Skip to main content

Advertisement

SpringerLink
Log in

Noninvasive monitoring of medical therapy

  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

An extensive literature base documents the substantial incremental prognostic value of nuclear cardiology compared with information provided by risk factors, clinical history, electrocardiographic stress testing results, and coronary arteriography. A smaller, well-established and growing literature addresses the unique potential of nuclear cardiology to assess therapeutic response of ischemic heart disease to lifestyle and medical therapies in individual patients. General guidelines focus on management of individual risk factors based on large studies, but may not reflect the optimum treatment strategy for an individual patient. The central rationale for noninvasive serial monitoring is to optimize the effectiveness and timing of lifestyle, medical, and revascularization therapies to minimize coronary event risk. Ideally, this monitoring of therapy should be early in the management of coronary artery disease (CAD) and guide the need for more intensive therapeutics. The application of technical advances in serial monitoring has the potential to revolutionize the way we diagnose and prevent CAD, even in asymptomatic patients. The potential long-term cost effectiveness of positron emission tomography and single-photon emission CT myocardial perfusion scintigraphy in detecting and monitoring treatment of CAD offers great promise for reducing coronary events in known or suspected ischemic heart disease.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. Pancholy SB, Fattah AA, Kamal AM, et al.: Independent and incremental prognostic value of exercise thallium single-photon emission computed tomographic imaging in women. J Nucl Cardiol 1995, 2(2 Pt 1):110–116.

    PubMed  CAS  Google Scholar 

  2. Iskandrian AS, Chae SC, Heo J, et al.: Independent and incremental prognostic value of exercise single-photon emission computed tomographic (SPECT) thallium imaging in coronary artery disease. J Am Coll Cardiol 1993, 22:665–670.

    Article  PubMed  CAS  Google Scholar 

  3. Risk stratification post myocardial infarction: implications from the INSPIRE trial. Accessible at http://www.cardiologyonline.com/wchd05/abstracts/3093%20Mahmarian.doc. When published in full form may change routine post MI care.

  4. Tuttle RT, Shaw L, Hanson MW, Borges-Neto S: Incremental prognostic power of adenosine SPECT myocardial perfusion imaging in high-risk patients for coronary artery disease: a comparison with cardiac catheterization data. J Nucl Cardiol 2005, 12:S55.

    Article  Google Scholar 

  5. Falk E, Shah PK, Fuster V: Coronary plaque disruption. Circulation 1995, 92:657–671.

    PubMed  CAS  Google Scholar 

  6. Ridker PM: Clinical Application of C-reactive protein for cardiovascular disease detection and prevention. Circulation 2003, 107:363–369.

    Article  PubMed  Google Scholar 

  7. Cannon CP, Braunwald E, McCabe CH, et al.: Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med 2004, 350:1495–1504.

    Article  PubMed  CAS  Google Scholar 

  8. Dakik HA, Kleiman NS, Farmer JA, et al.: Intensive medical therapy versus coronary angioplasty for suppression of myocardial ischemia in survivors of acute myocardial infarction. Circulation 1998, 98:2017–2023.

    PubMed  CAS  Google Scholar 

  9. Berman DS, Kang X, Schisterman EF, et al.: Serial changes on quantitative myocardial perfusion SPECT in patients undergoing revascularization or conservative therapy. J Nucl Cardiol 2001, 8:428–437. This paper not only shows the potential value of noninvasive monitoring of medical therapy but also the concept that larger stress defects may preferentially benefit from revascularization therapy.

    Article  PubMed  CAS  Google Scholar 

  10. Hachamovitch R, Hayes SW, Friedman JD, et al.: Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation 2003, 107:2900–2906. Retrospective, but it is one of the only papers demonstrating the ability to match the level of risk as assessed by SPECT with the level of intervention.

    Article  PubMed  Google Scholar 

  11. Merhige ME, Watson GM, Oliverio JG, et al.: Efficacy of lipid lowering therapy in inducing arrest or reversal of coronary disease: serial assessment of perfusion with PET predicts clinical outcome. J Nucl Cardiol 2004, 11:S32.

    Article  Google Scholar 

  12. Grundy SM, Cleeman JI, Merz NB, et al.: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation 2004, 110:227–239.

    Article  PubMed  Google Scholar 

  13. Leppo JA: Comparison of pharmacologic stress agents. J Nucl Cardiol 1996, 3(6 Pt 2):S22-S26.

    Article  PubMed  CAS  Google Scholar 

  14. Navare SM, Mather JF, Shaw LJ: Comparison of risk stratification with pharmacologic and exercise stress myocardial perfusion imaging: a meta-analysis. J Nucl Cardiol 2004, 11:551–561.

    Article  PubMed  Google Scholar 

  15. Slomka PJ, Berman DS, Germano G: Quantification of serial changes in myocardial perfusion. J Nucl Med 2004, 45:1978–1980.

    PubMed  Google Scholar 

  16. Schwartz RG, Pearson TA, Kalaria VG, et al.: Prospective serial evaluation of myocardial perfusion and lipids during the first six months of pravastatin therapy: coronary artery disease regression single photon emission computed tomography monitoring trial. J Am Coll Cardiol 2003, 42:600–610. This trial prospectively monitors beneficial changes in lipids and perfusion in aggressive medically treated patients demonstrating the potential value of noninvasive monitoring.

    Article  PubMed  CAS  Google Scholar 

  17. Itti E, Klein G, Rosso J, et al.: Assessment of myocardial reperfusion after myocardial infarction using automatic 3-dimensional quantification and template matching. J Nucl Med 2004, 45:1981–1988.

    PubMed  Google Scholar 

  18. Smanio P, Beraldo P, Mello R, et al.: Cardiac events after four years of a normal perfusion scintigraphy in diabetic women. J Nucl Cardiol 2005, 12:S104.

    Google Scholar 

  19. Wackers FJT, Young LH, Inzucchi SE, et al.: Detection of silent myocardial ischemia in asymptomatic diabetic subjects. Diabetes Care 2004, 27:1954–1961. Demonstrates the very high-risk of diabetics to develop future cardiovascular events and failure of clinical predictors.

    Article  PubMed  Google Scholar 

  20. Lautamäki RR, Airaksinen KEJ, Seppänen M: Rosiglitazone improves myocardial glucose uptake in ischemic regions in patients with type 2 Diabetes. A 16 week randomised, double-blind, placebo-controlled study. J Nucl Cardiol 2005, 12:S18.

    Article  Google Scholar 

  21. Marcassa CC, Campini R, Calza P, et al.: Long-term evolution of myocardial perfusion pattern at 99mTc-MIBI SPECT in stable CAD patients maintained on medical therapy. J Nucl Cardiol 2005, 12:S47.

    Article  Google Scholar 

  22. Mahmarian JJ, Shaw LJ, Olszlewski GH, et al.: Adenosine sestamibi SPECT post-infarction evaluation (INSPIRE) trial: a randomized, prospective multicenter trial evaluating the role of adenosine Tc-99m sestamibi SPECT for assessing risk and therapeutic outcomes in survivors of acute myocardial infarction. J Nucl Cardiol 2004, 11:458–469. This trial shows the ability of SPECT to accurately risk stratify postinfarction patients who have not yet been treated invasively. This study potentially defines patients who would be expected to benefit from revascularization before subjecting them to invasive testing.

    Article  PubMed  Google Scholar 

  23. Cannon CP, Weintraub WS, Demopoulos LA, et al. for the TACTICS-Thrombolysis in Myocardial Infarction 18 Investigators: Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001, 344:1879–1887.

    Article  PubMed  CAS  Google Scholar 

  24. de Winter RJ, Windhausen F, Cornel JH, et al.: Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005, 353:1095–1104.

    Article  PubMed  Google Scholar 

  25. Romero-Farina G, Candell-Riera J, Aguadé-Bruix SS, et al.: Evolution of left ventricular systolic function after coronary revascularization and medical treatment in patients with ischemic cardiomyopathy. J Nucl Cardiol 2005, 12:S33.

    Google Scholar 

  26. Desideri A, Cortigiani L, Christen AI, et al.: The extent of perfusion-F18-.uorodeoxyglucose positron emission tomography mismatch determines mortality in medically treated patients with chronic ischemic left ventricular dysfunction. J Am Coll Cardiol 2005, 46:1264–1269.

    Article  PubMed  Google Scholar 

  27. Wielepp JPP, Baller D, Pulawski E, et al.: Assessment of base-to-apex gradients of myocardial blood flow after statin therapy at different stages of coronary atherosclerosis. J Nucl Cardiol 2005, 12:S64.

    Google Scholar 

  28. Kudes MA, Schwartz RG, Mackin M, et al.: Comparison of lipid and scintigraphic responses accompanying statin therapy: SPECT Pravastatin CAD Regression Study. J Nucl Cardiol 2005, 12:S40.

    Article  Google Scholar 

  29. Masumoto A, Hirooka Y, Hironaga K, et al.: Effect of pravastatin on endothelial function in patients with coronary artery disease (cholesterol-independent effect of pravastatin). Am J Cardiol 2001, 88:1291–1294. Beyond LDL lowering, statin therapy clearly affects other pathways that mediate endothelial function and vasular health.

    Article  PubMed  CAS  Google Scholar 

  30. Kunnas TA, Lehtimaki T, Laaksonen R, et al.: Endothelial nitric oxide synthase genotype modulates the improvement of coronary blood flow by pravastatin: a placebo-controlled PET study. J Mol Med 2002, 80:802–807. This paper suggests a lipid-independent benefit from pravastatin study that may be mediated by genotypic differences in eNOS and may explain some of the heterogeneity of response to lipid therapy in clinical practice and trials.

    Article  PubMed  CAS  Google Scholar 

  31. Yasuhi WW, Akihiro S, Akio Y, et al.: A selective angiotensin receptor antagonist, termisaltan, produced regression of left ventricular hypertrophy with the improvement of myocardial perfusion and fatty acid metabolism. J Nucl Cardiol 2005, 12:S48.

    Google Scholar 

  32. Morita KK, Tsukamoto T, Naya M, et al.: Impact of smoking cessation on coronary vasomotor response assessed with O-15 labeled water and PET in healthy young smokers. J Nucl Cardiol 2005, 12:S76.

    Article  Google Scholar 

  33. Tio RA, Tan ES, Jessurun GAJ, et al.: PET for evaluation of differential myocardial perfusion dynamics after VEGF gene therapy and laser therapy in end-stage coronary artery disease. J Nucl Med 2004, 45:1437–1443.

    PubMed  Google Scholar 

  34. Blumenthal RS, Becker DM, Moy TF, et al.: Exercise thallium tomography predicts future clinically manifest coronary heart disease in a high-risk asymptomatic population. Circulation 1996, 93:915–923.

    PubMed  CAS  Google Scholar 

  35. Blumenthal RS, Becker DM, Yanek LR, et al.: Detecting occult coronary disease in a high-risk asymptomatic population. Circulation 2003, 107:702–707. This paper demonstrated the ability of SPECT to detect mild CAD in high-risk asymptomatic patients (sibling with CAD) and also provides insight regarding the probability that vasospasm contributes to detection of preclinical CAD with mild changes on SPECT MPS studies.

    Article  PubMed  Google Scholar 

  36. Sdringola S, Patel D, Gould KL: High prevalence of myocardial perfusion abnormalities on positron emission tomography in asymptomatic persons with a parent or sibling with coronary artery disease. Circulation 2001, 103:496–501. This is an important early study showing prevalence of preclinical CAD by PET in asymptomatic patients with CAD of first-degree relatives or with multiple coronary risk factors.

    PubMed  CAS  Google Scholar 

  37. Des Prez RD, Gillespie RL, Jaber WA, et al.: Cost-effectiveness of myocardial perfusion imaging: a summary of the currently available literature. J Nucl Cardiol 2005, 12:750–759.

    Article  PubMed  Google Scholar 

  38. Schwartz RG, Greenland P, Berman DS, et al.: Panel 4: evidenced based strategies for optimizing management of cardiovascular risk and therapy. Conference Proceedings: Seventh Nuclear Cardiology Invitational Conference. Edited by Cerquiera M, Udelson J. J Nucl Cardiol 2005, 12:480–509.

  39. Shaw LJ, Hachamovitch R, Berman DS, et al.: The economic consequences of available diagnostic and prognostic strategies for the evaluation of stable angina patients: an observational assessment of the value of precatheterization ischemia. J Am Coll Cardiol 1999, 33:661–669.

    Article  PubMed  CAS  Google Scholar 

  40. Underwood SR, Godman B, Salvani S, et al.: Economics of Myocardial Perfusion Imaging in Europe-the EMPIRE study. Eur Heart J 1999, 20:157–166.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Cardiology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 679, 14642-8679, Rochester, NY, USA

    Ronald G. Schwartz MD, MS

Authors
  1. Mark A. Kudes MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ronald G. Schwartz MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ronald G. Schwartz MD, MS.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Kudes, M.A., Schwartz, R.G. Noninvasive monitoring of medical therapy. Curr Cardiol Rep 8, 139–146 (2006). https://doi.org/10.1007/s11886-006-0025-y

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11886-006-0025-y

Keywords

Search

Navigation