Myocardial perfusion imaging using technetium-99m sestamibi in asymptomatic diabetic patients

Summary

Myocardial perfusion single-photon emission computed tomography (SPECT) has been extensively applied in the clinical assessment of patients with diabetes mellitus. The aim of the present study was to evaluate stress technetium- 99m sestamibi SPECT MPI perfusion in silent myocardial ischemia and its association with some clinical and laboratory parameters in an asymptomatic diabetic population. Patients, material, methods: 83 subjects (age: 57.1 ± 6.9 years) with at least five years history of type 2 diabetes, and no suspected or documented coronary artery disease (CAD) accomplished myocardial perfusion imaging; angiography was also performed in patients with abnormal MPI. Results: MPI results showed that 58 patients had normal myocardial perfusion, while 25 patients showed perfusion defects (23 reversible and 2 fixed) on MPI. 12 out of the 25 (48%) with abnormal MPI findings represented abnormal angiography. We observed that pretest likelihood of CAD (odds ratio 2.32; 95%-CI: 1.05–5.13; p = 0.038) and higher HbA1c level (odds ratio 1.70; 95%-CI, 1.07–2.71; p = 0.02) were independently associated with abnormal MPI. Conclusion: Occult CAD was present on MPI in 1/3 patients with DM without abnormal electro cardiographic findings or evidence of peripheral arterial disease.

Zusammenfassung

Die Myokard-Perfusions-SPECT (Single-Photon- Emissionscomputertomographie) wird bei der klinischen Untersuchung von Patienten mit Diabetes mellitus breit eingesetzt. Ziel dieser Studie war die stumme Myokardischämie anhand der myokardialen Perfusionsmessung (MPI) mittels Belastungs-Technetium-99m- Sestamibi-SPECT, auch in Bezug auf einige klinische und Laborparameter, bei einem Kollektiv asymptomatischer Diabetiker zu untersuchen. Patienten, Material, Methoden: Bei 83 Teilnehmern (Alter 57,1 ± 6,9 Jahre) mit einem seit mindestens fünf Jahren bestehenden Typ- 2-Diabetes ohne Verdacht auf bzw. Nachweis einer koronaren Herzkrankheit (KHK) wurde eine MPI durchgeführt; bei Patienten mit pathologischer MPI erfolgte außerdem eine Koronar- Angiographie. Ergebnisse: Die MPI zeigte bei 58 Patienten eine normale Myokardperfusion, während 25 Patienten Perfusionsdefekte in der MPI aufwiesen (23 reversibel und 2 irreversibel). Bei 12 der 25 Patienten mit pathologischem MPI-Befund (48%) war die Angiographie ebenfalls pathologisch. Die Vortest-Wahrscheinlichkeit für eine KHK (Odds-Ratio 2,32; 95%-CI: 1,05–5,13; p = 0,038) und höhere HbA1c-Spiegel (Odds-Ratio 1,70; 95%-CI: 1,07–2.71; p = 0,02) waren unabhängig voneinander mit einer pathologischen MPI assoziiert. Schlussfolgerung: In der MPI zeigte sich eine okkulte KHK bei 1/3 der Patienten mit Diabetes mellitus ohne pathologische EKG-Befunde oder Hinweise auf peri - phere arterielle Gefäßerkrankung.

Keywords

Myocardial perfusion imaging - asymptomatic diabetic patients - silent ischaemia - coronary artery disease - haemoglobin A1c

Schlüsselwörter

Myokardiale Perfusionsmessung - asymptomatische diabetische Patienten - stumme Ischämie - koronare Herzkrankheit - Hämo globin A1c

• References

• 1 Adamu U, Knollmann D, Almutairi B. et al. Stress/rest myocardial perfusion scintigraphy in patients without significant coronary artery disease. J Nucl Cardiol 2010; 17: 38-44.
• 2 Alqaisi F, Albadarin F, Jaffery Z. et al. Prognostic predictors and outcomes in patients with abnormal myocardial perfusion imaging and angiographically insignificant coronary artery disease. J Nucl Cardiol 2008; 15: 754-761.
• 3 Ammann P, Naegeli B, Rickli H. et al. Characteristics of patients with abnormal stress technetium ^99mTc sestamibi SPECT studies without significant coronary artery diameter stenoses. Clin Cardiol 2003; 26: 521-524.
• 4 Assadi M, Nabipour I, Saghari M. et al. The role of myocardial perfusion imaging in the screening of silent ischemia in diabetic patients. Iranian South Medical Journal 2010; 13: 59-71.
• 5 Consensus development conference on the diagnosis of coronary heart disease in people with diabetes: 10–11 February 1998, Miami, Florida. American Diabetes Association. Diabetes Care 1998; 21: 1551-1559.
• 6 Coutinho M, Gerstein HC, Wang Y, Yusuf S. The relationship between glucose and incident cardiovascular events. A metaregression analysis of published data from 20 studies of 95 783 individuals followed for 12.4 years. Diabetes Care 1999; 22: 233-240.
• 7 De Lorenzo A, Lima RS, Siqueira-Filho AG, Pantoja MR. Prevalence and prognostic value of perfusion defects detected by stress technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography in asymptomatic patients with diabetes mellitus and no known coronary artery disease. Am J Cardiol 2002; 90: 827-832.
• 8 Delcour KS, Khaja A, Chockalingam A. et al. Outcomes in patients with abnormal myocardial perfusion imaging and normal coronary angiogram. Angiology 2009; 60: 318-321.
• 9 Di Carli MF, Bianco-Batlles D, Landa ME. et al. Effects of autonomic neuropathy on coronary blood flow in patients with diabetes mellitus. Circulation 1999; 100: 813-819.
• 10 Fard-Esfahani A, Assadi M, Saghari M. et al. The role of myocardial perfusion imaging in the evaluation of patients undergoing percutaneous transluminal coronary angioplasty. Hellenic J Cardiol 2009; 50: 396-401.
• 11 Gerstein HC. Glucose: a continuous risk factor for cardiovascular disease. Diabet Med 1997; 14 (Suppl. 03) S25-31.
• 12 Gibbons RJ, Abrams J, Chatterjee K. et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina–summary article: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. Circulation 2003; 107: 149-158.
• 13 Gimelli A, Marzullo P, L'Abbate A, Rovai D. 'Falsepositive' myocardial perfusion imaging: correlation with cardiovascular risk factors and effect on eventfree survival. J Cardiovasc Med (Hagerstown) 2008; 9: 707-713.
• 14 Giri S, Shaw LJ, Murthy DR. et al. Impact of diabetes on the risk stratification using stress single-photon emission computed tomography myocardial perfusion imaging in patients with symptoms suggestive of coronary artery disease. Circulation 2002; 105: 32-40.
• 15 Hasdai D, Gibbons RJ, Holmes Jr DR. et al. Coronary endothelial dysfunction in humans is associated with myocardial perfusion defects. Circulation 1997; 96: 3390-3395.
• 16 Iskandrian AE. The Achilles heel of SPECT imaging: the false-positive scans–or are they?. J Nucl Cardiol 2006; 13: 747-748.
• 17 Janand-Delenne B, Savin B, Habib G. et al. Silent myocardial ischemia in patients with diabetes: who to screen. Diabetes Care 1999; 22: 1396-1400.
• 18 Kang X, Berman DS, Lewin H. et al. Comparative ability of myocardial perfusion single-photon emission computed tomography to detect coronary artery disease in patients with and without diabetes mellitus. Am Heart J 1999; 137: 949-957.
• 19 Kang X, Berman DS, Lewin HC. et al. Incremental prognostic value of myocardial perfusion single photon emission computed tomography in patients with diabetes mellitus. Am Heart J 1999; 138: 1025-1032.
• 20 Khaw KT, Wareham N, Bingham S. et al. Association of hemoglobin A1c with cardiovascular disease and mortality in adults: the European prospective investigation into cancer in Norfolk. Ann Intern Med 2004; 141: 413-420.
• 21 Kjaer A, Meyer C, Nielsen FS. et al. Dipyridamole, cold pressor test, and demonstration of endothelial dysfunction: a PET study of myocardial perfusion in diabetes. J Nucl Med 2003; 44: 19-23.
• 22 Liu YH, Sinusas AJ, De Man P. et al. Quantification of SPECT myocardial perfusion images: methodology and validation of the Yale-CQ method. J Nucl Cardiol 1999; 6: 190-204.
• 23 Marshall SM, Barth JH. Standardization of HbA1c measurements–a consensus statement. Diabet Med 2000; 17: 5-6.
• 24 Miller TD, Rajagopalan N, Hodge DO. et al. Yield of stress single-photon emission computed tomography in asymptomatic patients with diabetes. Am Heart J 2004; 147: 890-896.
• 25 National Heart Foundation clinical guidelines for the assessment and management of dyslipidaemia. Dys- lipidaemia Advisory Group on behalf of the scientific committee of the National Heart Foundation of New Zealand. N Z Med J 1996; 109: 224-231.
• 26 Nishioka T, Amanullah AM, Luo H. et al. Clinical validation of intravascular ultrasound imaging for assessment of coronary stenosis severity: comparison with stress myocardial perfusion imaging. J Am Coll Cardiol 1999; 33: 1870-1878.
• 27 Noble GL, Heller GV. Single-photon emission computed tomography myocardial perfusion imaging in patients with diabetes. Curr Cardiol Rep 2005; 7: 117-123.
• 28 Park S, Barrett-Connor E, Wingard DL. et al. GHb is a better predictor of cardiovascular disease than fasting or postchallenge plasma glucose in women without diabetes. The Rancho Bernardo Study. Diabetes Care 1996; 19: 450-456.
• 29 Passa P, Drouin P, Issa-Sayegh M. et al. Coronary disease and diabetes. Diabets Metab 1995; 21: 446-451.
• 30 Pop-Busui R, Kirkwood I, Schmid H. et al. Sympathetic dysfunction in type 1 diabetes: association with impaired myocardial blood flow reserve and diastolic dysfunction. J Am Coll Cardiol 2004; 44: 2368-2374.
• 31 Rajagopalan N, Miller TD, Hodge DO. et al. Identifying high-risk asymptomatic diabetic patients who are candidates for screening stress singlephoton emission computed tomography imaging. J Am Coll Cardiol 2005; 45: 43-49.
• 32 Rasulova N, Singh A, Demetriadou O. et al. Clinical significance of myocardial perfusion abnormalities in patients with varying degree of coronary artery stenosis. Nucl Med Commun 2008; 29: 129-136.
• 33 Soman P, Dave DM, Udelson JE. et al. Vascular endothelial dysfunction is associated with reversible myocardial perfusion defects in the absence of obstructive coronary artery disease. J Nucl Cardiol 2006; 13: 756-760.
• 34 Storto G, Sorrentino AR, Pellegrino T. et al. Assessment of coronary flow reserve by sestamibi imaging in patients with typical chest pain and normal coronary arteries. Eur J Nucl Med Mol Imaging 2007; 34: 1156-1161.
• 35 Wackers FJ, Chyun DA, Young LH. et al. Resolution of asymptomatic myocardial ischemia in patients with type 2 diabetes in the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study. Diabetes Care 2007; 30: 2892-2898.
• 36 Wackers FJ, Young LH, Inzucchi SE. et al. Detection of silent myocardial ischemia in asymptomatic diabetic subjects: the DIAD study. Diabetes Care 2004; 27: 1954-1961.
• 37 Zellweger MJ, Hachamovitch R, Kang X. et al. Prognostic relevance of symptoms versus objective evidence of coronary artery disease in diabetic patients. Eur Heart J 2004; 25: 543-550.