BACKGROUND:Evaluation of tolerability, safety, and prognostic implications of adenosine stress myocardial perfusion imaging (MPI) in octogenarians. METHODS:370 octogenarians (49% known coronary artery disease) were studied. Hemodynamic response, MPI-related data, and rest-left ventricular ejection fraction (LVEF) based on echocardiography were registered per patient, and prospective follow-up was performed to document all-cause death (ACD), cardiac death (CD), myocardial infarction (MI), and late revascularization. RESULTS:No deaths or MIs were observed during adenosine infusion or the short-term post-infusion period. 86% of patients were able to tolerate a 6-minute infusion. All side effects terminated spontaneously after infusion cessation, except for one case of pulmonary oedema. After 9.3 years, there were 124 ACDs, 62 CDs, 16 MIs, and 35 revascularizations. Differences between survival curves of summed stress score (SSS)-based risk groups were significant for all end points (P < .001). SSS and LVEF were independent predictors of all end points (P ≤ .01) and lung uptake of cardiac end points. ΔHR <10 bpm (OR = 1.78, P = .004) and inability to increase HR by >10 bpm and decrease systolic blood pressure by >10 mmHg (OR = 2, P = .02) during adenosine infusion were independent predictors of ACD and CD, respectively. Hemodynamic response variables, SSS, and lung uptake provided incremental prognostic value over pre-test data for ACD and CD. CONCLUSIONS:In octogenarians, adenosine stress MPI is well tolerated and provides effective long-term risk stratification.

To evaluate differences in side-effects and hemodynamic response between men and women undergoing regadenoson-stress SPECT myocardial perfusion imaging (MPI). The initial population of the study included 858 consecutive patients who underwent regadenoson-stress MPI at our institution. These patients underwent prospective assessment and classification of regadenoson-induced side-effects in six categories and recording of heart rate (HR) and blood pressure (BP) before and after regadenoson administration. From this initial population, after adjustment with 1:1 propensity matching using gender as the dependent variable and age, BMI, diabetes mellitus, hypertension, smoking, presence of coronary artery disease, LVEF, baseline systolic and diastolic blood pressure (BP) and HR, on-going use of cardio-active medications during test, and abnormal MPI scan as independent variables, a population of 279 pairs of opposite gender was formed and studied. Compared with men, women had a significantly higher rate of any side-effect (71% vs. 58%, p = 0.002), chest pain (23% vs. 12%, p < 0.001), gastrointestinal discomfort (20% vs. 12%, p = 0.01), dizziness (12% vs. 5%, p = 0.002), and headache (20% vs. 13%, p = 0.03) and similar rates of dyspnea and other side-effects. Women demonstrated a higher median HR-response compared with men (41% (− 8, 127) vs. 34% (− 5, 106), p = 0.001) while men demonstrated a lower median systolic BP response (− 3% (− 27, 48) vs. 0% (− 36, 68), p = 0.02) compared with women. Gender is independently associated with a differential response to regadenoson with regard to overall side-effects and HR-response. These observations have the potential of important management and prognostic implications respectively.

Background: Myocardial viability (VIA) prevalence in post myocardial infarction (MI) patients (pts) in association with angina (ANG) or not has not been prospectively evaluated.Methods and Findings: Fifty-five post-MI pts with reduced ejection fraction (EF≤40%) underwent stress thallium-201 scintigraphy (Tl-201) viability (VIA) evaluation.ANG at exercise-treadmill-test (ETT) (Borg scale) and at everyday-life (Canadian Cardiovascular Society -CCS) classification was recorded.Groups VIA (29 pts -53%) vs non-VIA respectively had similar EF (31 ± 7)% vs (33 ± 8)% (NS), higher diseased vessels number 2.8 ± 1.6 vs 1.9 ± 1.3 (p=0.02),CCS 1.7 ± 0.8 vs 1.3 ± 0.6 (p<0.05),CCS≥2 71% vs 41% (p<0.03).Five pts from each group reported ETT ANG (17% vs 21% -NS), with Borg scale 7.7 ± 3.0 vs 7.2 ± 2.4 (NS).CCS≥2 was associated with greater 201 Tl reversibility indices within stress defect (p<0.04) or total myocardial mass reversibility (p<0.02).Binary logistics analysis associated VIA positively with number of diseased vessels and negatively with smoking, while CCS≥2 ANG positively with number of diseased vessels.The main limitation is the relatively small number of pts.Conclusions: Viability, while not significantly correlated to ETT angina, was positively associated only with more frequent everyday-life (CCS) angina.Clinically, in ischemic cardiomyopathy VIA evaluation is indicated, regardless of ANG.

Evaluation of the long-term prognostic value of myocardial perfusion imaging (MPI) in octogenarians.

We attempted to validate the performance of a fast myocardial perfusion imaging (MPI) protocol in diagnostically challenging patients.

To test, if in octogenarians, treadmill exercise with myocardial perfusion imaging (exercise-MPI) can risk stratify for large artery or chronic CAD-related ischemic stroke (LACCIS).

Although the use of myocardial perfusion imaging (MPI) for prognostic purposes in general population is well understood, its role in very elderly patients is not extensively studied.

Objectives/background: Although Duke treadmill score (DTS) is the most widely used risk stratification method in younger patients undergoing exercise treadmill test (ETT) its specific value in the elderly is not established.Methods: 137 patients aged >= 80 years who underwent ETT myocardial perfusion imaging (MPI) were studied. DTS and MPI (including summed stress scores, SSS) related data were registered per patient and follow up was performed to document cardiac death (CD), myocardial infarction (MI) and late (>3 months) revascularization (LR). Kaplan Meir and Cox regression survival analysis were employed to determine the prognostic value of DTS in relation to MPI data for these endpoints.Results: After a median follow up duration of 6.7 years 28 deaths, 7 CDs, 4 non fatal MIs and 12 LRs were observed. Incidence rates of CD/MI were significantly different only between low and high risk SSS categories (p = 0.044). Risk groups by DTS had no significant differences in survival free of CD/MI (p = 0.743) in contrast to risk groups according to SSS (p = 0.026), while both DTS and SSS based risk groups had significantly different survival free of CD/MI or LR. SSS was a significant univariate predictor of both CD/MI (HR 1.088, p = 0.019) and CD/MI or LR (HR 1.095, p < 0.001), but DTS only of the latter endpoint (HR 0.909, p = 0.003).Conclusions: In octogenarians DTS was found to be a significant predictor of the LR related endpoint but not of the hard endpoint of CD/MI, in contrast to SSS which was a powerful predictor of both soft and hard cardiac endpoints. (C) 2014 Elsevier Ireland Ltd. All rights reserved.

The precise localization of bone marrow stem cells (SCs) into the necrotic tissue after intracoronary infusion (ICI) may be important for the therapeutic outcome. This study aims to examine the correlation between Tl-201 and Tc-99m-hexa-methyl-propylene-amine-oxime (HMPAO) images.

Autonomic Disorders in Brugada Syndrome. Introduction: The aim of this study was to examine autonomic disorders in patients with Brugada syndrome by performing a cardiac sympathetic innervation evaluation, a head‐up tilt‐test (HUT) and heart rate variability (HRV) analysis. Methods and Results: We enrolled 20 patients with Brugada syndrome (mean age 42.5 ± 8.8 years), 9 with spontaneous and 11 with an induced type 1 electrocardiogram (ECG) in the setting of symptoms and 20 age‐matched controls. All subjects underwent a HUT with parallel measurements of plasma catecholamines and cortisol, a 123I‐metaiodobenzylguanidine single photon emission tomography, and HRV evaluation. Ten control subjects participated in the innervation portion of the study. The tilt‐test with clomipramine challenge was positive in 15 of 20 (75%) patients (7 spontaneous, 8 induced) and in 1 in controls (P < 0.01). A sympathoadrenal imbalance was shown in positive tests. The pattern of innervation in all groups was heterogenic and similar to controls with a trend towards lower measurements in patients with a spontaneous type 1 ECG and a positive HUT. HRV analysis did not reveal any significant differences during day and night. Four patients (20%) had sustained ventricular arrhythmias during a follow‐up of 31.1 ± 8.6 months, but no correlations with innervation or response to tilting were found. Conclusion: A high susceptibility to vasovagal syncope was observed in patients with Brugada syndrome, which could be disease‐related symptoms. Conversely, sympathetic innervation was observed to follow a physiological, heterogenic pattern; however, these factors did not have prognostic value for life‐threatening arrhythmias. (J Cardiovasc Electrophysiol, Vol. pp. 773‐780, July 2010)

Objectives: We investigated whether myocardial perfusion imaging (MPI) can demonstrate the effect of classical preconditioning.Methods: 21 patients with documented coronary artery disease (stenosis >= 70%) underwent two exercise stress tests (EST) with concomitant MPI, using TL-201 for the first and tetrofosmin-Tc-99m for the second. A third MPI was performed at rest, using Tc-99m. Total defect score was derived by summing tracer uptake in a 17 segments left ventricle model, graded on a 5-point scale. Tomographic images were also analyzed quantitatively, to derive the total defect size.Results: Maximum ST depression did not differ significantly between the two EST (2.2 +/- 1 vs 2.2 +/- 1mm, p = NS), however in the second EST longer times for onset of ischemic changes (228 +/- 94 vs 265 +/- 103 s, p = 0.01) and appearance of angina (282 +/- 153 vs 328 +/- 177 s, p = 0.04) were observed. Exercise perfusion abnormalities were significantly lower in the second MPI, in terms of both total defect score (19.2 +/- 11.5 vs 10 +/- 10.4, p < 0.0001) and total defect size (28.3 +/- 16.9 vs 13.8 +/- 15.8, p < 0.0001).Conclusion: Significant improvement in perfusion pattern was demonstrated in the second MPI, accompanied by delayed appearance of ischemic manifestations. The improvement in myocardial perfusion extends far beyond the changes that can be attributed to differences in myocardial uptake between tracers, reflecting the effect of classical preconditioning. (C) 2009 Elsevier Ireland Ltd. All rights reserved.

Central issues in intracoronary infusion (ICI) of bone marrow (BM)‐cells to damaged myocardium for improving cardiac function are the cell number that is feasible and safe to be administrated as well as the retention of cells in the target area. Our study addressed these issues in eight patients with chronic ischemic cardiomyopathy undergoing ICI of selected BM‐progenitors. We could immunomagnetically isolate 0.8 ± 0.32 × 107 CD133+ cells and 0.75 ± 0.24 × 107 CD133−CD34+ cells from 310 ± 40 ml BM. After labeling these cells with 99mTc‐hexamethylpropylenamineoxime, they were infused into the infarct‐related artery without any complication. Scintigraphic images 1 (eight patients) and 24 hours (four patients) after ICI revealed an uptake of 9.2% ± 3.6 and 6.8% ± 2.4 of the total infused radioactivity in the infarcted area of the heart, respectively; the remaining activity was distributed mainly to liver and spleen. We conclude that through ICI of CD133+ and CD133−CD34+ BM‐progenitors a significant number of them are preferentially attracted to and retained in the chronic ischemic myocardium.

We investigated the relation between R wave amplitude (RWA) and ST depression as well as the presence and extent of reversible ischemia in thallium-201 scanning in patients with known coronary artery disease (CAD) and found that RWA both at rest and during exercise testing (ET) correlates with the magnitude of ST depression in the same leads. Greater ST changes appear on leads with highest RWA. Thus lead selection strongly influences interpretation of ECG ischemic changes during ET in patients with CAD. An electrocardiographic result negative for ischemia in patients with low RWA should prompt the alternative use of echocardiography and scintigraphy.