC-LYSO. Los análisis de costes se realizaron desde la perspectiva del pagador de atención médica. El análisis de sensibilidad fue considerando las relaciones RCQ/RCP actuales (12%/88%). RESULTADOS: Al combinar los resultados del electrocardiograma de esfuerzo y de la gammagrafía, los valores de coste-efectividad para la RCQ variaron entre 112.589€ (isquemia electrocardiográfica y gammagráfica) y 2.814.715€ (sin isquemia)/evento evitado, y entre 38.664 y 2.221.559€/LYSO; y para la RCP entre 18.824€ (isquemia electrocardiográfica y gammagráfica) y 46.377€ (sin isquemia)/evento evitado, y entre 6.464 y 36.604€/LYSO. Para el EC: los valores de coste-efectividad de la RCQ y RCP en presencia de isquemia electrocardiográfica y gammagráfica fueron de 269.904€/EC evitado y de 24.428€/EC evitado, respectivamente; y los €/LYSO de la RCQ y RCP fueron de 152.488 y 13.801, respectivamente. Se mantuvo la misma RCE para la proporción actual de pacientes revascularizados (12%/88%). CONCLUSIONES: El análisis combinado de las imágenes de la SPECT y del electrocardiograma de esfuerzo permite la diferenciación entre grupos de pacientes en donde la RCP y la RCQ son más rentables. La mayor RCE en relación con la RC, EC y MT se da en los pacientes con isquemia electrocardiográfica y gammagráfica. La RCP es más coste-efectiva que la RCQ

OBJECTIVE: The aim was to analyze the cost-effectiveness ratio (CER) of stress electrocardiogram (ES) and stress myocardial perfusion imaging (SPECT-MPI) according to coronary revascularization (CR) therapy, cardiac events (CE) and total mortality (TM). MATERIAL AND METHODS: A total of 8,496 consecutive patients who underwent SPECT-MPI were followed-up (mean 5.3±3.5years). Cost-effectiveness for coronary bypass (CABG) or percutaneous CR (PCR) (45.6%/54.4%) according to combined electrocardiographic ischemia and scintigraphic ischemia were evaluated. Effectiveness was evaluated as TM, CE, life-year saved observed (LYSO) and CE-LYSO; costs analyses were conducted from the perspective of the health care payer. A sensitivity analysis was performed considering current CABG/PCR ratios (12%/88%). RESULTS: When electrocardiogram and SPECT approaches are combined, the cost-effectiveness values for CABG ranged between 112,589€ (electrocardiographic and scintigraphic ischemia) and 2,814,715€ (without ischemia)/event avoided, 38,664 and 2,221,559€/LYSO; for PCR ranged between 18,824€ (electrocardiographic and scintigraphic ischemia) and 46,377€ (without ischemia)/event avoided, 6,464 and 36,604€/LYSO. To CE: the cost-effectiveness values of the CABG and CPR in presence of electrocardiographic and scintigraphic ischemia were 269,904€/CE-avoided and 24,428€/CE-avoided, respectively; and the €/LYSO of the CABG and PCR were 152,488 and 13,801, respectively. The RCE was maintained for the current proportion of revascularized patients (12%/88%). CONCLUSIONS: Combined ES and SPECT-MPI results, allows differentiation between patient groups, where the PCR and CABG are more cost-effective in different economic frameworks. The major CER in relation to CR, CE and TM occurs in patients with electrocardiographic and scintigraphic ischemia. PCR is more cost-effective than CABG

Cost-effectiveness of myocardial perfusion SPECT and stress test according to coronary revascularization therapy, cardiac events and total mortality: Register of 8,496 patients. / Coste-efectividad de la SPECT de perfusión miocárdica y de la prueba de esfuerzo en relación con la revascularización coronaria, eventos cardíacos y mortalidad total. Registro de 8.496 pacientes.

OBJECTIVE: The aim was to analyze the cost-effectiveness ratio (CER) of stress electrocardiogram (ES) and stress myocardial perfusion imaging (SPECT-MPI) according to coronary revascularization (CR) therapy, cardiac events (CE) and total mortality (TM). MATERIAL AND METHODS: A total of 8,496 consecutive patients who underwent SPECT-MPI were followed-up (mean 5.3±3.5years). Cost-effectiveness for coronary bypass (CABG) or percutaneous CR (PCR) (45.6%/54.4%) according to combined electrocardiographic ischemia and scintigraphic ischemia were evaluated. Effectiveness was evaluated as TM, CE, life-year saved observed (LYSO) and CE-LYSO; costs analyses were conducted from the perspective of the health care payer. A sensitivity analysis was performed considering current CABG/PCR ratios (12%/88%). RESULTS: When electrocardiogram and SPECT approaches are combined, the cost-effectiveness values for CABG ranged between 112,589€ (electrocardiographic and scintigraphic ischemia) and 2,814,715€ (without ischemia)/event avoided, 38,664 and 2,221,559€/LYSO; for PCR ranged between 18,824€ (electrocardiographic and scintigraphic ischemia) and 46,377€ (without ischemia)/event avoided, 6,464 and 36,604€/LYSO. To CE: the cost-effectiveness values of the CABG and CPR in presence of electrocardiographic and scintigraphic ischemia were 269,904€/CE-avoided and 24,428€/CE-avoided, respectively; and the €/LYSO of the CABG and PCR were 152,488 and 13,801, respectively. The RCE was maintained for the current proportion of revascularized patients (12%/88%). CONCLUSIONS: Combined ES and SPECT-MPI results, allows differentiation between patient groups, where the PCR and CABG are more cost-effective in different economic frameworks. The major CER in relation to CR, CE and TM occurs in patients with electrocardiographic and scintigraphic ischemia. PCR is more cost-effective than CABG.

El patrón de discordancia motilidad-perfusión en la gated-SPECT de reposo sugiere necrosis no transmural en la resonancia magnética cardiaca / Motion-perfusion mismatch-pattern on rest-gated SPECT suggests non-transmural necrosis on cardiac magnetic resonance

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Obtención de una fórmula que mejora la estimación del consumo máximo de oxígeno en las pruebas de esfuerzo con bicicleta ergométrica / Obtaining a formula that improves maximum oxygen consumption estimation in cycle ergometer exercise tests

Objetivos: Valorar si la estimación del consumo máximo de oxígeno (CMO2) en MET (unidad metabólica) mediante las tablas propuestas en las guías de la Sociedad Española de Cardiología (SEC) es un método suficientemente fiable cuando se aplica a las pruebas de esfuerzo con bicicleta ergométrica. Material y métodos: Se obtuvo el CMO2 en MET por consumo de gases en bicicleta ergométrica en 97 sujetos sanos (grupo i) y se comparó con la estimación de los MET obtenida mediante tabla en la que solo intervienen los vatios y el peso del paciente. Mediante la introducción de variables clínicas y ergométricas se obtuvo una fórmula con mejor ajuste para el cálculo de los MET validándose en 289 pacientes (grupo ii) con gated-SPECT de perfusión miocárdica normal. Resultados: En los individuos del grupo i se observó una buena correlación entre los MET estimados con la tabla y los MET obtenidos mediante consumo de gases (CCI: 0,93). Sin embargo, la fórmula con mejor ajuste para la estimación de los MET en los pacientes del grupo ii incluyó los vatios, el índice de masa corporal (IMC), la edad y el sexo (MET = 11,820 − 0,054 × edad − 0,189 × IMC + 1,031 × sexo + 0,020 × vatios) (mujer: 0, hombre: 1). Esta fórmula permitió la reclasificación de un 46,9% de los individuos del grupo ii en la categoría < 5 MET con respecto a la estimación por tabla. Conclusiones: La estimación de los MET mediante la tabla convencional es fiable, aunque el ajuste óptimo, cuando se aplica a sujetos con gated-SPECT de perfusión miocárdica de esfuerzo normal, se obtiene al considerar, además de los vatios, el IMC, la edad y el sexo (AU)

Objectives: To evaluate if the estimation of the maximal oxygen consumption (MO2C) in METs (metabolic equivalents) by means of the table proposed in the guidelines of the Spanish Society of Cardiology is a sufficiently reliable method when applied to the bicycle exercise test. Material and methods: The MO2C in METs was obtained by gas-exchange analysis on bicycle ergometer tests in 97 healthy subjects (group i). It was compared with the estimate of METs using the table in which only watts and patient's weight were included. A better-adjusted formula was validated in 289 subjects with normal exercise myocardial perfusion gated-SPECT (group ii) using the introduction of clinical and ergometric variables. Results: In group i individuals a good correlation between METs estimated with the table and those obtained through gas-exchange analysis (CCI: 0.93) was observed. However, the best adjusted formula to estimate METs in group ii subjects included watts, body mass index (BMI), age and gender (METS = 11.820 − 0.054 × age − 0.189 × BMI + 1.031 × gender + 0.020 × watts) (women: 0, men: 1). This formula allowed the reclassification of 46.9% of group ii subjects into the category < 5 METs versus the estimation by table. Conclusions: Estimating the METs with the conventional table is reliable. However, the best adjustment in subjects with normal bicycle exercise SPECT was obtained when, in addition to watts and BMI, age and gender were also considered (AU)

SPECT, angio-TC coronaria, coronariografía invasiva e imágenes de fusión en la cardiopatía isquémica estable / SPECT, coronary angio-CT, invasive coronary angiography and fusion images in stable coronary disease

Objetivos: Valorar la información de la SPECT, de la angio-TC coronaria y de las imágenes híbridas de fusión en los pacientes con cardiopatía isquémica estable en los que se practica una coronariografía invasiva (CI). Material y métodos: Se ha incluido en forma prospectiva a 46 pacientes (65,98 ± 8,3 años) con enfermedad coronaria, valorándose la información de dichas técnicas en el diagnóstico de la enfermedad multivaso, en la detección del vaso culpable y en el manejo de los pacientes. Resultados: En la CI, 29 de los 46 pacientes (63%) presentaban enfermedad multivaso: la SPECT la diagnosticó en un 48,2% y la angio-TC en un 89,6%. La concordancia entre la angio-TC y la CI en el diagnóstico del vaso culpable fue del 77% (kappa 0,6) y entre la SPECT y la CI del 73% (kappa 0,56). Las imágenes híbridas obtenidas después del cateterismo no habrían aportado nueva información a la ya obtenida mediante la SPECT y la CI de cara al manejo terapéutico. Conclusiones: La angio-TC destaca en el diagnóstico de la enfermedad multivaso y en la detección del vaso culpable respecto a la CI. La SPECT resulta un buen complemento funcional de la CI en la detección del territorio más isquémico. No obstante, en los pacientes con cardiopatía isquémica estable en los que se ha realizado una SPECT como primer estudio no invasivo, si la decisión de practicar posteriormente una CI es clara, la realización de una angio-TC y la obtención de imágenes de fusión SPECT-TC no parecen indicadas, ya que no cambiaría el manejo terapéutico que se adopta sobre la base de la información de la SPECT y la CI (AU)

Objectives: To evaluate the usefulness of the information obtained with SPECT, coronary angio-CT and fusion images, in patients with stable ischemic disease who need invasive coronary angiography (IA). Material and methods: Forty-six patients (65.98 ± 8.3 years) with coronary disease were prospectively included. The fusion images generated after undergoing IA were used to evaluate the performance of these techniques in the diagnosis of multi-vessel coronary disease, the detection of the culprit vessel and the therapeutic management of these patients. Results: In the IA, 29 of the 46 patients (63%) had multi-vessel disease. SPECT could detect it in 48.2% and coronary angio-CT could detect it in 89.6%. Concordance between coronary angio-CT and IA in the diagnosis of the culprit vessel was 77% (kappa 0.6), and between SPECT and IA it was 73% (kappa 0.56). Although fusion images could have been obtained prior to IA, they would not have changed the therapeutic approach derived from SPECT and IA. Conclusions: Coronary angio-CT has a high ability for the diagnosis of multi-vessel disease and the culprit lesion, and SPECT is a good functional complement of the IA in the detection of the most ischemic territory. However, the performance of fusion images in patients with stable ischemic disease, who have undergone a SPECT as the first non-invasive study and need IA, does not seem indicated because they would not have changed the therapeutic management derived from SPECT and IA information (AU)

[SPECT, coronary angio-CT, invasive coronary angiography and fusion images in stable coronary disease]. / SPECT, angio-TC coronaria, coronariografía invasiva e imágenes de fusión en la cardiopatía isquémica estable.

OBJECTIVES: To evaluate the usefulness of the information obtained with SPECT, coronary angio-CT and fusion images, in patients with stable ischemic disease who need invasive coronary angiography (IA). MATERIAL AND METHODS: Forty-six patients (65.98±8.3 years) with coronary disease were prospectively included. The fusion images generated after undergoing IA were used to evaluate the performance of these techniques in the diagnosis of multi-vessel coronary disease, the detection of the culprit vessel and the therapeutic management of these patients. RESULTS: In the IA, 29 of the 46 patients (63%) had multi-vessel disease. SPECT could detect it in 48.2% and coronary angio-CT could detect it in 89.6%. Concordance between coronary angio-CT and IA in the diagnosis of the culprit vessel was 77% (kappa 0.6), and between SPECT and IA it was 73% (kappa 0.56). Although fusion images could have been obtained prior to IA, they would not have changed the therapeutic approach derived from SPECT and IA. CONCLUSIONS: Coronary angio-CT has a high ability for the diagnosis of multi-vessel disease and the culprit lesion, and SPECT is a good functional complement of the IA in the detection of the most ischemic territory. However, the performance of fusion images in patients with stable ischemic disease, who have undergone a SPECT as the first non-invasive study and need IA, does not seem indicated because they would not have changed the therapeutic management derived from SPECT and IA information.

[Obtaining a formula that improves maximum oxygen consumption estimation in cycle ergometer exercise tests]. / Obtención de una fórmula que mejora la estimación del consumo máximo de oxígeno en las pruebas de esfuerzo con bicicleta ergométrica.

OBJECTIVES: To evaluate if the estimation of the maximal oxygen consumption (MO2C) in METs (metabolic equivalents) by means of the table proposed in the guidelines of the Spanish Society of Cardiology is a sufficiently reliable method when applied to the bicycle exercise test. MATERIAL AND METHODS: The MO2C in METs was obtained by gas-exchange analysis on bicycle ergometer tests in 97 healthy subjects (group i). It was compared with the estimate of METs using the table in which only watts and patient's weight were included. A better-adjusted formula was validated in 289 subjects with normal exercise myocardial perfusion gated-SPECT (group ii) using the introduction of clinical and ergometric variables. RESULTS: In group i individuals a good correlation between METs estimated with the table and those obtained through gas-exchange analysis (CCI: 0.93) was observed. However, the best adjusted formula to estimate METs in group ii subjects included watts, body mass index (BMI), age and gender (METS=11.820-0.054×age-0.189×BMI+1.031×gender+0.020×watts) (women: 0, men: 1). This formula allowed the reclassification of 46.9% of group ii subjects into the category <5METs versus the estimation by table. CONCLUSIONS: Estimating the METs with the conventional table is reliable. However, the best adjustment in subjects with normal bicycle exercise SPECT was obtained when, in addition to watts and BMI, age and gender were also considered.

Variables que influyen en la indicación de una segunda gated-SPECT de perfusión miocárdica después una gated-SPECTde estrés-reposo normal / Variables that influence the indication of a second myocardial perfusion gated-SPECT after a normal stress-rest gated SPECT

Objetivo: El objetivo de este estudio fue investigar qué variables en el momento de la práctica de una gated-SPECT de perfusión miocárdica normal son predictoras de la indicación de una segunda gated-SPECT. Material y métodos: Estudio unicéntrico, prospectivo de cohorte. Se incluyeron consecutivamente 2.326 pacientes (edad 63,6 ± 13 años, 57,3% mujeres) sin defectos de perfusión y con una fracción de eyección del ventrículo izquierdo normal en una gated-SPECT de perfusión miocárdica estrés-reposo. Se estudiaron variables clínicas y ergométricas predictoras de la indicación de una nueva gated-SPECT y de la presencia de defectos reversibles de perfusión en esta última. Resultados: Durante un seguimiento medio de 3,6 ± 2 años después de una gated-SPECT normal se practicó una segunda gated-SPECT en 286 pacientes (12,3%). Las variables predictoras independientes que influyeron en la indicación de una segunda gated-SPECT fueron la presencia de 3 o más factores de riesgo cardiovascular (χ2: 5.501; HR: 1,4; p = 0,019), el antecedente de infarto agudo de miocardio (χ2: 3.862; HR: 1,4; p = 0,049), la revascularización coronaria previa (χ2: 41.063; HR: 2,5; p < 0,001), y una prueba de estrés positiva (χ2: 8.699; HR: 1,5; p = 0,003). La observación de defectos de perfusión en los 280 pacientes en que se realizó una segunda gated-SPECT de estrés-reposo fue más probable en pacientes de sexo masculino (χ2: 4.322; HR: 1,9; p = 0,038) que realizaron una primera gated-SPECT farmacológica pura (χ2: 7.182; HR: 2,6; p = 0,007). Conclusiones: En los pacientes con una gated-SPECT de perfusión miocárdica normal diversos factores clínicos y variables derivadas de la prueba de estrés influyen en la indicación de una segunda gated-SPECT y en la presencia de isquemia en esta última (AU)

Objective: The objective of this study was to investigate predictor variables at the moment of normal stress-rest myocardial perfusion gated SPECT for indication of a second gated SPECT. Material and Methods: A prospective, single center cohort study was conducted. We evaluated 2326 consecutive patients (age 63.6 ± 13 years, 57.3% females) without perfusion defects and with normal left ventricular ejection fraction on a myocardial perfusion gated SPECT. Clinical and stress test variables were studied to predict indication of a second gated SPECT and presence of reversible perfusion defects in the second gated SPECT. Results: During a mean follow-up of 3.6 ± 2 years a second gated SPECT was performed in 286 patients (12.3%). Independent predictor variables of a second gated SPECT were presence of three or more cardiovascular risk factors (χ2: 5.510; HR: 1.4; p = 0.019), previous acute myocardial infarction (χ2: 3.867; HR: 1.4; p = 0.049), previous coronary revascularization (χ2: 41.081; HR: 2.5; p < 0.001), and a positive stress test (χ2: 8.713; HR: 1.5; p = 0.003). Observation of perfusion defects in the 280 patients in whom a second stress-rest gated SPECT was performed was more likely in male patients (χ2: 4.322; HR: 1.9; p = 0.038) who had a first pure pharmacological gated-SPECT (χ2: 7.182; HR: 2.6; p = 0.007). Conclusions: In patients with a first normal myocardial perfusion gated SPECT, various clinical factors and variables derived from the stress test affect the indication of a second gated SPECT and the presence of ischemia in the latter (AU)

Authors' reply to "Analysis of the diastolic function by myocardial perfusion gated SPECT after coronary revascularization in acute myocardial infarction" / Réplica a "Análisis de la función diastólica mediante gated-SPECT de perfusión miocárdica tras revascularización coronaria en el infarto agudo de miocardio"

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[Variables that influence the indication of a second myocardial perfusion gated-SPECT after a normal stress-rest gated SPECT]. / Variables que influyen en la indicación de una segunda gated-SPECT de perfusión miocárdica después una gated-SPECTde estrés-reposo normal.

OBJECTIVE: The objective of this study was to investigate predictor variables at the moment of normal stress-rest myocardial perfusion gated SPECT for indication of a second gated SPECT. MATERIAL AND METHODS: A prospective, single center cohort study was conducted. We evaluated 2326 consecutive patients (age 63.6 ± 13 years, 57.3% females) without perfusion defects and with normal left ventricular ejection fraction on a myocardial perfusion gated SPECT. Clinical and stress test variables were studied to predict indication of a second gated SPECT and presence of reversible perfusion defects in the second gated SPECT. RESULTS: During a mean follow-up of 3.6 ± 2 years a second gated SPECT was performed in 286 patients (12.3%). Independent predictor variables of a second gated SPECT were presence of three or more cardiovascular risk factors (χ(2): 5.510; HR: 1.4; p=0.019), previous acute myocardial infarction (χ(2): 3.867; HR: 1.4; p=0.049), previous coronary revascularization (χ(2): 41.081; HR: 2.5; p<0.001), and a positive stress test (χ(2): 8.713; HR: 1.5; p=0.003). Observation of perfusion defects in the 280 patients in whom a second stress-rest gated SPECT was performed was more likely in male patients (χ(2): 4.322; HR: 1.9; p=0.038) who had a first pure pharmacological gated-SPECT (χ(2): 7.182; HR: 2.6; p=0.007). CONCLUSIONS: In patients with a first normal myocardial perfusion gated SPECT, various clinical factors and variables derived from the stress test affect the indication of a second gated SPECT and the presence of ischemia in the latter.

Análisis de la función diastólica mediante gated-SPECT de perfusión miocárdica tras revascularización coronaria en el infarto agudo de miocardio / Analysis of the diastolic function by myocardial perfusion gated SPECT after coronary revascularization in acute myocardial infarction

Objetivo. Valorar mediante gated-SPECT de perfusión miocárdica los cambios evolutivos de la función diastólica después de la revascularización coronaria percutánea (RCP) de un infarto agudo de miocardio (IAM). Material y métodos. Se estudiaron consecutivamente 32 pacientes (media 61,9±9,7 años; 7 mujeres) mediante 2 gated-SPECT de perfusión miocárdica en reposo: la primera gated-SPECT-1 con inyección de una dosis de 99mTc-tetrofosmina previa a la RCP y la segunda gated-SPECT-2 entre la cuarta y quinta semana después del IAM. Se valoraron los cambios de la velocidad máxima de llenado (Vmáx) y del tiempo a la velocidad máxima de llenado (TVmáx) entre ambos estudios, relacionándolos con la extensión del miocardio salvado (MS) y con los cambios observados en los volúmenes telediastólico (VTD) y telesistólico (VTS) y en la fracción de eyección del ventrículo izquierdo (FEVI). Resultados. En la gated-SPECT-2 se observó una mejoría de los parámetros de la función diastólica: la Vmáx aumentó significativamente (p = 0,011) mientras que el TVmáx disminuyó sin alcanzar significación estadística (p = 0,288). En el análisis multivariante, ajustado por variables clínicas y coronariográficas, el aumento de la Vmáx se relacionó significativamente con el porcentaje de MS (p = 0,030), el aumento de la FEVI (p = 0,004) y la reducción del VTS (p = 0,005). La mejoría del TVmáx solo se relacionó significativamente con el porcentaje de MS (p = 0,046). Por cada cm2 de aumento del área del MS la Vmáx aumentó 0,01 VTD/s y la TVmáx disminuyó 1,14 ms. Conclusiones. Tras la RCP en el IAM, la gated-SPECT de perfusión miocárdica permite valorar la mejoría significativa de la función diastólica que se relaciona fundamentalmente con la cantidad de MS (AU)

Objective. To evaluate the evolutive changes in diastolic function after percutaneous coronary revascularization (PCR) in acute myocardial infarction (AMI), using myocardial perfusion gated SPECT. Material and methods. Thirty-two patients (mean 61.9±9.7 years, 7 women) were studied by two at rest gated SPECT: the first gated-SPECT-1 was performed with an injection of a dose of 99mTc-tetrofosmin prior to PCR and the second gated-SPECT-2 between the fourth and fifth weeks after AMI. Changes of peak filling rate (PFR) and the time to peak filling rate (TTPF) were assessed between both studies, and were related to the extent of salvaged myocardium (SM), end-diastolic (EDV) and end-systolic (ESV) volumes, and left ventricular ejection fraction (LVEF) changes. Results. An improvement was observed in diastolic function parameters Gated-SPECT-2: PFR increased significantly (P=0.011) while the TTPF decreased without reaching statistical significance (P=0.288). In multivariate analysis, adjusted by clinical and coronary variables, improvement of PFR was significantly associated with percentage of SM (P=0.030), increase in LVEF (P=0.004) and with ESV volume reduction (P=0.005). Improvement of TTPF was only related significantly to the percentage of SM (P=0.046). PFR increased 0.01 EDV/sec. and TTPF decreased 1.14ms for each cm2 increase of the area of SM. Conclusions. After PCR in AMI, the myocardial perfusion gated SPECT makes it possible to assess the significant improvement in diastolic function mainly related to the amount of MS (AU)

[Analysis of the diastolic function by myocardial perfusion gated SPECT after coronary revascularization in acute myocardial infarction]. / Análisis de la función diastólica mediante gated-SPECT de perfusión miocárdica tras revascularización coronaria en el infarto agudo de miocardio.

OBJECTIVE: To evaluate the evolutive changes in diastolic function after percutaneous coronary revascularization (PCR) in acute myocardial infarction (AMI), using myocardial perfusion gated SPECT. METHODS: Thirty-two patients (mean 61.9±9.7 years, 7 women) were studied by two at rest gated SPECT: the first gated-SPECT-1 was performed with an injection of a dose of (99m)Tc-tetrofosmin prior to PCR and the second gated-SPECT-2 between the fourth and fifth weeks after AMI. Changes of peak filling rate (PFR) and the time to peak filling rate (TTPF) were assessed between both studies, and were related to the extent of salvaged myocardium (SM), end-diastolic (EDV) and end-systolic (ESV) volumes, and left ventricular ejection fraction (LVEF) changes. RESULTS: An improvement was observed in diastolic function parameters Gated-SPECT-2: PFR increased significantly (P=0.011) while the TTPF decreased without reaching statistical significance (P=0.288). In multivariate analysis, adjusted by clinical and coronary variables, improvement of PFR was significantly associated with percentage of SM (P=0.030), increase in LVEF (P=0.004) and with ESV volume reduction (P=0.005). Improvement of TTPF was only related significantly to the percentage of SM (P=0.046). PFR increased 0.01 EDV/sec. and TTPF decreased 1.14ms for each cm(2) increase of the area of SM. CONCLUSIONS: After PCR in AMI, the myocardial perfusion gated SPECT makes it possible to assess the significant improvement in diastolic function mainly related to the amount of MS.

Impacto de la gated-SPECT de perfusión miocárdica en la indicación de una coronariografía en pacientes con disfunción ventricular izquierda de origen isquémico / Impact of myocardial perfusion gated-SPECT on the decision to perform coronary angiography in patients with left ventricular dysfunction of ischemic origin

Objetivo. El objetivo de este estudio fue analizar como la gated-SPECT (Single Photon Emission Computed Tomography) de perfusión miocárdica influye en la práctica de una coronariografía en los pacientes con miocardiopatía isquémica (MI). Material y métodos. Se evaluaron consecutivamente 120 pacientes (edad media: 64,9±11,5 años, 25 mujeres) con MI (fracción de eyección ventricular izquierda ≤ 40%) mediante gated-SPECT de perfusión miocárdica (96 estrés-reposo y 24 sólo reposo) y sin coronariografía previa. La fracción de eyección (FE) fue obtenida en reposo mediante gated-SPECT. El origen isquémico de la disfunción sistólica se estableció mediante coronariografía en los 64 pacientes en que fue practicada después de la gammagrafía y por el antecedente de infarto de miocardio en el resto. Los resultados de la gated-SPECT se compararon con los de los 56 pacientes en los que no se indicó la coronariografía. Resultados. La isquemia miocárdica gammagráfica (HR: 5,2; IC 95%: 2,68 a 10,35) en los pacientes que habían podido realizar una prueba de estrés y la disminución severa de la fracción de eyección (FE<30%) (HR: 0,9; IC 95%: 0,89 a 0,99) fueron predictores independientes de la práctica de una coronariografía mientras que los criterios gammagráficos de viabilidad miocárdica no fueron determinantes, desde un punto de vista estadístico, para la práctica del cateterismo. Conclusiones. En los pacientes con MI, la demostración de isquemia y la reducción severa de la FE en la gated-SPECT de perfusión miocárdica influyeron en la indicación de una coronariografía, sin que los criterios gammagráficos de viabilidad tuvieran un impacto significativo en esta decisión(AU)

Objectives. The aim of this study was to analyze how the myocardial perfusion gated-SPECT (Single Photon Emission Computed Tomography) influences the practice of a coronary angiography in patients with ischemic cardiomyopathy (IM). Patients and methods. A total of 120 consecutive patients (mean age: 64.9±11.5 years, 25 female) with IM (left ventricular ejection fraction ≤40%) and without previous coronary angiography were evaluated by myocardial perfusion gated-SPECT (96 stress-rest and 24 only at rest). The ventricular ejection fraction (EF) was obtained at rest by gated-SPECT in all patients. The ischemic origin of the systolic dysfunction was established by means of coronary angiography in 64 patients and by previous myocardial infarction in the rest. Gated-SPECT results of these 64 patients were compared with those of 56 patients in whom coronary angiography had not been indicated. Result. Scintigraphic myocardial ischemia (HR: 5.2; CI 95%: 2.68 to 10.35) in patients who were able to perform the stress-rest test) and who had severely impaired EF (<30%) (HR: 0.9; CI 95%: 0.89 to 0.99) were the best independent predictors of coronary angiography. On the contrary, scintigraphic criteria of viability were not a determinant, from the statistical point of view, of coronary angiography in this series. Conclusions. In patients with IM, demonstration of ischemia and severe reduction of the EF, but not detection of viable myocardium, prompted the performance of coronary angiography(AU)

[Impact of myocardial perfusion gated-SPECT on the decision to perform coronary angiography in patients with left ventricular dysfunction of ischemic origin]. / Impacto de la gated-SPECT de perfusión miocárdica en la indicación de una coronariografía en pacientes con disfunción ventricular izquierda de origen isquémico.

OBJECTIVES: The aim of this study was to analyze how the myocardial perfusion gated-SPECT (Single Photon Emission Computed Tomography) influences the practice of a coronary angiography in patients with ischemic cardiomyopathy (IM). PATIENTS AND METHODS: A total of 120 consecutive patients (mean age: 64.9±11.5 years, 25 female) with IM (left ventricular ejection fraction ≤40%) and without previous coronary angiography were evaluated by myocardial perfusion gated-SPECT (96 stress-rest and 24 only at rest). The ventricular ejection fraction (EF) was obtained at rest by gated-SPECT in all patients. The ischemic origin of the systolic dysfunction was established by means of coronary angiography in 64 patients and by previous myocardial infarction in the rest. Gated-SPECT results of these 64 patients were compared with those of 56 patients in whom coronary angiography had not been indicated. RESULT: Scintigraphic myocardial ischemia (HR: 5.2; CI 95%: 2.68 to 10.35) in patients who were able to perform the stress-rest test) and who had severely impaired EF (<30%) (HR: 0.9; CI 95%: 0.89 to 0.99) were the best independent predictors of coronary angiography. On the contrary, scintigraphic criteria of viability were not a determinant, from the statistical point of view, of coronary angiography in this series. CONCLUSIONS: In patients with IM, demonstration of ischemia and severe reduction of the EF, but not detection of viable myocardium, prompted the performance of coronary angiography.

Protocolo corto esfuerzo reposo frente a protocolo largo en la gated-SPECT de perfusión miocárdica de pacientes con miocardiopatía isquémica / Short exercise-rest versus long myocardial perfusion gated SPECT protocols in patients with ischemic cardiomyopathy

Objetivo. Analizar la función sistólica ventricular izquierda y la perfusión miocárdica entre los protocolos corto esfuerzo reposo en un solo día y largo en 2 días de la gated-SPECT (Single Photon Emision Computed Tomography) de perfusión miocárdica en pacientes con miocardiopatía isquémica. Métodos. Estudio prospectivo de 40 pacientes (59,6±8,9 años, 3 mujeres) con miocardiopatía isquémica (fracción de eyección (FE) ventricular izquierda <=40%) estudiados mediante gated-SPECT. Entre 5–10 días después de realizar el protocolo corto esfuerzo reposo (gated-SPECT-1) los pacientes fueron recitados para un segundo estudio de reposo (gated-SPECT-2) para comparar los resultados de la FE y de las diferencias de la suma de puntuación de perfusión en reposo (ΔSPR=SPR1–SPR2) y de la suma de puntuación de perfusión diferencial (ΔSPD=SPD1–SPD2) entre ambos protocolos. Resultados. En 26 pacientes (65%) la FE de la gated-SPECT-2 fue superior (37 vs 34%, p=0,008) a la de la gated-SPECT-1 y en 11 pacientes (27,5%) el incremento fue >=5%. No hubo diferencias clínicas ni coronariográficas significativas entre los pacientes con y sin aumento de la fracción de eyección >=5%. En el análisis múltivariante ΔSPR (IC95%: −1,1 a −29,2) y ΔSPD (0,179–1,236) fueron predictoras del incremento de la FE ≥5% entre ambos estudios. Conclusiones. En los pacientes con miocardiopatía isquémica la práctica de un protocolo corto esfuerzo reposo puede infravalorar la FE del ventrículo izquierdo. El aturdimiento miocárdico postestrés y la posible contaminación de las imágenes de reposo con las del esfuerzo previo en el protocolo corto permitirían explicar en parte estos resultados(AU)

Objective. The purpose of this study was to analyze left systolic ventricular function and myocardial perfusion characteristics between short one day exercise-rest and long two days gated SPECT (Single Photon Emission Computed Tomography) protocols in patients with ischemic cardiomyopathy (ICM). Methods. A prospective study of 40 patients (59.6±8.9 years, 3 women) with IHD (left ventricular ejection fraction (EF) <=40%) was performed with myocardial perfusion gated SPECT. From 5 to 10 days after a one-day exercise-rest study (gated SPECT-1), patients were called back for a second rest study (gated SPECT-2) in order to compare EF and differences in perfusion summed rest score (ΔSRS=SRS1–SRS2) and summed difference score (ΔSDS=SDS1–SDS2) between both protocols. Results. Between rest-gated SPECT-1 (short protocol) and rest-gated SPECT-2 (long protocol) EF increased (34% vs 37%, P= 0.008) in 26 patients (65%), and in 11 patients (27.5%) the increase was >=5%. There were no significant differences in clinical and coronary angiography variables between patients with and without increase of the EF >=5%. In the multivariate analysis, ΔSRS (95% CI: −1.1 to −29.2) and ΔSDS (0.179–1.236) were predictors for this EF increase between both studies. Conclusions. Exercise-rest short protocol can underestimate EF in patients with CM. Stunning but also contamination of rest images by previous exercise images in a short protocol could explain these results(AU)

[Short exercise-rest versus long myocardial perfusion gated SPECT protocols in patients with ischemic cardiomyopathy]. / Protocolo corto esfuerzo reposo frente a protocolo largo en la gated-SPECT de perfusión miocárdica de pacientes con miocardiopatía isquémica.

OBJECTIVE: The purpose of this study was to analyze left systolic ventricular function and myocardial perfusion characteristics between short one day exercise-rest and long two days gated SPECT (Single Photon Emission Computed Tomography) protocols in patients with ischemic cardiomyopathy (ICM). METHODS: A prospective study of 40 patients (59.6±8.9 years, 3 women) with IHD (left ventricular ejection fraction (EF) ≤40%) was performed with myocardial perfusion gated SPECT. From 5 to 10 days after a one-day exercise-rest study (gated SPECT-1), patients were called back for a second rest study (gated SPECT-2) in order to compare EF and differences in perfusion summed rest score (ΔSRS=SRS1-SRS2) and summed difference score (ΔSDS=SDS1-SDS2) between both protocols. RESULTS: Between rest-gated SPECT-1 (short protocol) and rest-gated SPECT-2 (long protocol) EF increased (34% vs 37%, P= 0.008) in 26 patients (65%), and in 11 patients (27.5%) the increase was ≥5%. There were no significant differences in clinical and coronary angiography variables between patients with and without increase of the EF ≥5%. In the multivariate analysis, ΔSRS (95% CI: -1.1 to -29.2) and ΔSDS (0.179-1.236) were predictors for this EF increase between both studies. CONCLUSIONS: Exercise-rest short protocol can underestimate EF in patients with CM. Stunning but also contamination of rest images by previous exercise images in a short protocol could explain these results.