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CLINICAL STUDIES

Regional myocardial blood flow reserve impairment and metabolic changes suggesting myocardial ischemia in patients with idiopathic dilated cardiomyopathy

Ad F. M. van den Heuvel, MD^a, Dirk J. van Veldhuisen, MD, PhD, FACC^a, Ernst E. van der Wall, MD, PhD, FACC^*, Paul K. Blanksma, MD, PhD^a, Hans-Marc J. Siebelink, MD^a, Willem M. Vaalburg, PhD, Wiek H. van Gilst, PhD^a and Harry J. G. M. Crijns, MD, Phd^a

^a Department of Cardiology, University Hospital Groningen, Groningen, The Netherlands
^* Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
National Positron Emission Tomography Center, University Hospital Groningen, Groningen, The Netherlands

Manuscript received March 19, 1999; revised manuscript received July 27, 1999, accepted September 14, 1999.

Reprint requests and correspondence: Dr. D. J. van Veldhuisen, Department of Cardiology/Thoraxcenter, University Hospital Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
d.j.van.veldhuisen{at}thorax.azg.nl

OBJECTIVES

We performed positron emission tomography (PET) to evaluate myocardial ischemia in patients with idiopathic dilated cardiomyopathy (IDC).

BACKGROUND

Patients with IDC have anatomically normal coronary arteries, and it has been assumed that myocardial ischemia does not occur.

METHODS

We studied 22 patients with IDC and 22 control subjects using PET with nitrogen-13 ammonia to measure myocardial blood flow (MBF) at rest and during dipyridamole-induced hyperemia. To investigate glucose metabolism, fluorine-18 deoxyglucose (¹⁸FDG) was used. For imaging of oxygen consumption, carbon-11 acetate clearance rate constants (k_mono) were assessed at rest and during submaximal dobutamine infusion (20 µg/kg body weight per min).

RESULTS

Global MBF reserve (dipyridamole-induced) was impaired in patients with IDC versus control subjects (1.7 ± 0.21 vs. 2.7 ± 0.10, p < 0.05). In patients with IDC, MBF reserve correlated with left ventricular (LV) systolic wall stress (r = –0.61, p = 0.01). Furthermore, in 16 of 22 patients with IDC (derived by dipyridamole perfusion) mismatch (decreased flow/increased ¹⁸FDG uptake) was observed in 17 ± 8% of the myocardium. The extent of mismatch correlated with LV systolic wall stress (r = 0.64, p = 0.02). The MBF reserve was lower in the mismatch regions than in the normal regions (1.58 ± 0.13 vs. 1.90 ± 0.18, p < 0.05). During dobutamine infusion k_mono was higher in the mismatch regions than in the normal regions (0.104 ± 0.017 vs. 0.087 ± 0.016 min^–1, p < 0.05). In the mismatch regions ¹⁸FDG uptake correlated negatively with rest k_mono (r = –0.65, p < 0.05), suggesting a switch from aerobic to anaerobic metabolism.

CONCLUSIONS

Patients with IDC have a decreased MBF reserve. In addition, low MBF reserve was paralleled by high LV systolic wall stress. These global observations were associated with substantial myocardial mismatch areas showing the lowest MBF reserves. In geographically identical regions an abnormal oxygen consumption pattern was seen together with a switch from aerobic to anaerobic metabolism. These data support the notion that regional myocardial ischemia plays a role in IDC.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   CHF = congestive heart failure   CI = confidence interval   18FDG = fluorine-18 deoxyglucose   IDC = idiopathic dilated cardiomyopathy   LV = left ventricular   LVEF = left ventricular ejection fraction   MBF = myocardial blood flow   NYHA = New York Heart Association   PET = positron emission tomography   O2max = peak oxygen consumption

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