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The Impact of Left Ventricle Ejection Fraction Reduction and Transient Ischemic Dilation in Patients With Normal
Paulo Medeiros1, Bárbara Pereira2, Jorge Rodrigues3
1Cardiology, Hospital de Braga, Braga, PRT.
Insights
Patients with normal single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) but with reduced left ventricle ejection fraction (LVEF) or increased left ventricle volumes indicating transient ischemic dilatation (TID) have a higher incidence of significant coronary artery disease (CAD). These non-perfusion markers identify high-risk individuals.
Area of Science:
- Cardiology
- Medical Imaging
- Diagnostic Medicine
Background:
- Coronary artery disease (CAD) is a major cause of mortality in developed nations.
- Non-invasive functional imaging, like single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI), is recommended for patients with intermediate-to-high pretest probability of CAD.
- Beyond perfusion, non-perfusion predictors like transient ischemic dilatation (TID) and reduced left ventricle ejection fraction (LVEF) are debated in CAD assessment.
Purpose of the Study:
- To evaluate the incidence of significant CAD in patients exhibiting non-perfusion high-risk markers despite a normal SPECT-MPI.
- To investigate the prognostic value of LVEF reduction and TID on SPECT-MPI in identifying significant CAD.
Main Methods:
- A retrospective, observational, longitudinal study of 197 patients with normal SPECT-MPI.
- Inclusion criteria included age ≥18 years and availability of gated SPECT for LVEF and volume analysis.
- Non-perfusion high-risk markers included LVEF reduction ≥5% and TID (stress/rest left ventricle volume ratio ≥ 1.15). The primary endpoint was significant CAD on invasive coronary angiography.
Main Results:
- 26% of patients showed LVEF reduction ≥5%, and 24.9% had a stress/rest end-systolic volume ratio ≥ 1.15.
- Patients with LVEF reduction ≥5% and those with a stress/rest end-systolic volume ratio ≥ 1.15 had a significantly shorter time to the primary endpoint (significant CAD).
- These findings suggest these non-perfusion markers are associated with adverse outcomes.
Conclusions:
- In patients with normal SPECT-MPI perfusion, LVEF reduction ≥5% and a stress/rest end-systolic volume ratio ≥ 1.15 are associated with a significantly higher incidence of significant CAD.
- These non-perfusion markers can identify high-risk individuals even with normal myocardial perfusion on SPECT-MPI.
- The study highlights the importance of considering non-perfusion parameters in the comprehensive assessment of CAD risk.
Introduction:
Coronary artery disease (CAD) is a leading cause of death in developed countries. Non-invasive functional imaging modalities are currently recommended as initial diagnostic tests in patients with an intermediate-high pretest probability of CAD. Single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) creates images of regional myocardial tracer uptake, reflecting relative myocardial blood flow. However, there are other non-perfusion predictors of CAD, such as transient ischemic dilatation (TID) and reduced post-stress left ventricle ejection fraction (LVEF). Available data regarding these parameters is controversial. The aim of our study was to evaluate the incidence of significant CAD in patients with non-perfusion high-risk markers of ischemia despite a normal SPECT-MPI.
Methods:
Single-center, observational, retrospective, and longitudinal study. Inclusion criteria were age ≥18 years, normal SPECT-MPI, and availability of gated study for LVEF and volume analysis. Exclusion criteria were any known cardiomyopathy or congenital heart disease and known CAD. Non-perfusion high-risk markers: LVEF reduction ≥5% on post-stress images; TID (defined as a stress/rest left ventricle volume ratio ≥ 1.15), including end-systolic, end-diastolic, and mean volumes. The primary endpoint was the identification of significant CAD (stenosis >70% on an epicardial coronary artery or >50% on the left main artery) on invasive coronary angiography.
Results:
A total of 197 patients met the inclusion criteria. Mean age was 64 ± 12.6 years and 59.4% (n = 117) of patients were male. Overall, 26% of patients had LVEF reduction ≥5% on stress study; 24.9% had a stress/rest end-systolic volume ratio ≥ 1.15; 7.1% had a stress/rest mean volume ratio ≥ 1.15; 7.1% had a stress/rest end-diastolic volume ratio ≥ 1.15. Time-to-primary endpoint was significantly lower in patients with LVEF reduction ≥5% on stress study (67.99 (95% CI 60.49-75.49) vs. 77.56 months (95% CI 75.14-79.99); p = 0.003) and in patients with stress/rest end-systolic volume ratio ≥ 1.15 (68.39 (95% CI 60.69-76.10) vs. 77.31 months (95% ICCI 74.68-79.76); p = 0.013).
Conclusion:
In patients with normal perfusion on SPECT-MPI, the incidence of significant CAD was significantly higher in those with LVEF reduction ≥ 5% on stress study and in those with a stress/rest end-systolic volume ratio ≥ 1.15, during a follow-up period of five years.
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