Value of metabolic imaging with positron emission tomography for evaluating prognosis in patients with coronary artery disease and left ventricular dysfunction

doi:10.1016/0002-9149(94)90327-1

The American Journal of Cardiology

Volume 73, Issue 8, 15 March 1994, Pages 527-533

https://doi.org/10.1016/0002-9149(94)90327-1 Get rights and content

Abstract

Patients with coronary artery disease (CAD) and severe left ventricular (LV) dysfunction have a high but variable annual mortality and some may benefit from myocardial revascularization. This study aimed to evaluate the prognostic value of positron emission tomography (PET), and its interrelation with the choice of medical therapy or revascularization for predicting survival and improvement in symptoms of heart failure in patients with CAD and LV dysfunction. Ninety-three consecutive patients with angiographic CAD and a mean LV ejection fraction of 0.25 who underwent cardiac PET studies for assessment of hypoperfused yet viable myocardium (“mismatch pattern”) using N-13 ammonia and 18-F deoxyglucose were followed up for an average of 13.6 months. Fifty patients underwent medical treatment and 43 underwent revascularization. The Cox model analysis showed that the extent of mismatch had a negative effect (p = 0.02), whereas revascularization had a positive effect on survival (p = 0.04). The annual survival probability of patients with mismatch receiving medical therapy was lower than of those without mismatch (50 vs 92%, p = 0.007). Patients with mismatch who underwent revascularization had a higher survival rate than those treated medically (88 vs 50%, p = 0.03). The presence of mismatch also predicted improvement in heart failure symptoms after revascularization (p < 0.001). These results suggest that the presence of mismatch in patients with CAD and severe LV dysfunction is associated with poor annual survival with medical therapy. Revascularization in patients with PET mismatch appears to be associated with improved survival and heart failure symptoms.

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Citation Excerpt :
Both myocardial infarction and myocardial hibernation can lead to impaired diastolic and systolic function. It is estimated that up to 50% of patients with impaired systolic function and coronary artery disease have hibernating myocardium and revascularization can improve cardiac function in many cases.41 For patients with New York Heart Association Class III or IV congestive heart failure, 5-year mortality is 50% and patients with a prolonged QRS duration have higher mortality near 70%.42
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Coronary artery disease (CAD) is associated with high morbidity and mortality. In patients with ischemic heart failure, revascularization can lead to left ventricular (LV) function recovery and improved survival. Viability imaging aims at identifying patients in whom the benefits of revascularization outweigh the risks. As a marker of glucose metabolism, 18F-fluorodeoxyglucose (18F-FDG) can identify hibernating myocardium. Viability imaging with 18F-FDG is one of the most sensitive imaging techniques for the detection of hibernating myocardium. In this article, the physiopathology of myocardial hibernation will be reviewed and the evidence supporting the use of viability imaging, with emphasis on 18F-FDG imaging technique and preparation, will be reviewed.
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Non-invasive assessment of ischemic heart disease remains a challenging task, even with a large armory of diagnostic modalities. Positron emission tomography (PET) is an advanced radionuclide technique that has been available for decades. Originally used as a research tool that contributed to advances in the understanding of cardiovascular pathophysiology, it is now becoming established in clinical practice and is increasingly used in the diagnosis and risk stratification of patients with ischemic heart disease. PET myocardial perfusion imaging has a mean sensitivity and specificity of around 90% for the detection of angiographically significant coronary artery disease, and is also highly accurate for assessing the prognosis of patients with ischemic heart disease. Depending on the radiotracer used, it can provide information not only on myocardial perfusion but also on myocardial metabolism, which is essential for viability assessment. The potential of this imaging technique has been further increased with the introduction of hybrid scanners, which combine PET with computed tomography or cardiac magnetic resonance imaging, offering integrated morphological and functional information and hence comprehensive assessment of the effects of atherosclerosis on the myocardium. The scope of this review is to summarize the role of PET in ischemic heart disease.
A multiplicidade de técnicas de diagnóstico existentes, para avaliação da doença cardíaca isquémica, pode representar um desafio na escolha da mais adequada se não forem conhecidas as características de cada uma, nomeadamente, potencialidades, disponibilidade, riscos inerentes e custos. A tomografia de emissão de positrões (PET) é uma técnica de imagem com várias décadas de evolução. Usada inicialmente no campo da investigação, contribuiu para avanços significativos na compreensão da fisiopatolologia cardiovascular. Atualmente, tem um papel cada vez mais relevante no diagnóstico e estratificação de risco da doença cardíaca isquémica. A imagem de perfusão miocárdica por PET tem uma especificidade e sensibilidade médias de 90% para a deteção de doença coronária arterial significativa. Dependendo do radiofármaco escolhido, a informação poderá versar sobre a perfusão miocárdica mas também sobre o seu metabolismo, essencial, na apreciação da viabilidade. O potencial desta técnica de imagem aumentou com a introdução das câmaras híbridas que a combinam com a tomografia computorizada ou com a ressonância magnética cardíaca. Estas integram informação morfológica e funcional, fornecendo uma avaliação completa das consequências da aterosclerose no miocárdio. Com esta revisão pretendeu dar-se uma panorâmica da aplicação da PET no âmbito da doença cardíaca isquémica.
Evaluation of myocardial viability by Nuclear Medicine
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La viabilidad miocárdica es un concepto originado en la observación de la mejoría de la función ventricular posterior a la revascularización miocárdica. Su identificación no implica necesariamente la recuperación funcional después de la intervención. Puede ser evaluada mediante varios métodos no invasivos de imagen cardiaca que aportan información complementaria haciendo de su abordaje un método multimodal. Las modalidades de imagen disponibles se seleccionarán de acuerdo con la información requerida para el manejo clínico. Los métodos de Medicina nuclear proveen información acerca de la anatomía, fisiología y perfusión miocárdica, identificando lesiones coronarias funcionalmente significativas, segmentos viables y función sistólica global y regional ventricular izquierda. La perfusión miocárdica por tomografía computarizada por emisión de fotón único, SPECT-MPI gatillado, cuenta con evidencia de un adecuado rendimiento operativo y costoefectivo que permite evaluar de manera apropiada la presencia de viabilidad. La tomografía por emisión de positrones –PET- permite evaluar viabilidad, enfermedad microvascular coronaria, enfermedad coronaria sin obstrucción epicárdica significativa, isquemia subendocárdica e insuficiencia cardiaca. La decisión de revascularización es multifactorial e individualizada, en cuyo caso la determinación de viabilidad es uno de los factores de análisis.
Myocardial viability is a concept arising from the observation of the improvement in ventricular function after myocardial revascularisation. Its identification does not necessarily imply functional recovery after the intervention. It can be evaluated by several non-invasive cardiac imaging methods that provide complimentary information, making its approach a multimodal method. The imaging modes available are selected depending on the information required for clinical management. The Nuclear Medicine methods provide information on the anatomy, myocardial physiology and perfusion, identifying functionally significant coronary lesions, viable segments, global systolic and regional left ventricular function. Gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), has shown to be a suitable and cost-effective tool to effectively evaluated viability. Positron emission tomography (PET) can evaluate viability, coronary microvascular disease, coronary disease without significant epicardial obstruction, subendocardial ischaemia, and heart failure. The decision to revascularise depends on many factors and is individualised, in which case viability is one of the analysis factors.
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N-Terminal Pro B-Type Natriuretic Peptide and High-Sensitivity Cardiac Troponin T Levels Are Related to the Extent of Hibernating Myocardium in Patients With Ischemic Heart Failure
2017, Canadian Journal of Cardiology
Increased N-terminal pro b-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) can identify patients with heart failure (HF) who are at increased risk of cardiac events. The relationship of these biomarkers to the extent of hibernating myocardium and scar has not been previously characterized in patients with ischemic left ventricular dysfunction and HF.
Patients with ischemic HF meeting recruitment criteria and undergoing perfusion and fluorodeoxyglucose–positron emission tomography to define myocardial hibernation and scar were included in the study. A total of 39 patients (mean age 67 ± 8 years) with New York Heart Association class II-IV HF and ischemic cardiomyopathy (ejection fraction [EF], 27.9% ± 8.5%) were enrolled in the study.
Serum NT-proBNP and hs-cTnT levels were elevated in patients with ≥ 10% hibernating myocardium compared with those with < 10% (NT-pro-BNP, 7419.10 ± 7169.5 pg/mL vs 2894.6 ± 2967.4 pg/mL; hs-cTnT, 789.3 ± 1835.3 pg/mL vs 44.8 ± 78.9 pg/mL; P < 0.05). The overall receiver operating characteristic under the curve value for NT-proBNP and hs-cTnT to predict hibernating myocardium was 0.76 and 0.78, respectively (P < 0.05). The NT-proBNP (P = 0.02) and hs-cTnT (P < 0.0001) levels also correlated with hibernation, particularly in patients with ≥ 10% scar, independent of EF, age, and estimated glomerular filtration rate. No differences were noted in biomarker levels for patients with vs those without ≥ 10% scar.
NT-proBNP and hs-cTnT levels are elevated in patients with ischemic HF hibernation and are correlated with the degree of hibernation but not with the presence or extent of scar. Taken together, these data support the novel concept that NT-proBNP and hs-cTnT release in patients with ischemic HF reflects the presence and extent of hibernating myocardium.
L’augmentation du propeptide natriurétique de type B N-terminale (NT-proBNP) et de la troponine T cardiaque à haute sensibilité (TnTc-hs) permet de repérer les patients atteints d’insuffisance cardiaque (IC) qui sont exposés à un risque accru d’événements cardiaques. La relation de ces biomarqueurs avec l’ampleur de l’hibernation et des cicatrices myocardiques n’a pas encore été définie chez les patients atteints d’une dysfonction ventriculaire gauche et d’une IC d’origine ischémique.
Les patients atteints d’une IC d’origine ischémique qui répondaient aux critères de recrutement et qui subissaient une perfusion et une tomographie par émission de positons au fluorodésoxyglucose pour définir l’hibernation et les cicatrices myocardiques ont été inclus dans l’étude. Un total de 39 patients (âge moyen de 67 ± 8 ans) atteints d’une IC et d’une cardiomyopathie d’origine ischémique de classe II à IV de la New York Heart Association (fraction d’éjection [FE], 27,9 % ± 8,5 %) ont été inscrits à l’étude.
Les concentrations sériques de NT-proBNP et de TnTc-hs étaient élevées chez les patients qui présentaient une hibernation myocardique ≥ 10 % comparativement à ceux qui présentaient une hibernation myocardique < 10 % (NT-proBNP, 7419,10 ± 7169,5 pg/ml vs 2894,6 ± 2967,4 pg/ml ; TnTc-hs, 789,3 ± 1835,3 pg/ml vs 44,8 ± 78,9 pg/ml ; P < 0,05). La valeur globale de l’aire sous la courbe ROC (Receiver Operating Characteristic) du NT-proBNP et de la TnTc-hs pour prédire l’hibernation myocardique était respectivement de 0,76 et de 0,78 (P < 0,05). Les concentrations de NT-proBNP (P = 0,02) et de TnTc-hs (P < 0,0001) corrélaient aussi avec l’hibernation, particulièrement chez les patients ayant des cicatrices ≥ 10 %, indépendamment de la FE, de l’âge et de l’estimation des débits de filtration glomérulaire. On ne notait aucune différence dans les concentrations des biomarqueurs chez les patients ayant des cicatrices ≥ 10 % par rapport à ceux n’ayant pas de cicatrices ≥ 10 %.
Les concentrations de NT-proBNP et de TnTc-hs étaient élevées chez les patients ayant une hibernation d’IC d’origine ischémique et corrélaient au degré d’hibernation, mais non avec la présence ou l’ampleur des cicatrices. Ensemble, ces données appuient le nouveau concept selon lequel la libération de NT-proBNP et de TnTc-hs chez les patients atteints d’IC d’origine ischémique reflète la présence et l’ampleur de l’hibernation myocardique.

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^☆: This study was supported in part by the Director of the Office of Energy Research, Office of Health and Environmental Research, Washington, D.C.; and Research Grants HL-29845 and HL 02022-05 from the National Institutes of Health, Bethesda, Maryland.

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Value of metabolic imaging with positron emission tomography for evaluating prognosis in patients with coronary artery disease and left ventricular dysfunction☆

Abstract

Am J Cardiol

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J Am Coll Cardiol

Am Heart J

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J Am Coll Cardiol

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Ann Thorac Surg

The natural history of congestive heart failure: the Framingham study

N Engl J Med