Trends in coronary artery disease and associated risk factors in sub-Saharan Africans.

It has been suggested that the prevalence of coronary artery disease (CAD) is steadily increasing in sub-Saharan Africa. To address this issue, we conducted a Medline search of English language articles on cardiovascular diseases-and specifically CAD in Africa- from 1966 to 1997. The prevalence of CAD and related complications is relatively low in most regions in Africa compared to that obtained in the economically developed countries, although the situation is rapidly changing due to trends in urbanization, changes in lifestyle, acquisition of technology and the increasing numbers of tertiary care institutions. There are variations in reported prevalence rates within the different regions, but there is an upward trend in all the regions of the sub-Saharan Africa. This trend is believed to be related to the increasing frequencies of CAD risk factors in the subcontinent.

Incidence of major cardiovascular events in black patients with normal myocardial stress perfusion study results.

BACKGROUND: Previous studies have shown that the risk of major cardiovascular events at 1 year is less than 1% in patients with normal myocardial stress perfusion study results. However, the racial distribution of patients enrolled in these studies is not known. Hence, the prognostic value of normal stress perfusion study results in black patients is not well established. Our objective was to determine the incidence of major cardiovascular events in black patients with normal stress perfusion study results over a 12-month period. METHODS AND RESULTS: We searched the nuclear cardiology database at our institution for all black patients who had normal stress perfusion study results between January 1990 and December 1996. We excluded patients with a history of coronary revascularization, valvular heart disease, cardiomyopathy, congenital heart disease, left bundle branch block, or pre-excitation syndrome. Patients were followed up for at least 12 months from the time of inclusion. A total of 592 patients were enrolled and were followed up for 18 +/- 6 months (mean +/- SD). Of these, 388 underwent treadmill exercise testing, 155 underwent dipyridamole stress testing, and the remainder underwent dobutamine stress testing. Perfusion studies were performed in all patients with thallium 201 single photon emission computed tomography imaging. During the follow-up period, 11 cardiac deaths and 7 myocardial infarctions (MIs) occurred. The incidence of cardiac deaths was 1.2% per year, and that of nonfatal MIs was 0.8% per year. The total incidence of major cardiovascular events was 2% per year. In patients who underwent treadmill exercise testing, the incidence of major cardiovascular events was 1% per year. Performance of a pharmacologic stress test and a prior MI were significantly associated with death or nonfatal MI (P <.05). CONCLUSIONS: The overall incidence of major cardiovascular events in black patients after normal exercise perfusion study results were obtained was low (1%). However, black patients who had normal perfusion study results but underwent pharmacologic stress testing or had a history of MI were at intermediate risk. These patients require close surveillance for major cardiovascular events.

Measurement of myocardial blood flow with PET using 1-11C-acetate.

UNLABELLED: 11C-acetate has been used extensively for the noninvasive assessment of myocardial oxygen consumption and viability with PET. The use of early uptake of acetate by the heart to measure myocardial perfusion has been proposed. This study evaluated the application of 11C-acetate for absolute measurement of myocardial blood flow using a simple compartmental model that does not require blood sampling. METHODS: Eight healthy volunteers and 13 subjects with concentric left ventricular hypertrophy were studied under resting conditions with both 11Cacetate and 15O-water. Myocardial blood flow with 11C-acetate was obtained by fitting the first 3 min of the blood and tissue tracer activity curves to a two-compartment model. Flows obtained were compared with a validated approach using 15O-water. RESULTS: In healthy volunteers, regional myocardial perfusion at rest estimated with 11C-acetate was comparable with values obtained with 15O-water (1.06 +/- 0.25 and 0.96 +/- 0.12 mL/g/min, respectively). Perfusion in subjects with left ventricular hypertrophy was also comparable if the recovery coefficient (FMM) used was corrected for ventricular mass. If a fixed FMM was used, flow was greatly overestimated. FMM could be estimated from left ventricular mass (FMM = 0.46 + 0.002 x mass, r = 0.86, P < 0.0001). CONCLUSION: The results of this study suggest that 11C-acetate can be applied to quantitatively estimate myocardial perfusion under resting conditions using a two-compartment model without the need for blood sampling, provided that an appropriate FMM is chosen. This approach should increase the usefulness of this tracer and obviate administration of a separate tracer to independently measure perfusion.

Use of wavelet transforms in analysis of time-activity data from cardiac PET.

UNLABELLED: Because of its intrinsic quantitative properties, PET permits measurement of myocardial perfusion and metabolism in absolute terms (i.e., mL/g/min). However, quantification has been limited by errors produced in image acquisition, selection of regions of interest, and data analysis. The goal of this study was to evaluate a newly developed, novel, wavelet-based noise-reduction approach that can objectively extract biologic signals hidden within dynamic PET data. METHODS: Quantification of myocardial perfusion using dynamic PET imaging with 82Rb, H2(15)O, and 13NH3 was selected to evaluate the effects of the wavelet-based noise-reduction protocol. Dynamic PET data were fitted to appropriate mathematic models before and after wavelet-based noise reduction to get flow estimates. Time-activity curves, precision, accuracy, and differentiating capacity derived from the wavelet protocol were compared with those obtained from unmodified data processing. A total of 84 human studies was analyzed, including 43 at rest (18 82Rb scans, 18 H2(15)O scans, and 7 13NH3 scans) and 41 after coronary hyperemia with dipyridamole (17 82Rb scans, 17 H2(15)O scans, and 7 13NH3 scans). RESULTS: For every tracer tested under all conditions, the wavelet method improved the shape of blood and tissue time-activity curves, increased estimate-to-error ratios, and maintained fidelity of flow in regions as small as 0.85 cm3. It also improved the accuracy of flow estimates derived from 82Rb to the level of that achieved with H2(15)O, which was not affected markedly by the wavelet process. In studies of patients with coronary disease, regional heterogeneity of myocardial perfusion was preserved and flow estimates in infarcted regions were differentiated more easily from normal regions. CONCLUSION: The wavelet-based noise-reduction method effectively and objectively extracted tracer time-activity curves from data with low signal-to-noise ratios and improved the accuracy and precision of measurements with all tracer techniques studied. The approach should be generalizable to other image modalities such as functional MRI and CT and, therefore, improve the ability to quantify dynamic physiologic processes.

Absolute quantitation of coronary steal induced by intravenous dipyridamole.

OBJECTIVE: The study was done to determine whether coronary steal (defined as an absolute decrease in perfusion from resting blood flow) is induced by intravenous (IV) dipyridamole in patients with severe coronary artery disease (CAD). BACKGROUND: Myocardial ischemia during coronary vasodilation is usually attributed to coronary steal. However, there is limited data on the absolute magnitude of coronary steal in humans. METHODS: Eighteen patients with multivessel CAD underwent dynamic positron emission tomography (PET) imaging with 13NH3 at rest and after infusion of IV dipyridamole. Eight myocardial sectors were analyzed per short axis slice and myocardial blood flow calculated with a two-compartment model in absolute terms. RESULTS: Coronary steal occurred in 8 of the 18 patients. In the 8 patients with coronary steal, myocardial blood flow decreased from 90 +/- 18 ml/100 g/min at rest to 68 +/- 27 ml/100 g/min following dipyridamole in the segments with steal, and increased from 87 +/- 19 to 138 +/- 16 ml/100 g/min following dipyridamole in the segments without steal. Significant clinical correlates of coronary steal were either ST elevation or the combination of ST depression and angina. CONCLUSIONS: Coronary vasodilation with IV dipyridamole is associated with significant reductions in blood flow to collateral-dependent myocardium consistent with coronary steal in about 45% of patients with severe CAD.

Long-term outcome of patients with intermediate-risk exercise electrocardiograms who do not have myocardial perfusion defects on radionuclide imaging.

BACKGROUND: The appropriate management of patients with intermediate-risk Duke treadmill scores is not established. The purpose of this study was to determine the long-term risk of subsequent cardiovascular events in patients with an intermediate-risk treadmill score who do not have myocardial perfusion defects on radionuclide imaging. METHODS AND RESULTS: The existing databases of the nuclear cardiology laboratories of 4 academic institutions were searched retrospectively. A total of 4649 patients were identified who had intermediate-risk Duke treadmill scores (-10 to 4), normal or near-normal exercise single photon-emission computed tomographic myocardial perfusion images using either thallium-201 or technetium-99m sestamibi, and no previous coronary revascularization. Follow-up was 95% complete. Cardiovascular survival was 99.8% at 1 year, 99.0% at 5 years, and 98.5% at 7 years. Cardiac survival free of myocardial infarction was similarly high at 96.6% at 7 years. Cardiac survival free of myocardial infarction or revascularization was 87.1% at 7 years. Near-normal scans and cardiac enlargement were independent predictors of time to cardiac death. Seven-year cardiac survival was still high at 97.0% in the 357 patients with near-normal scans and normal cardiac size and somewhat lower, at 89.0%, in the 167 patients with cardiac enlargement. CONCLUSIONS: Patients with an intermediate-risk treadmill score but with normal or near-normal exercise myocardial perfusion images and normal cardiac sizes are at low risk for subsequent cardiac death and can be safely managed medically until their symptoms warrant revascularization. The appropriate management of patients with cardiac enlargement will remain a matter of clinical judgment.

Usefulness of positron emission tomography in defining myocardial viability in patients referred for cardiac transplantation.

Positron emission tomography imaging detected evidence of viability in 17 of 33 patients with evidence of infarction only on their thallium scans who were referred for transplant evaluation. Eleven of these 17 underwent revascularization with excellent outcome.

Freehand three-dimensional echocardiography for measurement of left ventricular mass: in vivo anatomic validation using explanted human hearts.

OBJECTIVES: We sought to validate freehand three-dimensional echocardiography for measuring left ventricular mass and to compare its accuracy and variability with those of conventional echocardiographic methods. BACKGROUND: Accurate measurement of left ventricular mass is clinically important as a predictor of morbidity and mortality. Freehand three-dimensional echocardiography eliminates geometric assumptions used by conventional methods, minimizes image positioning errors using a line of intersection display and increases sampling of the ventricle. Preliminary studies have shown it to have high accuracy and low variability. METHODS: Twenty-eight patients awaiting heart transplantation were examined by conventional and freehand three-dimensional echocardiography. Left ventricular mass was determined by the M-mode ("Penn-cube") method, the two-dimensional truncated ellipsoid method and three-dimensional surface reconstruction. The ventricles of 20 explanted hearts were obtained, trimmed and weighed. Echocardiographic mass by each method was compared with true mass by linear regression. Accuracy, bias and interobserver variability were calculated. RESULTS: For three-dimensional echocardiography, the correlation coefficient, standard error of the estimate, root mean square percent error (accuracy), bias and interobserver variability were 0.992, 11.9 g, 4.8%, -4.9 g and 11.5%, respectively. For the two-dimensional truncated ellipsoid method they were 0.905, 38.5 g, 15.6%, 15.4 g and 23.3%. For the M-mode ("Penn-cube") method they were 0.721, 96.9 g, 53.0%, 109.2 g and 19.5%. CONCLUSIONS: Freehand three-dimensional echocardiography for measurement of left ventricular mass has high accuracy and low variability and is superior to conventional methods in hearts of abnormal size and geometry.

Visual estimation of ejection fraction by two-dimensional echocardiography: the learning curve.

Our purpose was to determine the learning curve of visual estimation of ejection fraction (EF) by echocardiography. Sixty consecutive patients, who had clinically indicated echocardiography and radionuclide ventriculography (RVG) within 1 month were selected. Five standard views were reviewed independently by a first-year cardiology fellow, a private cardiologist, and an experienced echocardiographer. Observers were given feedback of the RVG EFs immediately after estimating the EF on each study. To assess the effect of learning, the echocardiographic studies were divided into three groups of 20 and were read successively by each observer. A statistical comparison of the two methods was performed for each group. The correlation between the two techniques for the first group of studies was marginal. There was a significant improvement in the correlation with subsequent groups. The correlation did not change significantly with the last group of studies compared with the second group. In conclusion, visual estimation of EF by two-dimensional echocardiography can be learned, with a learning curve of approximately 20 studies if immediate feed-back is available.

Assessment of cardiac function by three-dimensional echocardiography compared with conventional noninvasive methods.

BACKGROUND: Reliable, serial, noninvasive quantitative estimation of left ventricular ejection fraction is essential for selecting and timing therapeutic interventions in patients with heart disease. Equilibrium radionuclide angiography is widely used for this purpose but has well-recognized limitations. Advantages of echocardiography over equilibrium radionuclide angiography include assessment of wall motion, valvular pathology, and cardiac hemodynamics, in addition to portability, lack of radiation exposure, and substantially lower cost. However, conventional echocardiographic techniques are limited by geometric assumptions, image positioning errors, and use of subjective visual methods. To overcome these limitations, a three-dimensional echocardiographic method was developed. This study compares ejection fraction by three-dimensional echocardiography, quantitative two-dimensional echocardiography, and subjective two-dimensional echocardiographic visual estimation with that by equilibrium radionuclide angiography. METHODS AND RESULTS: Fifty-one unselected patients with suspected heart disease underwent left ventricular ejection fraction determination by equilibrium radionuclide angiography and three-dimensional echocardiography using an interactive line-of-intersection display and a new algorithm, ventricular surface reconstruction, for volume computation. In 44 patients, ejection fractions were also estimated visually by experienced observers from two-dimensional echocardiography and by quantitative two-dimensional echocardiography using an apical biplane summation-of-disks algorithm. An excellent correlation was obtained between three-dimensional echocardiography and equilibrium radionuclide angiography (r = .94 to .97, SEE = 3.64% to 5.35%; limits of agreement, 10.3% to 13.3%) without significant underestimation or overestimation. SEE values and limits of agreement were twofold to threefold lower than corresponding values for all two-dimensional echocardiographic techniques. In addition, interobserver variability was significantly lower for the three-dimensional echocardiographic method (10.2%) than for the apical biplane summation-of-disks method (26.1%) and subjective visual estimation (33.3%). CONCLUSIONS: Determination of ejection fraction by three-dimensional echocardiography yields results comparable to those obtained by equilibrium radionuclide angiography and is substantially superior to all two-dimensional echocardiographic methods. Therefore, three-dimensional echocardiography may be used for accurate serial quantification of left ventricular function as an alternative to equilibrium radionuclide angiography.

Assessment of left ventricular enlargement from planar thallium-201 images.

Although a subjective assessment of left ventricular (LV) size can be made from planar thallium images, the validity of this practice had not been critically assessed. The objective of this study was to determine the accuracy of planar thallium imaging in the assessment of LV size by using two-dimensional guided M-mode echocardiographic measurements as the standard. Consecutive patients (n = 100) who had clinically indicated stress thallium and echocardiography done within a time interval of 1 month were selected. LV size was classified as dilated or normal on immediate and 4-hour-delayed thallium scans by the consensus of two blinded observers. When present, perfusion defects were noted. LV end-diastolic internal diameter (LVIDd) was measured on M-mode images. The mean LVIDd was 5.7 cm in patients with dilated LVs compared with 5.0 cm in those with normal LVs (p < 0.01). By using an LVIDd of 5.6 cm as the upper limit of normal, the sensitivity and specificity of planar thallium imaging for detection of left ventricle enlargement were 87% and 86%, respectively. Corresponding positive and negative predictive accuracies in this population were 65% and 96%, respectively. There was a higher incidence of fixed defects in group 1 (p < 0.01). We conclude that LV enlargement can be easily and reliably determined from routine planar thallium images.