Reduction of the LVEF measured with gSPECT after 1-3 hours after physical exercise in CAD

W. Cholewinski; B. Stefaniak; E. Poniatowicz-Frasunek; A. Tarkowska

doi:10.1055/s-0038-1625196

Nuklearmedizin - NuclearMedicine, Table of Contents

Nuklearmedizin 2004; 43(05): 150-157
DOI: 10.1055/s-0038-1625196

Original Articles

Schattauer GmbH

Reduction of the LVEF measured with gSPECT after 1-3 hours after physical exercise in CAD

Reduktion der mit gSPECT gemessenen LVEF 1-3 Stunden nach Belastung bei KHK

Authors

W. Cholewinski

¹Department of Nuclear Medicine (Head: Prof. Dr. hab. med. Anna Tarkowska), Medical University of Lublin, Poland
B. Stefaniak

¹Department of Nuclear Medicine (Head: Prof. Dr. hab. med. Anna Tarkowska), Medical University of Lublin, Poland
E. Poniatowicz-Frasunek

¹Department of Nuclear Medicine (Head: Prof. Dr. hab. med. Anna Tarkowska), Medical University of Lublin, Poland
A. Tarkowska

¹Department of Nuclear Medicine (Head: Prof. Dr. hab. med. Anna Tarkowska), Medical University of Lublin, Poland

Abstract

Summary:

Aim: It has been shown that exercise may lead to the myocardial stunning with reduction of LVEF, persisting for some time despite recovery of perfusion. The aim of this study was to check whether the post-stress decrease of LVEF lasts as long as 3 h after exercise. Patients, methods: The study was performed in 46 patients with CAD and in 10 normals (NMS). All patients underwent myocardial gSPECT after ^99mTc-tetrofosmin injection at rest and during stress with 2-day protocol. SPECT was started 1h after tracer injection at rest (R) and twice: 1h (S1) and 3hs (S3) after injection at stress. LVEF was calculated by the method of Germano et al. Results: All LVEF values were significantly lower in CAD patients than in the control group. In NMS mean LVEF was at rest similar to those obtained 1 h and 3 h after stress injection (59.0 ± 4.1, 60.0 ± 5.9, 58.0 ± 4.6, respectively; p >0.05). A post-exercise decrease of LVEF was observed in 2 normal patients both at S1 and at S3. In CAD group LVEF values were lower at S1 than at R (50.8 ± 13.6 versus 49.3 ± 12.8; p <0.05) and at S3 were lower than at S1 (49.3 ± 12.8 versus 46.0 ± 12.2;p <0.001). A significant decrease of LVEF was found in 18/46 patients 1 h post stress and in 36/46 3 h post stress. In patients with reversible perfusion decrease, a significant correlation was found between post-exercise deterioration of perfusion and post-exercise LVEF reduction both at S1 (r = 0.744; p <0.02) and at S3 (r = 0.734; p <0.02). Stress induced decrease in LVEF correlated also with severity of perfusion abnormalities. Conclusions: In the majority of patients with CAD physical stress applied for diagnostic purposes results in an impairment of the LV function. A decrease of the LVEF is observed 1 h after exercise, but it increases in frequency and grows stronger during the next 2 h. The post-stress LVEF reduction is related to the severity of perfusion abnormalities. Patients with CAD who underwent diagnostic stress test should remain under observation during several hours after termination of exercise.

Zusammenfassung:

Das Ziel dieser Arbeit war zu prüfen, ob die Verminde-rung der LVAF die 1 Stunde nach der Belastung auftritt, 3 Stunden nach Stress erhalten bleibt. Patienten, Methode: 46 Patienten mit koronarer Herzkrankheit (KHK) und 10 Gesunde (NMS) wurden untersucht. In allen Fällen wurde die Myokard-gSPECT nach ^99mTcTetrofosmin-Injektion in Ruhe und unter Belastung durchgeführt. Die SPECT-Akquisition wurde 1 h nach Injektion in Ruhe und zweimal (1 h, 3 h) nach Injektion unter Belastung gestartet. Die LVAF wurde nach der Methode von Germano et al. berechnet. Ergebnisse: Die von allen drei Untersuchungen gewonnene LVAF-Werte waren bei KHK signifikant niedriger, als bei NMS. In NMS war die mittlere LVAF 1 h nach der Ruheinjektion ähnlich den beiden Werten nach Belastung (59.0 ± 4.1; 60.0 ± 5.9; 58.0 ± 4.6; p >0.05). Die KHK-Patienten zeigten eine Stunde nach dem Stress niedrigere LVAF-Werte als nach Ruheinjektion (50.8 ± 13.6 versus 49.3 ± 12.8; p <0.05). Eine stärker ausgeprägte LVAF-Senkung wurde 3 h nach Belastung gefunden. (49.3 ± 12.8 versus 46.0 ± 12.2; p <0.001). Die Reduktion der LVAF zeigte sich bei 18/46 Patienten 1 h und bei 36/46 Patienten 3 h nach Stress. Bei Patienten mit reversiblen Perfusionsdefekten wurde eine signifikante Korrelation zwischen stressinduzierter Perfusionsverschlechterung und LVAF-Senkung 1 h (r = 0.744; p<0.02) und 3 h (r = 0.734; p <0.02) nach Belastung festgestellt. Stressinduzierte Reduktion der LVAF korrelierte auch mit dem Ausmaß der Perfusionsstörung. Schlussfolgerungen: Belastung, die für die diagnostische Zwecke angewandt wurde, führte bei den meisten KHK-Patienten zu einer Verschlechterung der Herzfunktion. Die Reduktion der LVAF zeigt sich 1 h nach Belastung, verstärkt sich aber und wurde häufiger während der folgenden 2 h. Die AF-Senkung nach Belastung ist mit der Intensität der Perfusionsstörung verbunden. KHKPatienten, die einer Belastung unterzogen werden, sollen danach einige Stunden lang unter Kontrolle stehen.

Key words:

Myocardial stunning - LVEF - gatedSPECT

Schlüsselwörter:

Myokard-Stunning - Stunning - LVEF - gSPECT

Full Text

References

References
1 Altschuld RA. Intracellular calcium regulatory system during ischemia and reperfusion. In: Myocardial ischemia: mechanisms, reperfusion, protection. Karmazyn M. (ed). Basel, Boston, Berlin: Birkhaeuser; 1996: 87-97.
2 Ambrosio G, Betocchi S, Pace L. Prolonged impairment of regional contractile function after resolution of exercise-induced angina. Evidence of myocardial stunning in patients with coronary artery disease. Circulation 1996; 94: 2455-64.
3 Ambrosio G, Tritto I. Clinical manifestations of myocardial stunning. Coron Artery Dis 2001; 12: 357-61.
4 Bavelaar-Croon C, America Y, Atsma D. et al. Comparison of left ventricular function at rest and post-stress in patients with myocardial infarction: Evaluation with gated SPECT. J Nucl Card 2001; 1: 10-8.
5 Berman DS, Germano G. The clinical value of assessing left ventricular function from gated SPECT perfusion studies. Rev Port Cardiol 2000; 19 (Suppl. 01) I31-7.
6 Bestetti A, Scalzi PB, Alessi A. et al. Detection and assessment of myocardial stunning with perfusion tomographic scintigraphy using gated SPECT. Ital Heart J 2000; 1 (Suppl. 06) 790-6.
7 Bestetti A, Di Leo C, Alessi A. et al. Post-stress end-systolic left ventricular dilation: a marker of endocardial post-ischemic stunning. Nucl Med Commun 2001; 22: 685-93.
8 Biedenstein S, Schaefers M, Stegger L. et al. Three-dimensional contour detection of left ventricular myocardium using elastic surfaces. Eur J Nuc Med 1999; 26: 201-7.
9 Braunwald E, Kloner RA. The stunned myocardium: prolonged post-ischemic ventricular dysfunction. Circulation 1982; 66: 1146-9.
10 Cwajg E, Cwajg J, He ZX. et al. Gated myocardial perfusion tomography for the assessment of left ventricular function and volumes: comparison with echocardiography. J Nucl Med 1999; 40: 1857-65.
11 Dakik HA, Alam S. Myocardial stunning induced and detected by adenosine stress perfusion imaging. J Nucl Cardiol 2001; 8: 711-2.
12 De Curzon OP, Ghaleh B, Tissier R. et al. Myocardial stunning in exercise-induced ischemia in dogs: lack of late preconditioning. Am J Physiol Heart Circ Physiol 2001; 280: H302-10.
13 Flamen P, Bossuyt A, Franken PR. Technetium-99m-tetrofosmin in dipyridamole-stress myocardial SPECT imaging: intraindividual comparison with technetium-99m-sestamibi. J Nucl Med 1995; 36: 2009-15.
14 Germano G, Kavanagh PB, Berman DS. An automatic approach to the analysis, quantitation and review of perfusion and function from myocardial perfusion SPECT images. Int J Card Imaging 1997; 13: 337-46.
15 Germano G, Kiat H, Kavanagh PB. et al. Automatic quantification of ejection fraction from gated myocardial perfusion SPECT. J Nucl Med 1995; 36: 2138-47.
16 Hashimoto J, Kubo A, Iwasaki R. Gated single-photon emission tomography imaging protocol to evaluate myocardial stunning after exercise. Eur J Nucl Med 1999; 26: 1541-6.
17 Heiba SI, Santiago J, Mirzaitehrane M. et al. Transient postischemic stunning evaluation by stress gated Tl-201 SPECT myocardial imaging: Effect on systolic left ventricular function. J Nucl Cardiol 2002; 9: 482-90.
18 Hittinger L, Shannon RP, Kohin S. et al. Exercise induced subendocardial dysfunction in dogs with left ventricular hypertrophy. Circ Res 1990; 66: 329-43.
19 Homans DC, Laxson DD, Sublett E. et al. Effect of exercise intensity and duration on regional function during and after exercise-induced ischemia. Circulation 1991; 83: 2029-37.
20 Homans DC, Sublett E, Dai X-Z. et al. Persistence of regional left ventricular dysfunction after exercise-induced myocardial ischaemia. J Clin Invest 1986; 77: 66-73.
21 Jain D, Wackers FJT, Mattera J. et al. Biokinetics of technetium-99m-tetrofosmin: myocar-dial perfusion imaging agent:implication for a one-day imaging protocol. J Nucl Med 1993; 34: 1254-9.
22 Jennings RB, Sommers HM, Herdson PB. et al. Ischaemic injury of myocardium. Ann NY Acad Sci 1969; 156: 61.
23 Johnson LL, Verdesca SA, Aude WY. Postischaemic stunning can affect left ventricular ejection fraction and regional wall motion on post-stress gated sestamibi tomograms. J Am Coll Cardiol 1997; 30: 1641-8.
24 Kloner RA, Allen J, Cox TA. et al. Stunned left ventricular myocardium after exercise tread-mill testing in coronary artery disease. Am J Cardiol 1991; 68: 329-34.
25 Kloner RA, Arimie RB, Kay GL. et al. Evidence for stunned myocardium in humans: a 2001 update. Coron Artery Dis 2001; 12: 349-56.
26 Lee DS, Yeo JS, Chung J-K. et al. Transient prolonged stunning induced by dipyridamole and shown on 1- and 24-hour poststress ^99mTcMIBI gated SPECT. J Nucl Med 2000; 41: 27-35.
27 Monnet X, Ghaleh B, Colin P. et al. Effects of heart rate reduction with ivabradine on exercise-induced myocardial ischemia and stunning. J Pharmacol Exp Ther 2001; 299: 1133-9.
28 Mousa SA, Carroll TR, Morgan RA. Acute effects of commonly used drugs in the cardiac care unit on the myocardial extraction kinetics of 99mTc-Sestamibi. Int J Clin Pharmacol Ther Toxicol 1991; 29: 14-8.
29 Mut F, Beretta M, Vidal I. et al. Identification of myocardial stunning by means of gated perfusion SPECT in patients undergoing ischaemic stress myocardial test. World J Nucl Med 2003; 2: 122-5.
30 Park JL, Lucchesi BR. Mechanisms of myocardial reperfusion injury. Ann Thorac Surg 1999; 68: 1905-12.
31 Paul AK, Hasegawa S, Yoshioka J. Exercise-induced stunning continues for at least one hour: Evaluation with quantitative gated single-photon emission tomography. Eur J Nucl Med 1999; 26: 410-5.
32 Paul AK, Hasegawa S, Yoshioka J. et al. Characteristics of regional myocardial stunning after exercise in gated myocardial SPECT. J Nucl Cardiol 2002; 9: 388-94.
33 Santamore WP, Corin W. The coronary circulation. In: Salmasi AM, Iskandrian AS. (eds). Cardiac output and regional flow in health and disease. Dordrecht (Netherlands): Luwer Academic Publishers; 1993: 411-31.
34 Santiago JF, Heiba SI, Jana S. et al. Transient ischemic stunning of the myocardium in stress thallium-201 gated SPECT myocardial perfusion imaging: segmental analysis of myocardial perfusion, wall motion and wall thickening changes. Eur J Nucl Med Mol Imaging 2002; 29: 979-83.
35 Schneider RM, Weintraub WS, Klein LW. et al. Rate of left ventricular functional recovery by radionuclide angiography after exercise in coronary artery disease. Am J Cardiol 1986; 57: 927-32.
36 Stegger L, Biedenstein S, Schaefers KP. et al. Elastic surface contour detection for the measurement of ejection fraction in myocardial perfusion SPET. Eur J Nucl Med 2001; 28: 48-55.
37 Tarkowska A, Chrapko B, Cholewinski W. et al. LVEF measured by gated SPECT after ^99mTc tetrofosmin injection at peak exercise. Eur J Nucl Med 2000; 27: A968.
38 Tarkowska A, Cholewinski W, Stefaniak B. Evaluation of ^99mTc tetrofosmin myocardial uptake defects during 3hrs after physical stress in patients with CAD. Eur J Nucl Med 2002; 29: A97.
39 Thaulow E, Guth BD, Heusch G. et al. Characteristics of regional myocardial stunning after exercise in dogs with chronic coronary stenosis. Am J Physiol 1989; 257: H113-9.