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CLINICAL STUDY

Variability of myocardial perfusion defects assessed by thallium-201 scintigraphy in patients with coronary artery disease not amenable to angioplasty or bypass surgery

Daniel Burkhoff, MD, PhD^*, James W. Jones, MD, PhD and Lewis C. Becker, MD, FACC

^* Department of Medicine, Columbia University, New York City, New York, USA
Department of Surgery, University of Missouri, Columbia, Missouri, USA
Department of Medicine, The Johns Hopkins University, Baltimore, Maryland, USA

Manuscript received January 17, 2001; revised manuscript received May 31, 2001, accepted June 19, 2001.

Reprint requests and correspondence: Dr. Daniel Burkhoff, Columbia University, Black Building 812, 650 W. 168th Street, New York, New York 10032
db59{at}columbia.edu

OBJECTIVES

We sought to assess the variability of results obtained with thallium scintigraphy as a method for tracking the extent of myocardial ischemia in medically refractory patients with angina who are not suitable for coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty.

BACKGROUND

New therapies are being evaluated for patients with "no option" angina in whom medical therapy has failed. Nuclear techniques, like thallium scintigraphy, are used in multicenter trials to evaluate whether such therapies improve myocardial perfusion. However, the variability of test results is unknown in this patient group in a multicenter study.

METHODS

The Angina Treatments: Lasers And Normal Therapies In Comparison (ATLANTIC) study was a randomized trial of transmyocardial laser revascularization (n = 182). Patients underwent dipyridamole thallium stress tests at baseline and 3, 6 and 12 months after enrollment. The control group (n = 90) was treated with constant medical therapy during the study and is a relevant group to investigate test variability. Test variability over time was quantified by the mean absolute change in the percentage of reversible perfusion defects between baseline and follow-up.

RESULTS

Baseline percent myocardium with ischemia averaged 17.0 ± 13.7% and did not change during follow-up. However, variations in the percent myocardium with reversible perfusion defects over time amounted to an average of 6 to 8 percentage points, or 43% to 55% of the baseline value. Only 13% of this variability was attributable to variability in image reconstruction and analysis.

CONCLUSIONS

As demonstrated in the ATLANTIC study, percent myocardial ischemia in control subjects receiving constant medical therapy varied in individual patients by an average of 50%. This may limit the utility of thallium scintigraphy to detect improved myocardial perfusion over time in response to therapy.

Abbreviations and Acronyms   ANOVA = analysis of variance   ATLANTIC = Angina Treatments: Lasers And Normal Therapies In Comparison study   CABG = coronary artery bypass graft surgery   MEDs = continued maximal antianginal therapy   PTCA = percutaneous transluminal coronary angioplasty   SAQ = Seattle Angina Questionnaire   TMR = transmyocardial revascularization   VI = variability index

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