Volume 34 Issue 1
Feb.  2010
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The clinical value of 99Tcm-N-NOET exercise and delayed myocardial perfusion imaging in patients with hypertension

  • Department of Nuclear Medicine, The First Hospital of Shanxi Medical University, Taiyuan 030001, China

  • Corresponding author: Si-jin LI, lisj-nm@sohu.com ; 
  • Received Date: 2009-10-05
  • Objective To investigate clinical significance of the 99Tcm-bis(N-ethoxy-N-ethyl-dithiocarbamato)nitridotechnetium(99Tcm-N-NOET)exercise and delayed myocardial perfusion imaging(MPI)in hypertensive patients. Methods Sixty patients with hypertension and 19 normal subjects were carried out 99Tcm-N-NOET exercise and delayed MPI, and analyzed the results of MPI, exercise electrocardiography(ECG), cardiac function parameters end-diastolic volume(EDV), end-systolic volume(ESV), left ventricular ejection fraction(LVEF), △LVEF(LVEF exercis-LVEF delay)and coronary angiography(CAG). Results ① Sixty patients with hypertension, 22 cases(36.7%)of exercise ECG were abnormal, 16 cases(26.7%)were the chest tightness in exercise, 13 cases(21.7%)were blood pressure excessive reaction in exercise; control group, 2 cases(10.5%)of exercise ECG were abnormal, 1 case(5.3%, 1/19)was chest tightness in exercise, no per-son was blood pressure response in excessive.②The positive rate of myocardial perfusion in hyper-tensive group was significantly higher than the control group(31.75%vs.5.30%, P < 0.05).③Cardial function parameters in hypertension group[exercise EDV=(79.75±29.10)ml, ESV=(28.82±15.73)ml, LVEF=(65.78± 1.27)%; delay EDV=(81.42±3.47)ml, ESV=(30.62±2.05)ml, LVEF=(64.20±9.70)%]and control group[exercise EDV=(79.63±21.65)ml, ESV=(27.37±10.71)ml, LVEF=(66.42±1.55)%; delay EDV=(82.89±4.96)ml, ESV=(31.42±3.06)ml, LVEF=(63.16±7.54)%]were no statistical difference(exercise EDV: t=0.161, ESV: t= 0.112, LVEF: t=0.261; delay EDV: t=0.276, ESV: t=0.197, LVEF: t=0.184, P > 0.05), △LVEF < 0%, 28 cases (46.7%)in hypertension group, 4 cases(21.1%)in control group, χ2=3.929, P < 0.05; 11 cases(57.9%)in MPI positive group, 12 cases(29.3%)in MPI negative group, χ2=4.501, P < 0.05.④Nineteen patients with hypertension underwent CAG, 11 cases were abnormal, 8 cases were normal.MPI results: 9 cases were ischemia, 10 cases were normal, and they were no statistical difference(χ2=0.25, P > 0.05).The sensitivity, specificity and accuracy of 99Tcm-N-NOET MPI were 72.7%, 87.5%and 78.9%. Conclusions ① 99Tcm-NNOET exercise and delayed MPI can diagnose whether hypertension patients with myocardial ischemia or not.②△LVEF of hypertensive patients reduced, △LVEF is lower in hypertensive patients of MPI-positive.
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  • [1] 董秋婷, 顼志敏. 原发性高血压临床防治的要点. 中国医刊, 2008, 43(09): 7-10. doi: 10.3969/j.issn.1008-1070.2008.09.003
    [2] 范中杰, 陈黎波, 杜延荣, 等. 99Tcm氮欧乙替心肌核素显像的冠心病诊断分析. 中华医学杂志, 2006, 86(26): 1845-1849. doi: 10.3760/j:issn:0376-2491.2006.26.011
    [3] 程燕, 李思进, 李险峰, 等. 99TcmN-NOET门控心肌灌注SPECT评价冠心病的价值. 国际放射医学核医学杂志, 2009, 33(5): 257-260. doi: 10.3760/cma.j.issn.1673-4114.2009.05.001
    [4] 李思进, 胡光, 刘建中, 等. 99TcmN-NOEt门控心肌显像的临床应用. 中华核医学杂志, 2002, 22(3): 161-162.
    [5] 刘海燕, 李思进, 武志芳, 等. 99Tcm-N-NOET运动MPI对可疑或确诊冠心病患者的预后评估价值. 中国医学影像技术, 2008, 24(5): 777-780. doi: 10.3321/j.issn:1003-3289.2008.05.038
    [6] Elhendy A, Schinkel AF, Van Domburg RT, et al. Prediction of cardiac death in hypertensive patients with suspected or known coronary artery disease by stress technetlnm-99m tetrofosmin myocardial perfusion imaging. J Hypertens, 2003, 21(10): 1945-1951. doi: 10.1097/00004872-200310000-00023
    [7] Elhendy A, van Domburg RT, Sozzi FB, et al. Impact of hypertension on the accuracy of exercise stress myocardial perfusion imaging for the diagnosis of coronary artery disease. Heart, 2001, 85(6): 655-661. doi: 10.1136/heart.85.6.655
    [8] Houghton JL, Frank MJ, Carr AA, et al. Relations among impaired coronary flow reserve, left ventricular hypertrophy and thallium perfusion defects in hypertensive patients without obstructive coronary artery disease. J Am coll cardiol, 1990, 15(1): 43-51. doi: 10.1016/0735-1097(90)90173-M
    [9] 李小鹰, 李蕊, 于雯, 等. 老年高血压左心室肥厚患者冠状循环微血管病理改变特点. 中华心血管病杂志, 2001, 29(9): 527-530. doi: 10.3760/j:issn:0253-3758.2001.09.006
    [10] 张欣, 张延军, 丁荣晶, 等. CAG正常的高血压患者心肌核素显像分析. 中国临床医学影像杂志, 2004, 15(4): 195-197.
    [11] Matsumoto N, Sato Y, Suzuki Y, et al. Incremental prognostic value of cardiac function assessed by ECG-gated myocardial perfusion SPECT for the prediction of future acute coronary syndrome. Circ J, 2008, 72(12): 2035-2039. doi: 10.1253/circj.CJ-08-0488
    [12] Yalçin H, Maza S, Yalçin F. Single photon emission computed tomography: an alternative imaging modality in left ventricular evaluation. Vasc Health Risk Manag, 2008, 4(5): 1069-1072.
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The clinical value of 99Tcm-N-NOET exercise and delayed myocardial perfusion imaging in patients with hypertension

    Corresponding author: Si-jin LI, lisj-nm@sohu.com; 
  • Department of Nuclear Medicine, The First Hospital of Shanxi Medical University, Taiyuan 030001, China
  • Received Date: 2009-10-05
  • Available Online: 2010-01-25

Abstract:  Objective To investigate clinical significance of the 99Tcm-bis(N-ethoxy-N-ethyl-dithiocarbamato)nitridotechnetium(99Tcm-N-NOET)exercise and delayed myocardial perfusion imaging(MPI)in hypertensive patients. Methods Sixty patients with hypertension and 19 normal subjects were carried out 99Tcm-N-NOET exercise and delayed MPI, and analyzed the results of MPI, exercise electrocardiography(ECG), cardiac function parameters end-diastolic volume(EDV), end-systolic volume(ESV), left ventricular ejection fraction(LVEF), △LVEF(LVEF exercis-LVEF delay)and coronary angiography(CAG). Results ① Sixty patients with hypertension, 22 cases(36.7%)of exercise ECG were abnormal, 16 cases(26.7%)were the chest tightness in exercise, 13 cases(21.7%)were blood pressure excessive reaction in exercise; control group, 2 cases(10.5%)of exercise ECG were abnormal, 1 case(5.3%, 1/19)was chest tightness in exercise, no per-son was blood pressure response in excessive.②The positive rate of myocardial perfusion in hyper-tensive group was significantly higher than the control group(31.75%vs.5.30%, P < 0.05).③Cardial function parameters in hypertension group[exercise EDV=(79.75±29.10)ml, ESV=(28.82±15.73)ml, LVEF=(65.78± 1.27)%; delay EDV=(81.42±3.47)ml, ESV=(30.62±2.05)ml, LVEF=(64.20±9.70)%]and control group[exercise EDV=(79.63±21.65)ml, ESV=(27.37±10.71)ml, LVEF=(66.42±1.55)%; delay EDV=(82.89±4.96)ml, ESV=(31.42±3.06)ml, LVEF=(63.16±7.54)%]were no statistical difference(exercise EDV: t=0.161, ESV: t= 0.112, LVEF: t=0.261; delay EDV: t=0.276, ESV: t=0.197, LVEF: t=0.184, P > 0.05), △LVEF < 0%, 28 cases (46.7%)in hypertension group, 4 cases(21.1%)in control group, χ2=3.929, P < 0.05; 11 cases(57.9%)in MPI positive group, 12 cases(29.3%)in MPI negative group, χ2=4.501, P < 0.05.④Nineteen patients with hypertension underwent CAG, 11 cases were abnormal, 8 cases were normal.MPI results: 9 cases were ischemia, 10 cases were normal, and they were no statistical difference(χ2=0.25, P > 0.05).The sensitivity, specificity and accuracy of 99Tcm-N-NOET MPI were 72.7%, 87.5%and 78.9%. Conclusions ① 99Tcm-NNOET exercise and delayed MPI can diagnose whether hypertension patients with myocardial ischemia or not.②△LVEF of hypertensive patients reduced, △LVEF is lower in hypertensive patients of MPI-positive.

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  • 高血压是冠心病的主要危险因素之一, 估计全国患病人数达2亿[1]。核素心肌灌注显像(myocardial perfusion imaging, MPI)在冠心病的诊断、危险分层及疗效判断中有重要的价值[2], 它在高血压患者的研究中应用较多, 其应用价值已得到肯定。本研究用99Tcm-双(N-乙氧基, N-乙基-二硫代氨基甲酸酯)氮化锝(99Tcm-bis(N-ethoxy-N-ethyl-dithiocarbamato)nitridotechnetium, 99Tcm-N-NOET)对高血压患者进行MPI, 并观察其在临床应用中的价值。

1.   资料和方法

    1.1.   研究对象

  • 高血压组患者60例, 均符合1999年WHO/ ISH高血压诊断标准, 其中男性38例、女性22例, 年龄35~73岁, 平均(54.1±10.4)岁, 病程0.2~30年, 平均(6.22±6.24)年。所有患者经生化、酶学、超声心动图等检查排除心肌梗死、糖尿病、风湿性心脏病、心肌炎、心肌病等疾病。正常对照组19例, 其中男性9例、女性10例, 年龄25~58岁, 平均(49.8±10.3)岁。两组年龄和性别均匹配。所有受试者行99Tcm-N-NOET运动+延迟门控MPI SPECT, 检查前皆停用扩张冠状动脉药物、钙通道阻滞剂及β受体阻滞剂24 h。其中高血压患者有19例(31.7%)行冠状动脉造影(coronary angiography, CAG), 狭窄≥50%者为诊断冠心病的阳性标准。

    • 1.2.   主要仪器和显像剂

  • 显像仪器为美国GE infiniaVC Hawkeye双探头SPECT。踏车仪器为GE cardiosoft运动测试及多功能心电分析仪(同时获得运动心电图)。显像剂为99Tcm-N-NOET(放化纯 > 95%), 99TcmO4-由中国原子能科学研究院同位素研究所提供, NOET由北京师宏药物研制中心提供。

    • 1.3.   图像采集与处理

  • 受检者行踏车运动, 达终止指标时(心率达次极量; 胸痛、心绞痛发作; 血压骤升或下降; 心电图ST段呈水平型或下斜型压低≥0.1 mv; 心率严重不齐等)静脉注射740~1110 MBq99Tcm-N-NOET, 15 min脂餐, 30 min行运动心肌显像, 3 h行延迟显像。探头配置低能高分辨型准直器, 能峰140 keV, 窗宽±20%, 放大倍数为1.28, 探头沿胸前从右前斜45°至左后斜45°, 3°一帧, 35 s/帧, 共采集60帧。重建采用Ramp-Butterworth滤波反投影(截止频率为0.52, 陡度因子为5), 处理成短轴、水平长轴、垂直长轴断层图像。上述图像操作和处理均由有经验的核医学医师专人完成。

    • 1.4.   图像分析

  • 将左室心肌分为9个心肌节段。60例高血压患者共540个心肌节段, 对照组19例共171个节段。心功能参数[舒张末期容积(end-diastolic volume, EDV)、收缩末期容积(end-systolic volume, ESV)、左室射血分数(left ventricular ejection fraction, LVEF)]应用定量门控心肌断层显像分析软件自动测得, △LVEF由LVEF运动-LVEF延迟计算获得。由两个以上有经验的医师阅片, 病变类型分为: 可逆性缺损、部分可逆性缺损、固定性缺损。以每一轴向连续2层以上、2个轴向同时发现缺损区为异常。

    • 1.5.   统计学方法

  • 采用SPSS13.0软件进行数据分析。计量资料结果符合正态分布用x±s表示, 两组间比较用t检验, 率的比较采用χ2检验, P < 0.05为有显著性差异。

2.   结果

    2.1.   运动中心电图及症状的比较

  • 高血压组60例患者中, 22例(36.7%)运动心电图呈阳性, 其中20例为ST-T改变、2例为心率失常, 其余38例运动心电图正常。16例(26.7%)运动中出现胸闷、胸痛, 13例(21.7%)运动中出现血压过度反应; 对照组19例正常者中, 2例(10.5%)运动心电图阳性, 1例(5.3%)运动中胸闷, 无1例在运动中血压过度反应。高血压组较对照组在运动中心电图异常和出现血压过度反应的发生率明显增高(χ2=4.662, P < 0.05)。

    • 2.2.   MPI的比较

  • 高血压组: 19例(31.7%)出现心肌灌注异常, 共计25(25/540, 4.63%)个节段, 其中21个节段(84.0%)为可逆性缺损, 2个节段(8.0%)为部分可逆性缺损, 2个节段(8.0%)为固定性缺损。对照组: 出现心肌灌注异常1例(5.3%), 1个节段(0.01%) MPI提示可逆性缺损, 高血压组MPI阳性率明显高于对照组(31.75%vs.5.3%, P < 0.05)。

    • 2.3.   心功能分析比较

  • 高血压组和对照组的运动和延迟的EDV、ESV、LVEF均无统计学差异(表 1)。显像中高血压组4例(6.7%)、正常对照组0例(0%)的运动LVEF < 50%;高血压组1例(1.7%)、正常对照组0例(0%), 延迟LVEF < 50%。高血压组△LVEF为负值的有28例(46.7%), 对照组有4例(21.1%), 高血压组心功能储备较对照组低(χ2=3.929, P < 0.05)。MPI阳性组和MPI阴性组之间运动和延迟EDV、ESV及LVEF均无统计学差异。MPI阳性组△LVEF为负值的有11例(57.9%), MPI阴性组有12例(29.3%), 两者比较有统计学差异(χ2=4.501, P < 0.05)。

    运动M像 延迟显像
    EDV(ml) ESV(mJ) LVEF(%) EDV(ml) ESV(ml) LVKK(%)
    高血压组 79.75±29.10 28.82±15.73 65.78±1.27 81.42±3.47 30.62±2.05 64.20±9.70
    对照组 79.63±21.65 27.37±10.71 66.42±1.55 82.89±4.96 31.42±3.06 63.16±7.5
    t值 0.161 0.112 0.261 0.276 0.197 0.184
    注：EDV为舒张未期容积，ESV为收缩末期容积，LVEF为左室射血分数。两组比较，各项参数均无统计学差异(P>0.05)。

    • 2.4.   MPI和CAG的比较

  • 19例行CAG的患者中, 11例冠脉造影异常, 8例正常; MPI结果: 9例心肌缺血, 10例正常, MPI和CAG均异常的有8例, MPI异常、CAG正常的有1例(图 1), MPI正常、CAG异常的有3例, MPI和CAG均异常的有7例。统计可知两种方法无差异(χ2=0.25, P > 0.05)。99Tcm-N-NOET运动+延迟门控MPI诊断高血压心肌缺血的灵敏度、特异度和准确率分别为72.7%、87.5%和78.9%。

3.   讨论

  • 99Tcm-N-NOET是与201Tl相似的“再分布”型显像剂, 一次注射就可以完成运动和延迟检查, 已有报道称此显像剂在心肌缺血的诊断中具有较好的临床应用价值[3-5]。高血压对心脏冠状动脉血管的损伤作用已明确, 因此MPI对高血压患者有较大的临床应用价值。

    本研究中, 高血压组患者中19例(31.7%)出现MPI异常, 对照组有1例(5.3%)MPI异常, 高血压组MPI阳性率明显高于对照组。Elhendy等[6]对601例高血压患者进行99Tcm-tetrofosmin MPI, 同样发现293例(49%)有可逆或固定的心肌灌注异常, 可见高血压患者异常率较高。

    19例行CAG的受检者中, 99Tcm-N-NOET MPI诊断高血压患者心肌缺血的灵敏度、特异度和准确率分别为72.7%、87.5%和78.9%。Elhendy等[7]曾报道, 99Tcm-甲氧基异丁基异腈(99Tcm-methoxyisobutylisonitrile, 99Tcm-MIBI)负荷MPI对137例高血压患者心肌缺血诊断的灵敏度、特异度和准确率分别为75%、72%、74%。这表明99Tcm-N-NOET诊断高血压患者心肌缺血与99Tcm-MIBI有相同的价值, 而且99Tcm-N-NOET只需注射一次, 可能有更好的临床应用前景。

    临床研究表明, 有心绞痛的高血压患者, 尽管CAG是正常的, 但会伴有冠状动脉储备功能的减低及小冠状动脉血管阻力增高[8]。李小鹰等[9]对高血压患者心肌组织病理评估后提出, 壁腔比值增大是高血压病血管重塑的特有改变, 也是其微血管病变的特征性标志。张欣等[10]报道, CAG正常的高血压患者心肌血流灌注出现异常的比率(65%, 13/20)明显高于正常对照组(10%, 1/10), 这从影像学角度间接证实了CAG正常的高血压患者冠状动脉微小血管及心肌纤维病变的存在, 并直观地显示了其病变的范围及缺血的程度。本研究中有1例CAG正常而MPI异常的高血压患者, 考虑与冠脉微血管病变有关。

    Matsumoto等[11]研究表明, 预测心脏死亡事件的最重要因素是运动试验后LVEF, LVEF < 45%, 患者生存率明显降低。本研究中, 高血压组有4例患者运动LVEF < 50%, 而对照组0例, 两组无统计学差异, 这可能与样本的选取有关, 同时我们正在随访中。研究表明, 运动后心肌缺血引发的心肌顿抑表现为运动试验后LVEF减低, 心肌缺血患者运动试验后LVEF低于静息状态下LVEF, 为心脏储备功能降低[12]。本研究以△LVEF为负值代表心脏储备功能降低, 高血压组△LVEF为负值的比率(46.7%)明显高于对照组(21.1%)(χ2=3.929, P < 0.05), 而高血压患者中, MPI阳性组△LVEF为负值的比率(57.9%)也明显高于MPI阴性组(29.3%)(χ2= 4.501, P < 0.05)。结果表明, 高血压患者的心脏储备功能降低, MPI阳性的高血压患者心脏储备功能降低更多。

    综上所述, 99Tcm-N-NOET运动和延迟门控MPI对高血压患者心肌缺血诊断的准确度较高, 并且可评价高血压患者的心脏储备功能。

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