Complete resolution of focal-on-diffuse myocardial activity pattern on FDG PET-CT by prolonging the dietary preparation protocol in cardiac sarcoidosis.

Patient preparation is crucial for reliable interpretation of cardiac inflammation FDG PET. We share our experience of improved reporting confidence and propose a simple approach of prolonging preparation (from 24 to 48 hours) with the high-fat, no-carbohydrate, and protein-permitted diet followed by fasting in cardiac sarcoidosis in cases with diffuse or focal-on-diffuse myocardial FDG uptake.

Prognostic value of silent myocardial infarction in patients with chronic kidney disease after kidney transplantation.

We have shown that silent myocardial infarction (SMI) on 12-lead ECG is associated with increased cardiovascular disease (CVD) risk in patients awaiting renal transplantation (RT). In this study, we evaluated the prevalence of SMI in patients undergoing RT and their prognostic value after RT. MI was determined by automated analysis of ECG. SMI was defined as ECG evidence of MI without a history of clinical MI (CMI). The primary outcome was a composite of CVD death, non-fatal MI and coronary revascularization after RT. Of the 1189 patients who underwent RT, a 12-lead ECG was available in >99%. Of the entire cohort 6% had a history of CMI while 7% had SMI by ECG. During a median follow-up of 4.6 years, 147 (12%) experienced the primary outcome (8% CVD death, 4% MI, 4% coronary revascularization) and 12% died. Both SMI and CMI were associated with an increased risk of CVD events and all-cause deaths. In a multivariable adjusted Cox-regression model, both SMI (adjusted hazard ratio 2.03 [1.25-3.30], p = .004) and CMI (2.15 [1.24-3.74], p = .007) were independently associated with the primary outcome. SMI detected by ECG prior to RT is associated with increased risk of CVD events after RT.

Evolution of symptoms in patients with stable angina after normal regadenoson myocardial perfusion imaging: The Radionuclide Imaging and Symptomatic Evolution study (RISE).

BACKGROUND: Assessment of quality of life in patients with stable angina and normal gated single-photon emission computed tomography myocardial perfusion imaging (MPI) remains undefined. Symptom evolution in response to imaging findings has important implications on further diagnostic testing and therapeutic interventions. METHODS: Prospective cohort study was conducted at the University of Alabama at Birmingham enrolling 87 adult participants with stable chest pain from the emergency room, hospital setting, and outpatient clinics. Patients underwent MPI with technetium-99m Sestamibi and had a normal study. Participants filled out Seattle Angina Questionnaires initially and at 3-month follow-up. RESULTS: Among the 87 participants (60 ± 12 years; 40% African American, 70% women, 29% diabetes), the mean score increased by an absolute value of 14.2 [95% CI 10.4-18.7, P < .001] in physical limitation, 23.2 [95% CI 17.1-29.4, P < .001] in angina stability, 10.9 [95% CI 7.6-14.1, P < .001] in angina frequency, and 20.6 [95% CI 16.5-24.7, P < .001] in disease perception. There was no significant change in the mean score of treatment satisfaction [- 1.4, 95% CI - 4.7 to 1.8, P = .38]. At 3-month follow-up, 28 of 87 participants (32%) were angina free. CONCLUSIONS: Patients with stable chest pain and normal MPI experience significant improvement in functional status, quality of life, and disease perception in the short term.

Effect of left ventricular mechanical dyssynchrony assessed pre-renal transplantation on cardiovascular death post transplantation.

BACKGROUND: SPECT myocardial perfusion imaging (MPI) provides an assessment of LV mechanical dyssynchrony (LVMD) which correlates with CVD outcomes in diverse populations including those awaiting renal transplant (RT). The current study examines the association of LVMD on pre-transplant MPI with long-term CVD mortality post RT. METHODS: We identified consecutive patients who underwent RT at the University of Alabama at Birmingham between 2008 and 2012 from our prospectively collected database. 675 patients in the database underwent MPI and had images amenable for phase analysis. A blinded investigator retrieved the studies and derived LVMD indices including histogram bandwidth (BW), standard deviation (SD), phase peak, phase skewness, and phase kurtosis. The primary outcome was CVD death after RT. RESULTS: The study cohort had a median age of 54 years, 56% were men, 43% had diabetes, and 7% had prior myocardial infarction. Patients were on dialysis for a median of 3.4 years prior to RT and 34% received living donor transplants. During a median follow-up time after RT of 4.7 years (IQR 3.5 to 6.3 years) 59 patients (9%) succumbed to CVD death. Patients with wider BW, wider SD, lower skewness, and lower kurtosis had an increased risk of CVD death. On multivariate adjustment, BW and skewness remained as independent predictors of CVD deaths. CONCLUSIONS: LVMD by phase analysis of gated SPECT MPI is associated with increased risk of CVD death after RT. This association is independent of demographics, comorbidities, and traditional findings on MPI and added incremental prognostic information. Assessment of LVMD should be considered for risk stratification in these patients.

The prognostic value of myocardial perfusion imaging in patients with type 2 myocardial infarction.

OBJECTIVES: The aim of this retrospective study is to evaluate the prognostic role of myocardial perfusion imaging (MPI) in patients with type 2 myocardial infarction (T2MI). BACKGROUND: T2MI is an increasingly common diagnosis in clinical practice. The management of this condition is controversial and the prognostic value of MPI has not been established in this setting. METHODS: We retrospectively studied T2MI patients who underwent vasodilator gated MPI within 90 days of T2MI at a single tertiary care institution in 2013. Abnormal myocardial perfusion was defined as the perfusion defect involving ≥ 5% of left ventricular (LV) myocardium. Abnormal LV ejection fraction (EF) was defined as < 50% by gated images. The primary outcome was a composite of death, myocardial infarction (other than index event) or coronary revascularization (CR). RESULTS: There were 234 patients (62 ± 14 years, 57% men) with T2MI (peak troponin 0.2 ng/ml, interquartile 0.1-1.4), of whom 136 (58%) had an abnormal MPI. During a median follow-up of 20 months, 155 patients (66%) had the primary outcome (39% death, 42% MI, 5% CR). An abnormal MPI was associated with an increased risk of the primary outcome with a hazard ratio of 1.56, 95%CI (1.12-2.18, P = .008) that remained statistically significant after multivariate adjustment (1.45, 95%CI (1.02-2.06, P = .04))). CONCLUSIONS: Patients with T2MI are at high risk for death or cardiac events in the intermediate term. More than one-half of patients with T2MI have an abnormal MPI and this is associated with the increased risk of cardiac events during follow-up. Risk stratification with MPI after T2MI may identify patients who would benefit from aggressive risk reduction.

Detection and quantitation of right ventricular reversible perfusion defects by stress SPECT myocardial perfusion imaging: A proof-of-principle study.

BACKGROUND: In patients with right dominant coronary circulation, the right ventricular (RV) myocardium and the inferior region of the left ventricular (LV) myocardium share a common source of blood flow. We hypothesized that stress/rest SPECT myocardial perfusion imaging (MPI) could detect reversible perfusion defects in the RV in some patients with LV inferior wall perfusion abnormalities. MATERIAL AND METHODS: We identified 2 groups of patients with LV inferior wall perfusion defects (with or without defects in other regions of LV myocardium) from our database. Patients in group 1 (n = 17) had reversible perfusion defects in the RV free wall by visual analysis, while patients in group 2 (n = 17) did not. The images were processed with filtered back projection and, separately, with iterative reconstruction. The images were then re-processed using an automated quantitative software that is specifically designed to include the RV in the region of interest. RESULTS: There were 76% men in group 1 and 94% in group 2 (P <0.05). The mean age was 65±20 in group 1 vs. 63±18 years in group 2 (P < 0.05). The stress type was exercise in 30% in group 1 and 35% in group 2, with the remaining patients studied with pharmacological stress testing (P = NS). The presence of RV reversible perfusion defects using filtered back projection was more evident in 13 patients (75%), while it was better seen with iterative reconstruction in 4 patients (25%). By automated analysis, the RV reversible perfusion defect size was 19 ± 14% of RV myocardium. CONCLUSION: This proof-of-principle study demonstrates that reversible RV perfusion defects suggestive of ischemia can be detected by SPECT myocardial perfusion imaging in some patients with LV inferior ischemia by visual analysis and can be quantitated by automated programs. Further studies on the diagnostic and prognostic relevance of assessing RV ischemia on SPECT MPI are needed.

Prognostic value of transient ischemic dilation with regadenoson myocardial perfusion imaging.

BACKGROUND: Transient ischemic dilation (TID) of the left ventricle seen on myocardial perfusion imaging (MPI) is sometimes used as a marker of severe coronary artery disease. The prognostic value of TID obtained using regadenoson, a selective adenosine A2A receptor agonist, as a stress agent for MPI has not been studied. METHODS: TID ratio was measured using an automated software program on consecutive patients with normal and abnormal perfusion pattern on regadenoson MPI at a single institution. An abnormal TID was defined as greater than 1.33. The primary outcome was a composite of cardiac death, non-fatal myocardial infarction (MI), and late coronary revascularization (CR, >90 days after MPI). RESULTS: The study population consisted of 887 patients (62 ± 12 years, 66% male, 48% diabetes, 46% prior CR, 75% with abnormal perfusion pattern, left ventricular ejection fraction-LVEF 55 ± 6%). An abnormal TID was present in 51 (6%) patients. Baseline characteristics were not different based on the presence or absence of TID. Early CR (≤90 days) was performed in 11 (22%) patients with vs 92 (11%) patients without TID (P = .04). During a mean follow-up of 29 ± 19 months, the primary outcome occurred in 271 (31%) patients (22% cardiac death, 6% MI, 9% late CR). TID was associated with increased risk of the primary outcome (log-rank P = .017), an association largely driven by late CR. In a Cox proportional model adjusted for multiple variables including perfusion defect size (PDS) and LVEF, the hazard ratio for TID was 1.92 (95% CI 1.20-3.08, P = .007). In the subset of patients with normal perfusion pattern, there was no association between TID and outcomes. CONCLUSIONS: TID on regadenoson MPI carries important prognostic information that is independent from PDS and LVEF, but this association is restricted to patients with abnormal perfusion on imaging.

Prognostic value of silent myocardial infarction in patients with chronic kidney disease being evaluated for kidney transplantation.

BACKGROUND: Patients with advanced chronic kidney disease (CKD) have increased risk of myocardial infarction (MI). Silent MIs (SMIs) are common in CKD patients and carry increased mortality risk. The prevalence and prognostic value of SMI in advanced CKD has not been evaluated. METHODS: We identified consecutive patients with advanced CKD who were evaluated for renal transplantation at the University of Alabama at Birmingham between June 2004 and January 2006. Clinical MI (CMI) was determined by review of medical records. SMI was defined as ECG evidence of MI without clinical history of MI. The primary end-point was a composite of death, MI, or coronary revascularization censored at time of renal transplantation. RESULTS: The cohort included 1007 patients with advanced CKD aged 48±12years (58% men, 43% diabetes, 75% on dialysis). The prevalence of SMI and CMI was 10.7% and 6.7%, respectively. The only independent predictor of SMI was older age (odds ratio for age ≥50yrs. 2.32, p<0.001). During a median follow-up of 28months, 376 (37%) patients experienced the primary outcome (33% death, 2% MI, 5% coronary revascularization). In a multivariable adjusted Cox-regression model, both SMI (adjusted HR 1.58, [1.13-2.20], p=0.007) and CMI (adjusted HR 1.67 [1.15-2.43], p=0.007) were independently associated with the primary outcome. Further, both SMI (HR 2.37 [1.15-4.88], p=0.02) and CMI (HR 4.02 [1.80-8.98], p=0.001) were associated with increased risk after renal transplantation. CONCLUSIONS: SMI is more common than CMI in patients with advanced CKD. Both SMI and CMI are associated with increased risk of future cardiovascular events.