Allan Johansen

Left Ventricular Diastolic Function in Type 2 Diabetes Mellitus Prevalence and Association With Myocardial and Vascular Disease

Background—Although type 2 diabetes mellitus is a risk factor for developing congestive heart failure, the mechanism leading to heart failure is unclear. We examined the prevalence of left ventricular (LV) systolic and diastolic dysfunction in patients with type 2 diabetes mellitus in relation to vascular function and myocardial perfusion. Methods and Results—A prospective observational study of 305 patients with type 2 diabetes mellitus (diabetes duration, 4.5±5.3 years) referred consecutively to a diabetes clinic were screened for LV systolic and diastolic function by echocardiography. Vascular function was estimated using noninvasive estimation of pulse pressure, carotid arterial compliance, total arterial compliance, and valvulo-arterial impedance. The prevalences of LV diastolic dysfunction and left atrial (LA) volume index >32 mL/m2 were 40% and 32%, respectively. The prevalence of myocardial ischemia on myocardial perfusion scintigraphy was more frequent in patients with grade 2 diastolic dysfunction and LA volume index >32 mL/m2 compared with those having normal or grade 1 diastolic dysfunction (P=0.002) or LA volume index ≤32 mL/m2 (P<0.001), respectively. Predictors of grade 2 diastolic dysfunction and LA dilation were summed stress score on myocardial perfusion scintigraphy, total arterial compliance, and valvulo-arterial impedance, whereas pulse pressure and carotid arterial compliance were not, after adjusting for age, sex, and diabetes duration. On multivariable modeling, summed stress score (P<0.001) and valvulo-arterial impedance (P=0.027) remained predictors of grade 2 diastolic dysfunction, and only summed stress score (P<0.001) was a predictor of LA dilation. Conclusions—Abnormal LV filling is closely associated with abnormal myocardial perfusion on myocardial perfusion scintigraphy, whereas the association of LV filling with vascular function is less prominent. Clinical Trial Registration—The trial has been registered at www.clinicaltrial.gov with Identifier: NCT00298844.Background— Although type 2 diabetes mellitus is a risk factor for developing congestive heart failure, the mechanism leading to heart failure is unclear. We examined the prevalence of left ventricular (LV) systolic and diastolic dysfunction in patients with type 2 diabetes mellitus in relation to vascular function and myocardial perfusion. Methods and Results— A prospective observational study of 305 patients with type 2 diabetes mellitus (diabetes duration, 4.5±5.3 years) referred consecutively to a diabetes clinic were screened for LV systolic and diastolic function by echocardiography. Vascular function was estimated using noninvasive estimation of pulse pressure, carotid arterial compliance, total arterial compliance, and valvulo-arterial impedance. The prevalences of LV diastolic dysfunction and left atrial (LA) volume index >32 mL/m2 were 40% and 32%, respectively. The prevalence of myocardial ischemia on myocardial perfusion scintigraphy was more frequent in patients with grade 2 diastolic dysfunction and LA volume index >32 mL/m2 compared with those having normal or grade 1 diastolic dysfunction ( P =0.002) or LA volume index ≤32 mL/m2 ( P <0.001), respectively. Predictors of grade 2 diastolic dysfunction and LA dilation were summed stress score on myocardial perfusion scintigraphy, total arterial compliance, and valvulo-arterial impedance, whereas pulse pressure and carotid arterial compliance were not, after adjusting for age, sex, and diabetes duration. On multivariable modeling, summed stress score ( P <0.001) and valvulo-arterial impedance ( P =0.027) remained predictors of grade 2 diastolic dysfunction, and only summed stress score ( P <0.001) was a predictor of LA dilation. Conclusions— Abnormal LV filling is closely associated with abnormal myocardial perfusion on myocardial perfusion scintigraphy, whereas the association of LV filling with vascular function is less prominent. Clinical Trial Registration— The trial has been registered at www.clinicaltrial.gov with Identifier: [NCT00298844][1]. Received December 13, 2008; accepted October 20, 2009. # CLINICAL PERSPECTIVE {#article-title-2} [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00298844&atom=%2Fcirccvim%2F3%2F1%2F24.atom

Interpretive intra- and interobserver reproducibility of rest/stress 99Tcm-sestamibi myocardial perfusion SPECT in a consecutive group of male patients with stable angina pectoris before and after percutaneous transluminal angioplasty.

Background Observer variability of 99Tcm-sestamibi myocardial perfusion imaging (MPI) has rarely been investigated. The aim of our study was to evaluate the interpretive reproducibility with this technique. Patients We report on 108 consecutive male patients with stable angina pectoris, investigated before and after percutaneous transluminal angioplasty (PTCA). Methods A 2-day rest/stress 99Tcm-sestamibi gated single photon emission computed tomography (SPECT) protocol was used. MPI was interpreted by two independent observers without knowledge of clinical data, using a 20-segment scoring model. Results Intra- and interobserver agreement was found to be good to excellent (κ = 0.71-0.85) with regard to the overall diagnosis as well as the individual vessel diagnosis (κ = 0.60-0.87). However, agreement was higher for left anterior descending coronary artery (LAD) and left circumflex coronary artery (LCX) vascular territories than for the right coronary artery (RCA) territory. Moderate to good intraobserver agreement (κ = 00.54-0.68) and slightly lower interobserver agreement (κ = 0.52-0.56) was found for segmental score interpretation. When comparing the interpretive reproducibility before and after PTCA intra- and interobserver agreement was better after PTCA, probably reflecting the increase in normal scans after revascularization. Conclusions In a group of consecutive male patients with stable angina pectoris interpretive reproducibility (overall and individual vessel diagnosis) was good to excellent. However, segmental scoring reproducibility was moderate to good.

Plasma osteoprotegerin is related to carotid and peripheral arterial disease, but not to myocardial ischemia in type 2 diabetes mellitus

BackgroundCardiovascular disease (CVD) is frequent in type 2 diabetes mellitus patients due to accelerated atherosclerosis. Plasma osteoprotegerin (OPG) has evolved as a biomarker for CVD. We examined the relationship between plasma OPG levels and different CVD manifestations in type 2 diabetes.MethodsType 2 diabetes patients without known CVD referred consecutively to a diabetes clinic for the first time (n = 305, aged: 58.6 ± 11.3 years, diabetes duration: 4.5 ± 5.3 years) were screened for carotid arterial disease, peripheral arterial disease, and myocardial ischemia by means of carotid artery ultrasonography, peripheral ankle and toe systolic blood pressure measurements, and myocardial perfusion scintigraphy (MPS). In addition, plasma OPG concentrations and other CVD-related markers were measured.ResultsThe prevalence of carotid arterial disease, peripheral arterial disease, and myocardial ischemia was 42%, 15%, and 30%, respectively. Plasma OPG was significantly increased in patients with carotid and peripheral arterial disease compared to patients without (p < 0.001, respectively), however, this was not the case for patients with myocardial ischemia versus those without (p = 0.71). When adjusted for age, HbA1c and U-albumin creatinine ratio in a multivariate logistic regression analysis, plasma OPG remained strongly associated with carotid arterial disease (adjusted OR: 2.12; 95% CI: 1.22-3.67; p = 0.008), but not with peripheral arterial disease or myocardial ischemia.ConclusionsIncreased plasma OPG concentration is associated with carotid and peripheral arterial disease in patients with type 2 diabetes, whereas no relation is observed with respect to myocardial ischemia on MPS. The reason for this discrepancy is unknown.Trial registration numberat http://www.clinicaltrial.gov: NCT00298844

Bone Scan Index predicts outcome in patients with metastatic hormone-sensitive prostate cancer.

To evaluate the Bone Scan Index (BSI) for prediction of castration resistance and prostate cancer‐specific survival (PCSS). In this retrospective study, we used novel computer‐assisted software for automated detection/quantification of bone metastases by BSI. Patients with prostate cancer are M‐staged by whole‐body bone scintigraphy (WBS) and categorised as M0 or M1. Within the M1 group, there is a wide range of clinical outcomes. The BSI was introduced a decade ago providing quantification of bone metastases by estimating the percentage of bone involvement. Being too time consuming, it never gained widespread clinical use.

High probability of disease in angina pectoris patients: Is clinical estimation reliable?

BACKGROUND According to most current guidelines, stable angina pectoris patients with a high probability of having coronary artery disease can be reliably identified clinically. OBJECTIVES To examine the reliability of clinical evaluation with or without an at-rest electrocardiogram (ECG) in patients with a high probability of coronary artery disease. PATIENTS AND METHODS A prospective series of 357 patients referred for coronary angiography (CA) for suspected stable angina pectoris were examined by a trained physician who judged their type of pain and Canadian Cardiovascular Society grade of pain. Pretest likelihood of disease was estimated, and all patients underwent myocardial perfusion scintigraphy (MPS) followed by CA an average of 78 days later. For analysis, the investigators focused on the approximate groups of patients with more severe disease, ie, typical angina (n=187), Canadian Cardiovascular Society grade 2 pain or higher (n=176) or high (higher than 85%) estimated pretest likelihood of disease (n=142). RESULTS In the three groups, 34% to 39% of male patients and 65% to 69% of female patients had normal MPS, while 37% to 38% and 60% to 71%, respectively, had insignificant findings on CA. Of the patients who had also an abnormal at-rest ECG, 14% to 21% of men and 42% to 57% of women had normal MPS. Sex-related differences were statistically significant. CONCLUSIONS Clinical prediction appears to be unreliable. Addition of at-rest ECG data results in some improvement, particularly in male patients, but it makes the high probability groups so small that the addition appears to be of limited clinical relevance.

Quantitative myocardial perfusion by O-15-water PET: individualized vs. standardized vascular territories

AIMS Reporting of quantitative myocardial blood flow (MBF) is typically performed in standard coronary territories. However, coronary anatomy and myocardial vascular territories vary among individuals, and a coronary artery may erroneously be deemed stenosed or not if territorial demarcation is incorrect. So far, the diagnostic consequences of calculating individually vs. standardly assessed MBF values have not been reported. We examined whether individual reassignment of vascular territories would improve the diagnostic accuracy of MBF with regard to the detection of significant coronary artery disease (CAD). METHODS AND RESULTS Forty-four patients with suspected CAD were included prospectively and underwent coronary CT-angiography and quantitative MBF assessment with O-15-water PET followed by invasive, quantitative coronary angiography, which served as reference. MBF was calculated in the vascular territories during adenosine stress according to a standardized 17-segment American Heart Association model and an individualized model, using CT-angiography to adjust the coronary territories to their feeding vessels. Individually defined territories deviated from standard territories in 52% of patients. However, MBF in the three coronary territories defined by standard and individualized models did not differ significantly, except in one patient, in whom the MBF of an individualized coronary territory deviated sufficiently as to change the test from a false positive to a true negative result in this particular territory. CONCLUSION Disparity between standardized and individualized vascular territories was present in half of the patients, but had little clinical impact. Still, caution should be taken not always to rely on standard territories, as this may at times cause misinterpretation.

Scatter and attenuation correction changes interpretation of gated myocardial perfusion imaging

Attenuation correction may improve the diagnostic accuracy of myocardial perfusion imaging (MPI). However, few studies have dealt with the clinical consequences for reporting. We compared routine reports based on scatter-corrected MPI (MPI-routine) with consensus readings of scatter-corrected (MPI-scatter) and scatter plus attenuation-corrected studies (MPI-attenuation) to investigate the impact of attenuation correction on reporting. One hundred consecutive stable angina patients (including 55 men) were investigated in a 99mTc-sestamibi 2-day gated protocol with scatter and attenuation correction. With MPI-routine, 53 patients had normal perfusion and 47 abnormal perfusion, compared to 62 and 38 with MPI-attenuation, and 54 and 46, respectively, with MPI-scatter. Agreement between MPI-routine and MPI-attenuation with respect to overall diagnosis (normal/abnormal perfusion) was 89% (kappa=0.78) compared to 95% (kappa=0.90) between MPI-routine and MPI-scatter. With MPI-attenuation, the overall routine diagnosis changed in 11 patients, of which ten cases were judged normal after scatter plus attenuation correction. The majority of the “normalised” studies were among patients with apparently single-vessel RCA disease as judged from MPI. Agreement rates with regard to normal, reversible or irreversible defects between MPI-attenuation and MPI-routine for the LAD, LCX and RCA territories were 88%, 97% and 85%, respectively, without significant sex differences. In conclusion, attenuation correction caused a change in diagnosis in approximately 10% of the patients, corresponding to one-fifth of the abnormal studies. In all but one case, the shift was from abnormal to normal, mostly because of a different interpretation in the RCA territory.

Prognostic value of myocardial perfusion imaging in patients with known or suspected stable angina pectoris: evaluation in a setting in which myocardial perfusion imaging did not influence the choice of treatment.

Objective:  Previous investigations on the prognostic value of myocardial perfusion imaging (MPI) were performed under circumstances in which the test result was known to the patients physician. We wanted to examine the prognostic value of MPI in patients with known or suspected stable angina in a setting in which MPI could not influence the diagnostic and therapeutic strategy.

Area of ischemia assessed by physicians and software packages from myocardial perfusion scintigrams

BackgroundThe European Society of Cardiology recommends that patients with >10% area of ischemia should receive revascularization. We investigated inter-observer variability for the extent of ischemic defects reported by different physicians and by different software tools, and if inter-observer variability was reduced when the physicians were provided with a computerized suggestion of the defects.MethodsTwenty-five myocardial perfusion single photon emission computed tomography (SPECT) patients who were regarded as ischemic according to the final report were included. Eleven physicians in nuclear medicine delineated the extent of the ischemic defects. After at least two weeks, they delineated the defects again, and were this time provided a suggestion of the defect delineation by EXINI HeartTM (EXINI). Summed difference scores and ischemic extent values were obtained from four software programs.ResultsThe median extent values obtained from the 11 physicians varied between 8% and 34%, and between 9% and 16% for the software programs. For all 25 patients, mean extent obtained from EXINI was 17.0% (± standard deviation (SD) 14.6%). Mean extent for physicians was 22.6% (± 15.6%) for the first delineation and 19.1% (± 14.9%) for the evaluation where they were provided computerized suggestion. Intra-class correlation (ICC) increased from 0.56 (95% confidence interval (CI) 0.41-0.72) to 0.81 (95% CI 0.71-0.90) between the first and the second delineation, and SD between physicians were 7.8 (first) and 5.9 (second delineation).ConclusionsThere was large variability in the estimated ischemic defect size obtained both from different physicians and from different software packages. When the physicians were provided with a suggested delineation, the inter-observer variability decreased significantly.

Observer reproducibility and validity of systems for clinical classification of angina pectoris: comparison with radionuclide imaging and coronary angiography

Objective:  To assess reproducibility and validity of clinical classification of angina pectoris (AP) patients.