Coronary artery disease
Identification of severe and extensive coronary artery disease by postexercise regional wall motion abnormalities in Tc-99m sestamibi gated single-photon emission computed tomography

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Abstract

Postexercise wall motion abnormality (WMA) in patients with normal resting myocardial perfusion may represent prolonged postischemic stunning, and may be related to the presence of severe angiographic coronary artery disease (CAD). This study assesses the diagnostic value of postexercise WMA by technetium-99m (Tc-99m) sestamibi gated single-photon emission computed tomography (SPECT) in patients with normal resting perfusion. Ninety-nine patients underwent exercise gated Tc-99m sestamibi/resting thallium-201 SPECT and coronary angiography within 90 days of nuclear testing. All patients had normal perfusion at rest. Multivariate logistic regression analysis demonstrated an incremental value of wall motion and perfusion over perfusion data alone in identifying severe and extensive CAD. Sensitivity for identifying any severely stenosed coronary artery by WMA was significantly higher than by severe perfusion defect (78% vs 49%, p <0.0001). Overall specificities of severe perfusion defect and WMA were 91% and 85%, respectively (p = NS). Thus, postexercise WMA detected by gated Tc-99m sestamibi SPECT in patients with normal resting perfusion is a sensitive marker of severe and extensive CAD.

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Patient population

The study group consisted of 99 consecutive patients who underwent separate acquisition dual-isotope resting thallium (Tl)-201/exercise gated Tc-99m sestamibi myocardial SPECT,7 and met the following criteria: (1) normal resting perfusion, and (2) coronary angiography performed within 90 days of SPECT with no intervening coronary event or revascularization procedure. Exclusion criteria were previous coronary bypass surgery, pathologic Q waves on the electrocardiogram at rest, complete left

Exercise and angiographic characteristics

Seventy-four of the 99 patients (75%) achieved a peak exercise heart rate ≥85% of their age-adjusted maximal predicted heart rate. Fifty-five patients (56%) had ischemic electrocardiographic response. Mean postexercise gated ejection fraction was 55 ± 9%. Ninety-one patients (92%) had ≥50% CAD, of whom 31 had 1-vessel, 30 had 2-vessel, and 30 had 3-vessel involvement. Luminal diameter narrowing of ≥90% was present in 71 patients (73%), of whom 50 had 1-vessel, 19 had 2-vessel, and 2 had

Discussion

The present study assessed the value of regional poststress myocardial dysfunction as a marker of severe individual coronary stenosis, and for prediction of severe and extensive CAD. Identification of severe obstructive CAD remains an important objective for noninvasive evaluation because it provides useful information for risk stratification. Although several serial angiographic studies have shown that 60% to 70% of all acute coronary syndromes evolve from mild to moderate obstructive lesions,

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