Circulation, Vol 83, 1660-1667, Copyright © 1991 by American Heart Association
RO Cannon 3d, V Dilsizian, PT O'Gara, JE Udelson, WH Schenke, A Quyyumi, L Fananapazir and RO Bonow
BACKGROUND. Exercise-induced abnormalities during thallium-201 scintigraphy
that normalize at rest frequently occur in patients with hypertrophic
cardiomyopathy. However, it is not known whether these abnormalities are
indicative of myocardial ischemia. METHODS AND RESULTS. Fifty patients with
hypertrophic cardiomyopathy underwent exercise 201Tl scintigraphy and,
during the same week, measurement of myocardial lactate metabolism and
hemodynamics during pacing stress. Thirty-seven patients (74%) had one or
more 201Tl abnormalities that completely normalized after 3 hours of rest;
26 had regional myocardial 201Tl defects, and 26 had apparent left
ventricular cavity dilatation with exercise, with 15 having coexistence of
these abnormal findings. Of the 37 patients with reversible 201Tl
abnormalities, 27 (73%) had metabolic evidence of myocardial ischemia
during rapid atrial pacing (myocardial lactate extraction of 0 mmol/l or
less) compared with four of 13 patients (31%) with normal 201Tl scans (p
less than 0.01). Eleven patients had apparent cavity dilatation as their
only 201Tl abnormality; their mean postpacing left ventricular
end-diastolic pressure was significantly higher than that of the 13
patients with normal 201Tl studies (33 +/- 5 versus 21 +/- 10 mm Hg, p less
than 0.001). There was no correlation between the angiographic presence of
systolic septal or epicardial coronary arterial compression and the
presence or distribution of 201Tl abnormalities. Patients with ischemic ST
segment responses to exercise had an 80% prevalence rate of reversible
201Tl abnormalities and a 70% prevalence rate of pacing- induced ischemia.
However, 69% of patients with nonischemic ST segment responses had
reversible 201Tl abnormalities, and 55% had pacing- induced ischemia.
CONCLUSIONS. Reversible 201Tl abnormalities during exercise stress are
markers of myocardial ischemia in hypertrophic cardiomyopathy and most
likely identify relatively underperfused myocardium. In contrast, ST
segment changes with exercise and systolic compression of coronary arteries
on angiography are unreliable markers of inducible myocardial ischemia in
hypertrophic cardiomyopathy. Apparent cavity dilatation during 201Tl
scintigraphy may indicate ischemia-related changes in left ventricular
filling, with elevation in diastolic pressures and endocardial compression.
ARTICLES
Myocardial metabolic, hemodynamic, and electrocardiographic significance of reversible thallium-201 abnormalities in hypertrophic cardiomyopathy
Cardiovascular Diagnosis Section, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md. 20892.
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