Radionuclide Imaging Techniques in the Thrombolytic Era

  • Diwakar Jain
  • Frans J. Th. Wackers
  • Barry L. Zaret
Part of the Developments in Cardiovascular Medicine book series (DICM, volume 160)

Abstract

Radionuclide imaging techniques have played an important role in the evaluation of left ventricular function, severity and extent of ischemia, viability and necrosis in patients with acute myocardial infarction. The information derived has formed a basis for risk stratification and selection of optimal treatment strategies for postinfarction patients in the prethrombolytic era. Reperfusion has altered the natural history of acute myocardial infarction. Effective early and sustained restoration of perfusion to acutely ischemic myocardium is the single most important factor in preserving myocardial function and reducing mortality and chronic disability. Current management strategies in acute myocardial infarction involve early diagnosis followed by prompt reperfusion, either pharmacologically or mechanically. Currently available thrombolytic agents achieve reperfusion in 75–80% of cases.1 When adequate reperfusion is not achieved with thrombolysis, immediate “salvage” angioplasty may be considered. Optimal utilization of reperfusion therapy would benefit from the availability of rapid non-invasive techniques for the early detection of reperfusion. Imaging may play a potential role in this as well as other areas in the diagnostic and therapeutic spectrum of reperfusion therapy in the modem era of coronary thrombolysis.

Keywords

Ischemia Stratification Cardiol Creatine Plasminogen 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Neuhaus KL, von Essen R, Tebbe U etal. Improved thrombolysis in acute myocardial infarction with front-loaded administration of attepase: results of the rt-PA-APSAC patency studt ( TAPS ). J Am Coll Cardiol 1992;19:885–891.PubMedCrossRefGoogle Scholar
  2. 2.
    Wackers F J Th, van der Schoot JB, Busemann Sokole et al. Noninvasive visualization of acute myocardial infarction in man with thallium-201. Br HeartJ 1975; 37: 741–747.CrossRefGoogle Scholar
  3. 3.
    Wackers F J Th. Thallium-201 myocardial scintigraphy in acute myocardial infarction and ischemia. Semn Nucl Med 1980;10:127–145.CrossRefGoogle Scholar
  4. 4.
    Gibson RS, Watson DD, Craddock GB et al. Prediction of cardiac events after uncomplicated myocardial infarction: A prospective study comparing predischarge exercise thallium-201 scintigraphy and coronary angiography. Circulation 1983;68: 321–326.PubMedCrossRefGoogle Scholar
  5. 5.
    Kaul S. A look at 15 years of planar thallium-201 imaging. Am Heart J 1989;118: 581–601.PubMedCrossRefGoogle Scholar
  6. 6.
    Kaul S, Finkelstein DM, Homma S, Leavitt M, Okada RD, Boucher CA. Superiority of quantitative exercise thallium-201 variables in determining long term prognosis in ambulatory patients with chest pain: A comparison with cardiac cathetrization. J Am Coll Cardiol 1988;12:25–34.PubMedCrossRefGoogle Scholar
  7. 7.
    Gill JB, Ruddy TD, Newell JB, Finklestein DM, Strauss HW, Boucher CA. Prognostic importance of thallium uptake by the lungs during exercise in coronary artery disease. N Engl J Med 1987;317:1485–89.CrossRefGoogle Scholar
  8. 8.
    Gibson RS, Watson DD, Carabello BA et al. Clinical implications of increased lung thallium-201 during exercise scintigraphy 2 weeks after myocardial infarction. Am J Cardiol 1982;49:1586–1593.PubMedCrossRefGoogle Scholar
  9. 9.
    Jain D, Lahiri A, Raftery EB. Lung thallium uptake on rest, stress and redistribution cardiac imaging: State-of-the-art-review. Am J Card Imag 1990;4:303–309.Google Scholar
  10. 10.
    Wackers F J Th, Berman DS, Maddahi J, et al. Technetium-99m Hexakis 2-Methoxyisobutyl Isonitrile: Human biodistribution, dosimetry, safety and preliminary comparison to thallium-201 for myocardial perfusion imaging. J Nucl Med 1989;30:301–311.PubMedGoogle Scholar
  11. 11.
    Kiat H, Maddahi J, Roy LT et al. Comparison of technetium-99m methoxyisobutyl isonitrile and thallium-201 for evaluation of coronary artery disease by planar and tomographic methods. Am Heart J 1989;117:1–17.PubMedCrossRefGoogle Scholar
  12. 12.
    Hendel RC, McSherry B, Karimeddini M, Leppo JA. Diagnostic value of new myocardial perfusion agent, Teboroxime ( SQ 30217 ), utilizing a rapid planar imaging protocol: preliminary results. J Am Coll Cardiol 1990;16:855–861.PubMedCrossRefGoogle Scholar
  13. 13.
    The Tetrofosmin Study Group. Comparative myocardial perfusion imaging with Tc-99m tetrofosmin and thallium-201: Results of Phase III International trial. Circulation 1992;86:1–506 ( abstract ).CrossRefGoogle Scholar
  14. 14.
    Jain D, Wackers FJ Th, Mattera J. McMahon M, Sinusas AJ, Zaret BL. Biokinetics of 99mTc-Tetrofosmin: Myocardial Perfusion Imaging Agent: Implications for a One Day Imaging Protocol. J Nucl Med 1993;34:1254–1259.PubMedGoogle Scholar
  15. 15.
    Kelley JD, Forster AM, Higley B, et al. Technetium-99m-tetrofosmin, a new radiopharmaceutical for myocardial perfusion imaging. J Nucl Med 1993;34:222–227.Google Scholar
  16. 16.
    Rossetti C, Vanoli G, Paganelli G et al. Q-12: A new 99mTc myocardial perfusion agent with optimized imaging properties: Evaluation in humans. J Nucl Med 1991; 32:1007 (abstract).Google Scholar
  17. 17.
    Boucher CA, Wackers F J Th, Zaret BL, Mena IG and the multicenter cardiolite study group. Technetium-99m-sestamibi myocardial imaging at rest for the assessment of myocardial infarction and first-pass ejection fraction. Am J Cardiol 1992;69:22–27.PubMedCrossRefGoogle Scholar
  18. 18.
    Wackers FJ Th. Thrombolytic therapy for myocardial infarction: Assessment of efficacy by myocardial perfsuion imaging with technetium-99m sestamibi. Am J Cardiol 1990;66:36E–41E.PubMedCrossRefGoogle Scholar
  19. 19.
    Zaret BL, Strauss HW, Hurley PJ et al. A noninvasive scintiphotographic method for detecting regional left ventricular dysfunction in man. N Engl J Med 1971; 284: 1165–1171.PubMedCrossRefGoogle Scholar
  20. 20.
    Strauss HW, Zaret BL, Hurley PJ et al. A scintiphotographic method for measuring left ventricular ejection fraction in man without cardiac cathetrization. Am J Cardiol 1971;28:575–581.PubMedCrossRefGoogle Scholar
  21. 21.
    The multicenter postinfarction research group. Risk stratification and survival after myocardial infarction. N Engl J Med 1983;309:331–336.CrossRefGoogle Scholar
  22. 22.
    Iskandrian A, Heo JK, Lyons E. Use of technetium-99m isonitrile ( RP-30A ) in assessing left ventricular perfusion and function at rest and during exercise in coronary artery disease and comparison with coronary angiography and exercise T1-201 SPECT imaging. Am J Cardiol 1989;64:207–211.CrossRefGoogle Scholar
  23. 23.
    Turi ZG, Rutherford JD, Roberts R et al. Electrocardiographic, enzymatic and scintigraphic criteria of acute myocardial infarction as determined from study of 726 patients ( a MILIS study ). Am J Cardiol 1985;55:1463–1468.PubMedCrossRefGoogle Scholar
  24. 24.
    Massie BM, Botvinick EH, Werner JA et al. Myocardial infarction scintigraphy with technetium 99m stannous pyrophosphate: An insensitive test for non transmural myocardial infarction. Am J Cardiol 1979;43:186–193.PubMedCrossRefGoogle Scholar
  25. 25.
    Johnson LL, Seldin DW, Becker LC et al. Antimyosin imaging in acute transmural myocardial infarction: Results of a multicenter clinical trial. J Am Coll Cardiol 1989;13:27–35.PubMedCrossRefGoogle Scholar
  26. 26.
    Berger HJ, Lahiri A, Leppo J et al. Antimyosin imaging in patients with ischemic chest pain: initial results of phase III multicenter trial. J Nucl Med 1988,29:805 ( abstract ).Google Scholar
  27. 27.
    Jain D, Crawley JCW, Lahiri A, Raftery EB. Indium-111 Antimyosin images compared with triphenyl tetrazolium chloride staining in a patient 6 days after myocardial infarction. J Nucl Med 1990;31:231–233.PubMedGoogle Scholar
  28. 28.
    Khaw BA, Scott J, Fallon JT, Cahill SL, Haber E, Homcy C. Myocardial injury: Quantitation by cell sorting initiated with antimyosin fluorescent spheres. Science 1982;217:1050–1053.PubMedCrossRefGoogle Scholar
  29. 29.
    Jain D, Lahiri A, Raftery EB. Immunoscintigraphy for detecting acute myocardial infarction without electrocardiographic changes. Br Med J 1990;300:151–153.CrossRefGoogle Scholar
  30. 30.
    Johnson LL, Seldin DW, Keller AM et al. Dual isotope thallium and indium antimyosin SPECT imaging to identify acute infarct patients at further ischemic risk. Circulation 1990;81:37–45.PubMedCrossRefGoogle Scholar
  31. 31.
    Schwaiger M, Hutchnis GD, Guibourg H et al. Evaluation of myocardial blood flow and metabolism using positron emmission tomography. Am J Card Imag 1989; 3: 266–272.Google Scholar
  32. 32.
    Scheibert HR, Henze E, Schon HR et al. 11C palmitate for the noninvasive evaluation of regional myocardial fatty acid metabolism with positron computed tomography. In vivo demonstration of the effects of substrate availability on myocardial metabolism. Am Heart J 1983;105:736–750.CrossRefGoogle Scholar
  33. 33.
    Sobel BE, Geltman EM, Tiefenbrunn AJ et al. Improvement of regional myocardial metabolism after coronary thrombolysis induced with tissue-type plasminogen activator or streptokinase. Circulation 1984;69:983–990.PubMedCrossRefGoogle Scholar
  34. 34.
    Soufer R. Metabolic imaging win positron emmission tomography during myocardial reperfusion. Am J Card Imag 1993;7:39–44.Google Scholar
  35. 35.
    Kloner RA, Przyklenk K, Patel B. Altered myocardial states: The stunned and hibernating myocardium. Am J Med 1989;86 (Suppl 1A ) 14–22.PubMedCrossRefGoogle Scholar
  36. 36.
    Simoons ML, Wijns W, Balakumaran K et al. The effect of intracoronary thrombolysis with streptokinase on myocardial thallium distribution and left ventricular function assessed by blood-pool scintigraphy. Eur Heart J 1982;3:433–440.PubMedGoogle Scholar
  37. 37.
    Decoster PM, Melin JA, Detry JMR et al. Coronary artery reperfusion in acute myocardial infarction: Assessment by pre-and postintervention thallium-201 myocardial perfusion imaging. Am J Cardiol 1985;55:889–895.CrossRefGoogle Scholar
  38. 38.
    Forman R, Kirk ES. Thallium-201 accumulation during reperfusion of ischemic myocardium: Dependence on regional blood flow rather than viability. Am J Cardiol 1984;54:659–663.PubMedCrossRefGoogle Scholar
  39. 39.
    Okada RD, Pohost GM. The use of preintervention and postintervention thallium imaging for assessing the early and late effects of experimental coronary arterial reperfusion in dogs. Circulation 1984;69:1153–1160.PubMedCrossRefGoogle Scholar
  40. 40.
    Wackers FJ Th, Gibbons RJ, Verani MS, et al. Serial quantitative planar techne-tium-99m isonitrile imaging in acute myocardial infarction: Efficacy for noninvasive assessment of thrombolytic therapy. J Am Coll Cardiol 1989;14:861–873.PubMedCrossRefGoogle Scholar
  41. 41.
    Gibbons RJ, Verani MS, Behrenbeck T et al. Feasibility of tomographic 99mTc-hexakis-2-methoxy-2-methoxypropyl-isonitrile imaging for the assessment of myocardial area at risk and effect of treatment in acute myocardial infarction. Circulation 1989;80:1277–1286.PubMedCrossRefGoogle Scholar
  42. 42.
    Christian TF, Schwartz RS, Gibbons RJ. Determination of infarct size in reperfusion therapy for acute myocardial infarction. Circulation 1992;86:81–90.PubMedCrossRefGoogle Scholar
  43. 43.
    Christian T, Gibbons R, Gersch BJ. Effect of infarct location on myocardial salvage assessed by technetium-99m isonitrile. J Am Coll Cardiol 1991,17:1308–1312.CrossRefGoogle Scholar
  44. 44.
    Heber K, Bresnahan JF, Bresnahan DR, Pellikka PA, Behrenbeck T, Gibbons RJ. Measurement of myocardium at risk by technetium-99m sestamibi: Correlation with coronary angiography. J Am Coll Cardiol 1992;19:67–73.CrossRefGoogle Scholar
  45. 45.
    Christian TF, Clemants IP, Behrenbeck T et al. Limitations of the electrocardiogram in estimating infarction size after acute reperfusion therapy of myocardial infarction. Ann lnt Med 1991;114:264–270.Google Scholar
  46. 46.
    Gibbons RJ, Holmes DR, Reeder G, bailey KR, Hopfenspriger MR, Gersch BJ. Immediate angioplasty compared with the administration of a thrombolytic agent followed by conservative treatment for myocardial infarction. N Engl J Med 1993; 328:685–691.PubMedCrossRefGoogle Scholar
  47. 47.
    Behrenbeck T, Pellikka PA, Huber KC, Bresnahan JF, Gersch BJ, Gibbons RJ. Primary angioplasty in myocardial infarction: Assessment of improved myocardial perfusion with technetium-99m isonitrile. J Am Coll Cardiol 1991;17:365–372.PubMedCrossRefGoogle Scholar
  48. 48.
    Gibbons RJ. Perfusion imaging with 99mTc-sestamibi for the assessment of myocardium at risk and the efficacy of acute treatment in myocardial infarction. Circulation 1991;84 (Suppl I): 1-37-1-42.Google Scholar
  49. 49.
    Ragosta M, Beller GA, Watson DD, Kaul S, Gimple LW. Quantitative planar rest-redistribution 201T1 imaging in detection of myocardial viability and prediction of improvement in left ventricular function after coronary bypass surgery in patients with severely depressed left ventricular function. Circulation 1993;87:1630–1641.PubMedCrossRefGoogle Scholar
  50. 50.
    O’Conner MK, Hammell TC, Gibbons RJ. In vitro validation of a simple tomographic technique for estimation of percent myocardium “at risk” following administration of Tc-99m-Isonitrile. Eur J Nucl Med 1990;17:69–76.CrossRefGoogle Scholar
  51. 51.
    Verani MS, Jeroudi MO, Mahmarian JJ et al. Quantification of myocardial infarction during coronary occlusion and myocardial salvage after reperfusion using cardiac imaging with technetium-99m-hexakis 2-methoxyisobutyl isonitrile. J Am Coll Cardiol 1988;12:1573–1581.PubMedCrossRefGoogle Scholar
  52. 52.
    Sinusas AJ, Trautman KA, Bergin JD, et al. Quantification of “area at risk” during coronary occlusion and degree of myocardial salvage after reperfusion with tech-netium-99m-methoxy isobutyl isonitrile. Circulation 1990;82:1424–1437.PubMedCrossRefGoogle Scholar
  53. 53.
    Barr SA, Zaret BL, Cannon CP, Wackers FJTh and the TIMI-4 and 5 investigators. Does decreasing defect size on serial quantitative planar Tc-99m-sestamibi imaging following thrombolytic therapy for acute myocardial infarction correlate with improved left ventricular function?. Abstract submitted for 66 th Scientific meeting of the American heart Association.Google Scholar
  54. 54.
    Ellis SG, van De Werf F, Ribeiro-SaSilva E, Topol EJ. Present stutus of rescue angioplsty: Current polarization of opinion and randomized trials. J Am Coll Cardiol 1992;19:681–686.PubMedCrossRefGoogle Scholar
  55. 55.
    Kircher BJ, Topol EJ, O’Neil WW, Pit B. Prediction of infarct coronary artery recanalization after intravenous thrombolytic therapy. Am J Cardiol 1987;59: 513–515.PubMedCrossRefGoogle Scholar
  56. 56.
    Calliff RM, O’Neil W, Stack RS et al. Failure of simple clinical measurement to predict perfusion status after intravenous thrombolysis. Ann Int Med 1988;108: 658–662.Google Scholar
  57. 57.
    Ellis AK, Little T, Masud AR, Liberman HA, Morris DC, Klocker FJ. Early noninvasive detection of successful reperfusion in patients with acute myocardial infarction. Circulation 1988;78:1352–1357.PubMedCrossRefGoogle Scholar
  58. 58.
    Shah PK, Cercek B, Lew AS, Ganz W. Angiographic validation of bedside markers of reperfusion. J Am Coll Cardiol 1993;21:55–61.PubMedCrossRefGoogle Scholar
  59. 59.
    Heller LI, Villegas B, Weiner BM, McSherry BA, Dahlberg ST, Leppo JA. Sequential teboroxime imaging during and after balloon occlusion of a coronary artery. J Am Coll Cardiol 1993;1:1319–1327.CrossRefGoogle Scholar
  60. 60.
    Chang PI, Shi QX, Maniawski P, et al. Tc-99m-Teborixime is a marker for reperfusion flow early after acute myocardial infarction. J Am Coll Cardiol 1992; 19: 338A ( Suppl A ) ( abstract ).Google Scholar
  61. 61.
    Califf RM, Harrelson-Woodlief L, Topol EJ. Left ventricular ejection fraction may not be useful as an endpoint of thrombolytic therapy comparative trials. Circulation 1990;82:1847–1853.PubMedCrossRefGoogle Scholar
  62. 62.
    Kennedy JW, Ritchie JL, Davis KB, Fritz JK. Western Washington randomized trial of intracoronary streptokinase in acute myocardial infarction. N Engl J Med 1983;309:1477–1482.PubMedCrossRefGoogle Scholar
  63. 63.
    Ritchie JL, Davis KB, Williams DL, Caldwell JH, Kennedy JW. Global and regional left ventricular function and tomographic radionuclide perfsuion: The Western Washington Intracoronary Streptokinase in Acute Myocardial Infarction Trial. Circulation 1984;70:867–875.PubMedCrossRefGoogle Scholar
  64. 64.
    Braunwald E. Myocardial reperfusion, limitation of infarct size, reduction of left ventricular dysfunction, and improved survival: Should the paradigm be expanded? Circulation 1989;79:441–444 ( editorial ).PubMedCrossRefGoogle Scholar
  65. 65.
    Zaret BL, Wackers FJ, Terrin M et al. Does left ventricular ejection fraction following thrombolytic therapy have the same prognostic impact as described in prethrombolytic era?. Results of TIMI II trial. Submitted for Publication.Google Scholar
  66. 66.
    Christian T, Behrenbeck T, Pellikka PA, Huber KC, Chesebro JH, Gibbons R. Mismatch of left ventricular function and infarct size demonstrated by technetium-99m isonitrile imaging after reperfusion therapy for acute myocardial infarction: Identification of myocardial stunning and hyperkinesia. J Am Coll Cardiol 1990;16:1632–1638.PubMedCrossRefGoogle Scholar
  67. 67.
    Zaret BL, Wackers FJTh, Terrin M et al. Assessment of global and regional left ventricular performance at rest and during exercise after thrombolytic therapy for acute myocardial infarction: Results of the Thrombolysis in Myocardial Infarction ( TIMI ) II study. Am J Cardiol 1992;69:1–9.PubMedCrossRefGoogle Scholar
  68. 68.
    Borer JS, Miller D, Schreiber T, Charash B, Gerling B. Radionuclide cineangiography in acute myocardial infarction: role in prognostication. Sem Nucl Med 1987;17:89–94.CrossRefGoogle Scholar
  69. 69.
    Moore CA, Cannon J, Watson DD et al. Thallium-201 kinetics in stunned myocardium characterized by severe postischemic systolic dysfunction. Circlation 1990; 81: 1622–1632.CrossRefGoogle Scholar
  70. 70.
    Granato JE, Watson DD, Flanagan TL et al. Myocardial thallium-201 kinetics and regional flow alteration with 3 hours of coronary occlusion and either rapid reperfusion through a totally patent vessel or slow reperfusion through a critical stenosis. J Am Coll Cardiol 1987;9:109–118.PubMedCrossRefGoogle Scholar
  71. 71.
    Sabia PJ, Powers ER, Ragosta M, Smith WH, Watson DD, Kaul S. Role of quantitative planar thallium-201 imaging for determining viability in patients with myocardial infarction and a totally occluded infarct-related artery. J Nucl Med 1993;34:728–736.PubMedGoogle Scholar
  72. 72.
    Dilsizian V, Bonow RO. Current diagnostic techniques of assessing myocardial viability in patients with hibernating and stunned myocardium. Circulation 1993; 87: 1–14.PubMedCrossRefGoogle Scholar
  73. 73.
    TIMI Study Group: Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction: Results to the Thrombolysis in Myocardial Infarction ( TIMI ) Phase II trial. N Engl J Med 1989;320:618–627.CrossRefGoogle Scholar
  74. 74.
    Ellis SG, Mooney MR, George BS et al. Randomized trial of late angioplasty versus conservative management for patients with residual stenosis after thrombolytic treatment of myocardial infarction. Circulation 1992;86:1400–6.PubMedCrossRefGoogle Scholar
  75. 75.
    Tilkemeier PL, Guiney TE, LaRaia PJ, Boucher CA. Prognostic value of predis-charge low-level exercise thallium testing after thrombolytic treatment of acute myocardial infarction. Am J Cardiol 1990;66:1203–1207.PubMedCrossRefGoogle Scholar
  76. 76.
    Maddahi J, DiCarli M. Antimyosin monoclonal antibody imaging to assess myocardial viability in the setting of acute thrombolysis. Am J Card Imag 1993;7:45–52.Google Scholar
  77. 77.
    Kayden DS, Wackers FJTh, Zaret BL. Silent ventricular dysfunction during routine activity after thrombolytic therapy for acute myocardial infarction. J Am Coll Cardiol 1990;15:1500–1506.PubMedCrossRefGoogle Scholar
  78. 78.
    Zaret BL, Jain D. Continuous monitoring of left ventricular function with miniaturized nonimaging detectors. In Zaret BL, Beller GA editors Nuclear Cardiology: State of the Art and Future Directions, publisher Mosby, St. Louis 1993 p 137–145.Google Scholar

Copyright information

© Springer Science+Business Media New York 1994

Authors and Affiliations

  • Diwakar Jain
    • 1
  • Frans J. Th. Wackers
    • 1
  • Barry L. Zaret
    • 1
  1. 1.Yale University School of MedicineUSA

Personalised recommendations